Ventral Hernia Reconstruction with GORE ENFORM Biomaterial

Introduction: Ventral hernia repair (VHR) is one of the most common surgeries performed in the United States. Degradable mesh is the recommended choice for patients presenting with high-risk co-morbidities or increased risk for infection. GORE® ENFORM BiomaterialTM is a biosynthetic degradable mesh that has recently been approved for use in ventral hernia reconstruction with no reports of its clinical outcomes. Methods: This study was a single surgeon case series. Patients were included in the study if they underwent VHR with GORE® ENFORM BiomaterialTM. The decision to use GORE® ENFORM BiomaterialTM was the senior surgeon's decision based on the patient's center for disease control classification. Patient comorbidities, hernia characteristics, postoperative hernia recurrence, and surgical site occurrences (SSOs) were collected at in-patient follow-up appointments and chart review. Patients were asked to complete preoperative and postoperative patient-reported outcomes (PROs) using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity short form 3a and the hernia-specific quality of life (HerQLes) survey. Results: A total of 15 patients were included in this study. The average length of follow-up was 315 days. Postoperatively, 26.7% of patients had an SSO with 4 surgical site infections. Two patients required an operative washout with mesh removal. One patient experienced hernia recurrence. Eight of the 15 patients completed preoperative and postoperative PROs. Conclusion: This is the first clinical study to report the outcomes of ventral hernia repair using ENFORM mesh. These results show that Enform mesh is an option to consider in complex ventral hernia reconstruction.

Advances in Hernia Care State of the Art

The field of hernia surgery has seen many recent advances and continues to evolve. Care of the hernia patient begins preoperatively by ensuring adequate preparation for surgery with surgeons now having the opportunity to accurately predict risk which can aid with informed consent. Imaging studies can now help surgeons diagnose and plan hernia surgery on an individual level based on hernia characteristics as well as abdominal wall musculature. In the operating room, new technology and surgical techniques have allowed surgeons to become increasingly sophisticated with goals of reducing tension on midline closures, utilizing minimally invasive and robotic techniques, and availability of new and varied mesh prosthetics. While modest improvements in outcomes have been witnessed by these advances, there is still opportunity for improvement which will be realized by continued research, use of registries, and education and training. Hernia prevention strategies focusing on minimally invasive surgery, laparotomy closure, and the use of prophylactic mesh will also help with the burden of incisional hernias. These advances in hernia surgery have led to the new field of Abdominal Core Health which helps represent this evolving and growing new subspecialty of general surgery.

Primary Uncomplicated Ventral Hernia Repair: Guidelines and Practice Patterns for Routine Hernia Repairs

Surgical repair of primary umbilical and epigastric hernias are among the most common abdominal operations in the world. The hernia defects range from small (<1 cm) to large and complex even in the absence of prior incision or repair. Mesh has generally been shown to decrease recurrence rates, and its use and location of placement should be individualized for each patient. Open, laparoscopic, and robotic approaches provide unique considerations for the technical aspects of primary repair with or without mesh augmentation.

The Trauma Activation Review Committee: Response to Undertriage During a Period of Rapid Growth at a Level II Trauma Center

Trauma triage criteria are constantly being refined for improved identification of severely injured patients. When errors occur, they should be tracked, and triage criteria adjusted to minimize these events. Two time periods of trauma registry data at a single rural level II trauma center were retrospectively compared to evaluate demographics, injuries, and outcomes to identify triage errors. In 300 activated trauma patients during 2011, overtriage was 23% and undertriage was 3.7%. In 1035 activated trauma patients during 2019, overtriage was 20.5% and undertriage was 2.2%. Mortality decreased over time overall. In 2019, Trauma I patients were older, spent more time on the ventilator, and in the ICU (all P < .001). Trauma II patients were also older, had lower ISS, hospital days, and ventilator days (all P < .001). During rapid growth, evaluation of overtriage and undertriage can provide useful feedback for hospital staff to refine triage choices and improve patient outcomes.

Teaching Small Bite Fascial Closure Technique: Improved Accuracy and Consistency Through Simulation

Despite evidence that small bite closure is beneficial, it is not well documented how accurately and consistently surgeons employ this technique. We created a felt model to simulate fascial closure and educate residents regarding small bites. This study aims to gauge accuracy and consistency of bite size in fascial closure and assess if utilizing a templated model could improve technique. Two 10 cm incisions were made in different pieces of felt. Residents were instructed to suture the incisions to simulate fascial closure by running the incisions closed with 1 cm and 5 mm bites respectively. The process was repeated with templated pieces of felt marking 1 and 0.5 cm to guide bite size. Residents were timed for each closure. The travel and distance from the midline for each bite was measured and analysis performed. 14 residents participated. Paired T-test compared means and standard deviations of bite size. Taking 5 mm bites took more time. Standard deviation of travel and right sided distance from midline were significantly smaller when a template was utilized. Standard deviation of travel as well as right sided distance was also improved when instructed to take 5 mm bites. This study demonstrates that a small bite technique results more closure and that when residents are instructed to take smaller bites. The adage, "aim small, miss small," holds true in fascial closure and may be one reason why small bites improve hernia rates. This study also suggests that the use of a template improves accuracy and consistency of closure regardless of bite size intention.

Robotic Plication of Rectus Diastasis with Associated Hernias: A Case Series

INTRODUCTION

Rectus diastases (RD) are caused by a weakening of the abdominal musculature and a widening of the linea alba. Some patients are often erroneously told that they are hernias. Despite the fact that they are not true hernias, they are often associated with true hernias and undergo concomitant repairs. Robotic plication of these diastases has been gaining more widespread use in the past few years, but literature regarding outcomes remains limited.

MATERIAL AND METHODS

All patients with RD and concomitant ventral hernia that underwent robotic repair were assessed from 2016 to present. Demographics, perioperative morbidity, and outcomes were reviewed, and descriptive analyses were performed.

RESULTS

This series consists of 14 patients with an average age of 50.7 years (range 33-78 years), 64% female, and 86% Caucasian. All patients had associated umbilical or ventral/incisional hernia with an average defect size of 7.1cm2 and average mesh size of 254cm2. Robotic transabdominal pre-peritoneal (RTAPP) repair was performed in 67% of cases and robotic extended total extraperitoneal (ReTEP) repair was performed in 33%. Two patients (17%) required conversion to open repair. Hospital length of stay was 0.7 days. There was no morbidity in these patients. At an average follow-up of 2.6 years (range 54-2122 days), the hernia/diastasis recurrence rate is 7.1%.

CONCLUSION

The results of this study suggest that robotic plication with intraperitoneal sublay mesh could be an acceptable surgical approach for RD associated with concomitant ventral hernia repair. Further investigation is required to assess outcomes in a larger group of patients and to determine long-term recurrence and complication rates.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume

Introduction

Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic.

Materials and methods

A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys.

Results

Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01).

Conclusions

Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Are Surgeons of the Abdominal Core Health Quality Collaborative Following Guidelines in Umbilical and Epigastric Hernia Repair?

BACKGROUND

Umbilical and epigastric hernias are among the top three most common hernia surgeries performed in the USA with varied techniques. The European and Americas Hernia Societies (EAHS) recently published guidelines for repair of umbilical and epigastric hernias. We evaluated how closely the general surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and to identify areas for possible improvement.

METHOD

Data from patients undergoing elective and emergent umbilical or epigastric hernia repair from 2013 to 2021 were extracted from the ACHQC database. The procedures performed on eligible subjects were compared to those proposed by the EAHS guidelines. Data was reported as a percentage and a cutoff of 70% was selected to determine compliance.

RESULTS

Based on these criteria, 11,088 patients were included and most of the recommendations, including appropriate preoperative antibiotic dosing (96.1% umbilical; 97.2% epigastric), permanent mesh selection (umbilical 97.8%; 96.1 epigastric), mesh fixation with suture (83.6% umbilical; 75.5% epigastric), use of mesh for open repair of hernias greater than 1 cm (83.6 umbilical; 85.7 epigastric), and primary defect closure during open (98.6% umbilical; 97.5% epigastric) and laparoscopic (99.6% umbilical; 100% epigastric) repair, were met.

DISCUSSION

Surgeons of the ACHQC adhere to most of the published guidelines on umbilical and epigastric hernia repair. Further research is needed to reinforce or modify the existing recommendations. Standardization of surgical approach will facilitate additional research needed to improve procedural efficiency, while reducing negative outcomes and cost.

Patient Referrals for Hernia Consultations through the International Hernia Collaboration (IHC) Online Social Media Platform

Social media platforms are becoming more ubiquitous in surgery with a mission to bring surgeons closer together through education and learning. The purpose of this project is to evaluate the social media posts relating to referral of patients through one of the online social media platforms. The International Hernia Collaboration closed Facebook site was queried with terms relating to referrals and descriptive statistics generated. There were a total of 36 posts relating to surgical referrals between October 2014 and January 2021. Posts were from 32 different surgeons and included 30 different locations throughout the United States. An online social media platform is a viable way to refer patients throughout the United States and abroad. Further study is needed to evaluate the role of social media for surgical referrals and its impact on patient care.

A prospective, multicenter trial of a long-term bioabsorbable mesh with Sepra technology in cohort of challenging laparoscopic ventral or incisional hernia repairs (ATLAS trial)

BACKGROUND

This prospective, multicenter, single-arm, open-label study evaluated P4HB-ST mesh in laparoscopic ventral or incisional hernia repair (LVIHR) in patients with Class I (clean) wounds at high risk for Surgical Site Occurrence (SSO).

METHODS

Primary endpoint was SSO requiring intervention <45 days. Secondary endpoints included: surgical procedure time, length of stay, SSO >45 days, hernia recurrence, device-related adverse events, reoperation, and Quality of Life at 1, 3, 6, 12, 18, and 24-months.

RESULTS

120 patients (52.5% male), mean age of 55.0 ± 14.9 years, and BMI of 33.2 ± 4.5 kg/m2 received P4HB-ST mesh. Patient-reported comorbid conditions included: obesity (86.7%), active smoker (45.0%), COPD (5.0%), diabetes (16.7%), immunosuppression (2.5%), coronary artery disease (7.5%), chronic corticosteroid use (2.5%), hypoalbuminemia (0.8%), advanced age (10.0%), and renal insufficiency (0.8%). Hernia types were primary ventral (44.2%), primary incisional (37.5%), recurrent ventral (5.8%), and recurrent incisional (12.5%). Patients underwent LVIHR in laparoscopic (55.8%) or robotic-assisted cases (44.2%), mean defect size 15.7 ± 28.3 cm2, mean procedure time 85.9 ± 43.0 min, and mean length of stay 1.0 ± 1.4 days. There were no SSOs requiring intervention beyond 45 days, n = 38 (31.7%) recurrences, n = 22 (18.3%) reoperations, and n = 2 (1.7%) device-related adverse events (excluding recurrence).

CONCLUSION

P4HB-ST mesh demonstrated low rates of SSO and device-related complications, with improved quality of life scores, and reoperation rate comparable to other published studies. Recurrence rate was higher than expected at 31.7%. However, when analyzed by hernia defect size, recurrence was disproportionately high in defects ≥7.1 cm2 (43.3%) compared to defects <7.1 cm2 (18.6%). Thus, in LVIHR, P4HB-ST may be better suited for small defects. Caution is warranted when utilizing P4HB-ST in laparoscopic IPOM repair of larger defects until additional studies can further investigate outcomes.

Exploring the Pharmacokinetics of Phenoxymethylpenicillin (Penicillin-V) in Adults: A Healthy Volunteer Study

This healthy volunteer study aimed to explore phenoxymethylpenicillin (penicillin-V) pharmacokinetics (PK) to support the planning of large dosing studies in adults. Volunteers were dosed with penicillin-V at steady state. Total and unbound penicillin-V serum concentrations were determined, and a base population PK model was fitted to the data.

The praziquantel in preschoolers (PIP) trial: study protocol for a phase II PK/PD-driven randomised controlled trial of praziquantel in children under 4 years of age

BACKGROUND

Over 200 million individuals worldwide are infected with Schistosoma species, with over half of infections occurring in children. Many children experience first infections early in life and this impacts their growth and development; however praziquantel (PZQ), the drug used worldwide for the treatment of schistosomiasis, only has regulatory approval among adults and children over the age of four, although it is frequently used "off label" in endemic settings. Furthermore, pharmacokinetic/pharmacodynamics (PK/PD) evidence suggests the standard PZQ dose of 40 mg/kg is insufficient in preschool-aged children (PSAC). Our goal is to understand the best approaches to optimising the treatment of PSAC with intestinal schistosomiasis.

METHODS

We will conduct a randomised, controlled phase II trial in a Schistosoma mansoni endemic region of Uganda and a Schistosoma japonicum endemic region of the Philippines. Six hundred children, 300 in each setting, aged 12-47 months with Schistosoma infection will be randomised in a 1:1:1:1 ratio to receive either (1) 40 mg/kg PZQ at baseline and placebo at 6 months, (2) 40 mg/kg PZQ at baseline and 40 mg/kg PZQ at 6 months, (3) 80 mg/kg PZQ at baseline and placebo at 6 months, or (4) 80 mg/kg PZQ at baseline and 80 mg/kg PZQ at 6 months. Following baseline treatment, children will be followed up for 12 months. The co-primary outcomes will be cure rate and egg reduction rate at 4 weeks. Secondary outcomes include drug efficacy assessed by novel antigenic endpoints at 4 weeks, actively collected adverse events and toxicity for 12 h post-treatment, morbidity and nutritional outcomes at 6 and 12 months, biomarkers of inflammation and environmental enteropathy and PZQ PK/PD parameters.

DISCUSSION

The trial will provide valuable information on the safety and efficacy of the 80 mg/kg PZQ dose in PSAC, and on the impact of six-monthly versus annual treatment, in this vulnerable age group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03640377 . Registered on 21 Aug 2018.

Methodological features of clinical pharmacokinetic-pharmacodynamic studies of antibacterials and antifungals: a systematic review

BACKGROUND

Pharmacokinetic (PK)-pharmacodynamic (PD) indices relate measures of drug exposure to antibacterial effect. Clinical PK-PD studies aim to correlate PK-PD indices with outcomes in patients. Optimization of dosing based on pre-clinical studies means that PK-PD relationships are difficult to establish; therefore studies need to be designed and reported carefully to validate pre-clinical findings.

OBJECTIVES

To describe the methodological features of clinical antibacterial and antifungal PK-PD studies that reported the relationship between PK-PD indices and clinical or microbiological responses.

METHODS

Studies published between 1980 and 2015 were identified through systematic searches. Methodological features of eligible studies were extracted.

RESULTS

We identified 85 publications containing 97 PK-PD analyses. Most studies were small, with fewer than 100 patients. Around a quarter were performed on patients with infections due to a single specific pathogen. In approximately one-third of studies, patients received concurrent antibiotics/antifungals and in some other studies patients received other treatments that may confound the PK-PD-outcome relationship. Most studies measured antimicrobial concentrations in blood/serum and only four measured free concentrations. Most performed some form of regression, time-to-event analysis or used the Hill/Emax equation to examine the association between PK-PD index and outcome. Target values of PK-PD indices that predict outcomes were investigated in 52% of studies. Target identification was most commonly done using recursive partitioning or logistic regression.

CONCLUSIONS

Given the variability in conduct and reporting, we suggest that an agreed set of standards for the conduct and reporting of studies should be developed.

Efficacy and Associated Drug Exposures of Isavuconazole and Fluconazole in an Experimental Model of Coccidioidomycosis

Coccidioides spp. are important pathogens in regions where they are endemic, and new treatment options are needed. Here, isavuconazonium sulfate (ISAVUSULF) and fluconazole (FLU) were evaluated in experimental disseminated coccidioidomycosis to characterize drug exposures associated with efficacy. Broth macrodilution was performed on Coccidioides isolates to measure minimal effective concentrations (MEC) and minimal fungicidal concentrations (MFC). Mice were inoculated with Coccidioides posadasii (Silveira strain). Treatment started 4 days postinoculation. In model 1, mice were treated for 19 days, followed by 30 days of off-therapy observation, measuring survival through day 49 and residual fungal burden. Treatments included ISAVUSULF (prodrug; 186, 279, or 372 mg/kg twice daily), FLU (20 or 100 mg/kg once daily), and no treatment. Model 2 included 7-day treatment with ISAVUSULF (prodrug; 74.4, 111.6, or 148.8 mg/kg twice daily), FLU (20 or 100 mg/kg once daily), and no treatment. Serial plasma and tissues samples were obtained for pharmacokinetics (PK) and fungal burden measurement, respectively. Fifty percent minimal effective concentration (MEC50) values were 0.39 mg/liter (isavuconazole [ISAV]) and 12.5 mg/liter (FLU). Treatment with ISAVUSULF186 or with either FLU dose resulted in higher survival compared to that in the untreated group. Treatment with ISAVUSULF186 or ISAVUSULF279 twice daily or FLU100 reduced fungal burden in all organs (model 1). In model 2, a >1 log10 CFU/organ reduction was demonstrated, with ISAV area under the concentration-time curve (AUC) values achieved with 111.6 mg/kg twice daily (56.8 mg · h/liter) in the spleen and liver. FLU AUC values of 100 and 500 mg·h/liter for 20 and 100 mg/kg doses, respectively, resulted in a >1 log10 CFU/organ mean reduction in all organs. ISAVUSULF and FLU improved survival and reduced fungal burden. Increasing plasma drug exposures resulted in decreases in fungal burden.

Population Pharmacokinetics of Piperacillin in Non-Critically Ill Patients with Bacteremia Caused by Enterobacteriaceae

This study analyzes the pharmacokinetic variability of piperacillin in non-critically ill patients with Enterobacteriaceae bloodstream infections (EBSI) and explores predicted clinical outcomes and piperacillin-related neurotoxicity under different renal conditions. Hospitalized, non-critically ill patients treated with piperacillin–tazobactam for EBSI were included. Four serum samples per patient were collected and analyzed. A population pharmacokinetic model was developed using the Pmetrics package for R. Monte Carlo simulations of various dosage regimens of 4 g piperacillin, administered q8 h or q12 h by short (0.5 h) or long (4 h) infusion, following the different glomerular filtration rate (GFR) categories used to classify chronic kidney disease (Kidney Disease: Improving Global Outcomes, KDIGO) to determine the probability of target attainment (PTA) using a free drug concentrations above the minimal inhibitory concentration (fT > MIC) of 50% for efficacy and targets for piperacillin-associated neurotoxicity. Twenty-seven patients (102 samples) were included. Extended piperacillin infusions reached a PTA > 90% (50%fT > MIC) within the susceptibility range, although a loading dose did not greatly improve the expected outcome. Long infusions reduced the expected toxicity in patients with severe renal impairment. The study supports the use of extended infusions of piperacillin in non-critically ill patients with EBSI. No benefits of a loading dose were expected in our population. Finally, extended infusions may reduce the risk of toxicity in patients with severe renal impairment.

Prospective, multicenter study of P4HB (Phasix™) mesh for hernia repair in cohort at risk for complications: 3-Year follow-up

BACKGROUND

This study represents a prospective, multicenter, open-label study to assess the safety, performance, and outcomes of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh for primary ventral, primary incisional, or multiply-recurrent hernia in subjects at risk for complications. This study reports 3-year clinical outcomes.

MATERIALS AND METHODS

P4HB mesh was implanted in 121 patients via retrorectus or onlay technique. Physical exam and/or quality of life surveys were completed at 1, 3, 6,12, 18, 24, and 36 months, with 5-year (60-month) follow-up ongoing.

RESULTS

A total of n = 121 patients were implanted with P4HB mesh (n = 75 (62%) female) with a mean age of 54.7 ± 12.0 years and mean BMI of 32.2 ± 4.5 kg/m2 (±standard deviation). Comorbidities included: obesity (78.5%), active smokers (23.1%), COPD (28.1%), diabetes mellitus (33.1%), immunosuppression (8.3%), coronary artery disease (21.5%), chronic corticosteroid use (5.0%), hypo-albuminemia (2.5%), advanced age (5.0%), and renal insufficiency (0.8%). Hernias were repaired via retrorectus (n = 45, 37.2% with myofascial release (MR) or n = 43, 35.5% without MR), onlay (n = 8, 6.6% with MR or n = 24, 19.8% without MR), or not reported (n = 1, 0.8%). 82 patients (67.8%) completed 36-month follow-up. 17 patients (17.9% ± 0.4%) experienced hernia recurrence at 3 years, with n = 9 in the retrorectus group and n = 8 in the onlay group. SSI (n = 11) occurred in 9.3% ± 0.03% of patients.

CONCLUSIONS

Long-term outcomes following ventral hernia repair with P4HB mesh demonstrate low recurrence rates at 3-year (36-month) postoperative time frame with no patients developing late mesh complications or requiring mesh removal. 5-year (60-month) follow-up is ongoing.

Laparotomy Closure: A Review of Available Education Training Models

INTRODUCTION

As studies continue to provide advanced knowledge concerning abdominal wall closure after laparotomy, there have been many improvements in surgical techniques and recommended closure materials. However, there continues to be a high rate of incisional hernias following exploratory laparotomies. The goal of this review is to provide a comprehensive assessment of available educational models for laparotomy closure.

MATERIAL AND METHODS

A comprehensive literature review was made using PubMed, Cochrane, and NCBI MeSH databases to find the most relevant articles associated with various abdominal closure models using specific keywords.

RESULTS

Human cadaver, animal, synthetic, and virtual reality models were reviewed. Strengths and limitations of each model were described.

CONCLUSION

Each model has practical benefits in its ability to mimic in vitro anatomy and the experiential similarities to actual laparotomy closure. However, there are also limitations and potential cost-prohibitive factors for individual models. Overall, while there have been some advances in synthetic and virtual models, human cadaver and porcine models remain the most similar to human abdominal wall closures.

The Effect of Tack Fixation Methods on Outcomes in Laparoscopic Ventral Hernia Repair

Background and Objectives: There are weak data comparing the safety and efficacy of absorbable and permanent tacks in laparoscopic ventral hernia repair with tack-only mesh fixation. In this study, we compared recurrence and complications rates following hernia repair using either only absorbable or only permanent tacks. Methods: Data from the Americas Hernia Society Quality Collaborative database were retrospectively reviewed as accessed on June 30, 2017. The query included patients 18 years of age or older, who had undergone laparoscopic ventral hernia repair with mesh using tack-only fixation. Study groups were divided into patients who had only absorbable tacks used and those with only permanent tacks. Propensity score matching was applied to strengthen the groups. Results: There were no significant differences in demographics, comorbidities, or hernia characteristics between the groups. There were no significant differences in length of stay, hernia recurrence rate, or surgical site infection. The permanent tack group had a significantly higher rate of surgical site occurrences (SSOs), as evidenced by a higher rate of seroma formation. Conclusion: When comparing the rates of complications and recurrences between absorbable and permanent tacks in the setting of laparoscopic ventral hernia repair with tack-only mesh fixation, the only significant difference found was that the permanent group had a higher rate of SSO due to seroma formation. Because this complication did not lead to an increased intervention rate, the clinical significance of this finding remains in question.

An Evaluation of Tension Measurements During Myofascial Release for Hernia Repair

Tension-free repairs have revolutionized the way we repair hernias. To help reduce undue tension when performing ventral hernia repair, multiple different techniques of myofascial releases have been described. The purpose of this project is to evaluate tension measurements for commonly performed myofascial releases in abdominal wall hernia repair. Patients undergoing myofascial release techniques for their ventral hernias were enrolled in a prospective Institutional Review Board-approved protocol to measure abdominal wall tension from June 1, 2011 to August 1, 2019. Abdominal wall tensions were measured using tensiometers before and after myofascial release techniques. Descriptive statistics were performed and data were analyzed. Thirty patients had tension measurements (5 anterior myofascial separation, 25 posterior myofascial separation with transversus abdominis release [TAR]). Average age was 60.1 years (range 29-81), 83% Caucasian, 53% female, and 42% recurrent hernias. The average hernia defect in patients undergoing anterior myofascial release was 117.3 cm2, and the average mesh size was 650 cm2. The reduction in tension after anterior release was 4.7 lbs (2.7 lbs vs 7.4 lbs). The average hernia defect in patients undergoing posterior myofascial release (TAR) was 183 cm2, and the average mesh size was 761.36 cm2. The reduction in tension after bilateral posterior rectus sheath incision was 2.55 lbs (5.01 lbs vs 7.56 lbs) with 0.66 lbs further reduction in tension after TAR (4.35 lbs vs 5.01). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair. Preliminary data show tension reductions associated with the different myofascial release techniques and, with further study, may be a useful intraoperative adjunct for decision making in hernia repair.

Physiologic Tension: Technique for Measuring and Baseline Values

Tension is one of the most discussed terms related to hernia surgery and repair. Despite the universally accepted opinion that tension and reduction of tension are important concepts in hernia repair, there is very little known about the physiologic tension of the abdominal wall related to ventral hernia repair. The purpose of this project was to attempt to measure physiologic tension in patients without hernia repair and help determine a normal baseline tension. Patients were enrolled in a prospective institutional review board–approved protocol to measure abdominal wall tension from February 2014 to present. Patients undergoing abdominal surgery without hernia repair were included. Demographic information and operative details were documented. Abdominal wall tensions were measured using scales attached to Kocher clamps that are clamped to the fascia and then brought together in the midline. Total tension, surgeon's estimation of tension, and grading of the fascia were recorded. Descriptive statistics were calculated. Eleven patients met the inclusion criteria and had tension measurements performed during surgery. The average age was 58 years, with 55 per cent of them being white and 82 per cent being male, with an average BMI of 27. Operations included exploratory laparotomy for small bowel pathology in six patients, colorectal surgery in three patients, and splenectomy in a trauma patient. Average tension measurements for these patients were 1.9 lbs. Surgeon grading of tension was an average of 2.2 (range, 1–5). Obtaining tension measurements is feasible during abdominal surgery. Physiologic tension seems to be approximately 2 pounds. Further study is needed with a larger sample of patients.

Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost

Enhanced recovery after surgery (ERAS) may improve patients’ postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology – nephrectomy and cystectomy, spinal fusion, cardiac surgery—coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.

The Effect of Fixation Methods on Outcomes in Laparoscopic Ventral Hernia Repair

INTRODUCTION

The ideal fixation methods in laparoscopic ventral hernia repair continue to be debated. Early series touted the importance of suture and tack fixation; however, due to the perceived concern for increased pain, newer tack-only fixation methods have emerged. The purpose of this study was to compare fixation methods in laparoscopic ventral hernia repairs using a large hernia database.

MATERIALS AND METHODS

We retrospectively reviewed data from the Americas Hernia Society Quality Collaborative (AHSQC) database comparing two groups of fixation (all tacks vs. all sutures and tacks and sutures and permanent tacks vs. sutures and absorbable tacks). The primary outcome measures were hernia recurrence, hospital length of stay, surgical site infection, surgical site occurrence, pain intensity scores, and quality-of-life scores evaluated at 30 days, six months, one year, and two years, Propensity score matching was used to strengthen the retrospective nature of the study.

RESULTS

Eight hundred and fifty-two patients were included for analysis; 426 patients with tack-only fixation and 426 with tack and suture fixation. Eight hundred and four total patients were included for analysis; 402 patients with sutures with permanent tacks and 402 patients with sutures and absorbable tacks. For both comparisons, there was no significant difference in hospital length of stay, hernia recurrence rate, surgical site infection rate, surgical site occurrence rate, or surgical site occurrence requiring procedural intervention (p>0.05). There was also no significant difference in pain scores and quality-of-life scores at baseline, 30 days, six months, and one year. The only significant difference was in quality of life at two years. Patients with sutures and tacks had better quality-of-life scores compared with patients with tacks only (64 vs. 39, p<0.001).

CONCLUSION

Data available in the AHSQC database reviewed in this study indicate that there were no clinically significant differences between types of fixation methods when used in laparoscopic ventral hernia repair.

Mid-Year Medical Knowledge Milestones and ABSITE Scores in First-Year Surgery Residents

OBJECTIVE

Accreditation Council for Graduate Medical Education (ACGME) Surgery milestone ratings in the "Knowledge of Diseases and Conditions" (MK1) sub competency have been shown to correlate with American Board of Surgery In Training Examination (ABSITE) scores, and hypothesized to predict them. To better assess the predictive value of the MK1 milestone and avoid the potential bias caused by previous years' ABSITE scores, we designed a study including only first-year (PGY-1) residents and analyzed the correlation between their mid-year MK1 ratings and their scores in the ABSITE they took approximately a month later.

METHODS

De-identified United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, mid-year MK1 milestone ratings and the subsequent ABSITE standard scores for the five academic years from 2014-2015 to 2018-2019 were collected and tabulated for 247 PGY-1 preliminary- and categorical-track residents from ten ACGME-accredited surgery residency programs.

RESULTS

The mid-year rating of PGY-1 residents' MK1 was predictive of their subsequent first ABSITE score for the entire cohort and for the categorical residents' subset. Notably, controlling for all other independent predictors, each half-point increase in MK1 rating was associated with a 25-point increase in ABSITE score. Preliminary residents performed significantly worse on the ABSITE, and their scores did not correlate significantly with their MK1 ratings.

CONCLUSIONS

The mid-year rating of PGY-1 residents' MK1 was predictive of their subsequent first ABSITE score for the entire cohort and for the categorical but not the preliminary residents. This finding suggests that evaluators correctly rated MK1 higher in the categorical residents who did perform better on the subsequent ABSITE.

Clinical Application of the Measurement of Abdominal Wall Tension in Hernia Repair

Abdominal wall tension is an integral concept in hernia repair. Most of the described techniques attempt to reduce abdominal wall tension by using mesh prosthetics or myofascial release. Although the concept of a "tension-free" hernia repair is well-understood and appreciated by surgeons, quantitative information about abdominal wall tension is limited. This review evaluates the published literature related to abdominal wall tension and summarizes how the measurement of intraoperative tension can guide clinical decision-making. Most of the methods and techniques for measuring abdominal wall tension are similar and involve the use of tensiometers. However, there is no accepted standardized technique. Baseline tension measurements confirm the concept of a baseline physiological tension, and it has been observed that tension does not correlate with hernia width. When the tension is considered to be too great during hernia repair, intraoperative techniques such as myofascial release can be used to reduce tension to physiological values. Emerging data from clinical studies on tension have added to our understanding of the mechanics and physiology of the abdominal wall. Standardized devices and measurement techniques need to be developed and validated to foster the utility of tension measurements in hernia repair.

An Evaluation of Fascial Closure Techniques in Open Ventral Hernia Repair: Practice Patterns and Short-Term Outcomes

The best method for fascial closure during hernia repair remains unknown. This study evaluates the impact of fascial closure techniques on short-term outcomes. All patients undergoing open ventral hernia repair were queried using the Americas Hernia Society Quality Collaborative database. Analysis was stratified by suture type (absorbable and permanent) and technique (figure-of-eight, running, and interrupted). Outcome measures included SSI, surgical site occurrence (SSO), SSO requiring intervention, recurrence rate, and quality of life. Descriptive statistics and logistic regression were used. The study included 6544 patients. Two-thirds of surgeons closed fascia during ventral hernia repair with absorbable suture and one-third with permanent suture. In the absorbable group, 17 per cent used figure-of-eight, 46 per cent running, and 4 per cent interrupted suture. In the permanent group, 13 per cent used figure-of-eight, 8 per cent running, and 11 per cent interrupted suture. There was no significant association between SSO and closure technique ( P = 0.2). However, SSO and suture type were significant ( P < 0.001) with the odds of SSO for closure with absorbable suture being 62 per cent higher than the odds of permanent. Fascial closure technique and suture type had no significant association ( P > 0.5) with SSI, SSO requiring intervention, hernia recurrence rate, or HerQLes or NIH PROMIS 3a scores at 30 days or 6 months. Fascial closure technique and suture material do not have a major impact on outcomes in ventral hernia repair. Despite a significantly higher rate of SSO for absorbable sutures than permanent, this did not increase the rate of interventions.

An Evaluation of Fascial Closure Techniques in Open Ventral Hernia Repair: Practice Patterns and Short-Term Outcomes

The best method for fascial closure during hernia repair remains unknown. This study evaluates the impact of fascial closure techniques on short-term outcomes. All patients undergoing open ventral hernia repair were queried using the Americas Hernia Society Quality Collaborative database. Analysis was stratified by suture type (absorbable and permanent) and technique (figure-of-eight, running, and interrupted). Outcome measures included SSI, surgical site occurrence (SSO), SSO requiring intervention, recurrence rate, and quality of life. Descriptive statistics and logistic regression were used. The study included 6544 patients. Two-thirds of surgeons closed fascia during ventral hernia repair with absorbable suture and one-third with permanent suture. In the absorbable group, 17 per cent used figure-of-eight, 46 per cent running, and 4 per cent interrupted suture. In the permanent group, 13 per cent used figure-of-eight, 8 per cent running, and 11 per cent interrupted suture. There was no significant association between SSO and closure technique (P = 0.2). However, SSO and suture type were significant (P < 0.001) with the odds of SSO for closure with absorbable suture being 62 per cent higher than the odds of permanent. Fascial closure technique and suture type had no significant association (P > 0.5) with SSI, SSO requiring intervention, hernia recurrence rate, or HerQLes or NIH PROMIS 3a scores at 30 days or 6 months. Fascial closure technique and suture material do not have a major impact on outcomes in ventral hernia repair. Despite a significantly higher rate of SSO for absorbable sutures than permanent, this did not increase the rate of interventions.

Practice Patterns and Attitudes of Surgeons on the Use of Prophylactic Mesh to Prevent Parastola Hernia: A Cross-sectional Survey

Information about surgeons' attitudes toward using prophylactic mesh (PM) for parastomal hernia (PSH) prevention is limited.

PURPOSE

A survey was conducted to assess attitudes/beliefs and surgical practice related to PM use for preventing PSH.

METHODS

A cross-sectional email survey was conducted during April 2017 among members (surgeons) of the American Hernia Society, European Hernia Society, and International Hernia Collaboration. Survey items included participant demographic characteristics, knowledge about the incidence of PSH, number of permanent stomas created annually, beliefs/opinions (knowledge/interest) regarding the use of PM, and surgical practices (mesh type and position). Data were collected and tallied using SurveyMonkey. Descriptive statistics were used to analyze the data.

RESULTS

Of the 5445 emails sent, 497 responses were received, 235 (47.3%) from the United States and 197 (39.6%) from Europe. The majority of participants were general surgeons (371, 74.6%); a small percentage were colorectal surgeons (37, 7.4%). Most respondents (353, 71.0%) reported at least 11 years of surgical experience, with 37.3% reporting >20 years' experience. The majority of respondents (340, 68.4%) created <15 ostomies per year, more than half (252, 50.7%) consider the incidence of PSH 30% or below, and 107 (22%) use PM. The most common reason for not using mesh was concern about mesh-related complications (141, 41.5%). When asked about type of mesh, most surgeons (153/245, 62.4%) preferred permanent mesh and an open retromuscular approach (97/278, 34.9%).

CONCLUSION

Results of the present survey show ongoing ambiguity regarding the use of PM for PSH prevention. Education to increase awareness about the incidence of PSH and well-designed safety and effectiveness studies of preventive strategies are needed to help surgeons optimize PSH prevention strategies.

Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost

Enhanced recovery after surgery (ERAS) may improve patients' postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology - nephrectomy and cystectomy, spinal fusion, cardiac surgery-coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.

Physiologic Tension: Technique for Measuring and Baseline Values

Tension is one of the most discussed terms related to hernia surgery and repair. Despite the universally accepted opinion that tension and reduction of tension are important concepts in hernia repair, there is very little known about the physiologic tension of the abdominal wall related to ventral hernia repair. The purpose of this project was to attempt to measure physiologic tension in patients without hernia repair and help determine a normal baseline tension. Patients were enrolled in a prospective institutional review board-approved protocol to measure abdominal wall tension from February 2014 to present. Patients undergoing abdominal surgery without hernia repair were included. Demographic information and operative details were documented. Abdominal wall tensions were measured using scales attached to Kocher clamps that are clamped to the fascia and then brought together in the midline. Total tension, surgeon's estimation of tension, and grading of the fascia were recorded. Descriptive statistics were calculated. Eleven patients met the inclusion criteria and had tension measurements performed during surgery. The average age was 58 years, with 55 per cent of them being white and 82 per cent being male, with an average BMI of 27. Operations included exploratory laparotomy for small bowel pathology in six patients, colorectal surgery in three patients, and splenectomy in a trauma patient. Average tension measurements for these patients were 1.9 lbs. Surgeon grading of tension was an average of 2.2 (range, 1-5). Obtaining tension measurements is feasible during abdominal surgery. Physiologic tension seems to be approximately 2 pounds. Further study is needed with a larger sample of patients.

Pharmacodynamics of the Novel Antifungal Agent F901318 for Acute Sinopulmonary Aspergillosis Caused by Aspergillus flavus

Background

Aspergillus flavus is one of the most common agents of invasive aspergillosis and is associated with high mortality. The orotomides are a new class of antifungal agents with a novel mechanism of action. An understanding of the pharmacodynamics (PD) of the lead compound F901318 is required to plan safe and effective regimens for clinical use.

Methods

The pharmacokinetics (PK) and PD of F901318 were evaluated by developing new in vitro and in vivo models of invasive fungal sinusitis. Galactomannan was used as a pharmacodynamic endpoint in all models. Mathematical PK-PD models were used to describe dose-exposure-response relationships.

Results

F901318 minimum inhibitory concentrations (MICs) ranged from 0.015 to 0.06 mg/L. F901318 induced a concentration-dependent decline in galactomannan. In the in vitro model, a minimum concentration:MIC of 10 resulted in suppression of galactomannan; however, values of approximately 10 and 9–19 when assessed by survival of mice or the decline in galactomannan, respectively, were equivalent or exceeded the effect induced by posaconazole. There was histological clearance of lung tissue that was consistent with the effects of F901318 on galactomannan.

Conclusions

F901318 is a potential new agent for the treatment of invasive infections caused by A flavus with PDs that are comparable with other first-line triazole agents.

Comparison of piperacillin exposure in the lungs of critically ill patients and healthy volunteers

Background

Severe infections of the respiratory tracts of critically ill patients are common and associated with excess morbidity and mortality. Piperacillin is commonly used to treat pulmonary infections in critically ill patients. Adequate antibiotic concentration in the epithelial lining fluid (ELF) of the lung is essential for successful treatment of pulmonary infection.

Objectives

To compare piperacillin pharmacokinetics/pharmacodynamics in the serum and ELF of healthy volunteers and critically ill patients.

Methods

Piperacillin concentrations in the serum and ELF of healthy volunteers and critically ill patients were compared using population methodologies.

Results

Median piperacillin exposure was significantly higher in the serum and the ELF of critically ill patients compared with healthy volunteers. The IQR for serum piperacillin exposure in critically ill patients was six times greater than for healthy volunteers. The IQR for piperacillin exposure in the ELF of critically ill patients was four times greater than for healthy volunteers. The median pulmonary piperacillin penetration ratio was 0.31 in healthy volunteers and 0.54 in critically ill patients.

Conclusions

Greater variability in serum and ELF piperacillin concentrations is observed in critically ill patients compared with healthy adult subjects and must be considered in the development of dosage regimens. Pulmonary penetration of antimicrobial agents should be studied in critically ill patients, as well as healthy volunteers, during drug development to ensure appropriate dosing of patients with pneumonia.

A Preliminary Assessment of Abdominal Wall Tension in Patients Undergoing Retromuscular Hernia Repair

A common technique for ventral and incisional hernia repair is the retrorectus repair (Rives-Stoppa). The posterior rectus sheath is incised bilaterally, and mesh is placed retromuscularly. There is little information on how this component separation technique affects abdominal wall tension. We evaluated abdominal wall tension in patients undergoing retrorectus repair of abdominal wall hernias. Patients undergoing retrorectus repair of their ventral hernias were enrolled in a prospective, Institutional Review Board-approved protocol to measure abdominal wall tension from 8/1/2013 to 8/2/2017. Demographic information and operative details were documented. Abdominal wall tensions were measured using scales attached to Kocher clamps that were clamped to the fascia and brought together in the midline. Measurements were made before and after incising the posterior rectus sheaths. Data were analyzed with a repeated measures analysis of variance (ANOVA), and differences between individual groups were analyzed by least square differences. Forty-five patients had tension measurements. Average age was 58 years (range 29-81)-78% Caucasian, 51% female, an average body mass index (BMI) of 35 kg/m2 (range 20-62), and 38% recurrent hernias. The average hernia defect was 121.9 cm2, and the average mesh size was 607.8 cm2. There was a significant reduction in tension after bilateral posterior rectus sheath incision (3.1 lbs vs. 5.6 lbs, p<0.0001). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair with retrorectus repair. Transection of the posterior rectus sheath decreases tension during hernia repair and may help guide surgeons regarding when to use this procedure.

Hernia prevention: practice patterns and surgeons' attitudes about abdominal wall closure and the use of prophylactic mesh

PURPOSE

The penetration of hernia prevention techniques into surgical practice remains unknown.

METHODS

A survey about knowledge/attitudes on hernia prevention was sent to the members of hernia societies.

RESULTS

The 497 respondents were mostly from the US (47%) or Europe (40%). Most reported practicing, but not measuring their suture-to-wound length closure of > 4:1 (63%) and practicing but not measuring the number of stitches (58%). Reasons for not using short stitch closure were: does not apply to patient population (19%), not familiar enough with methods to correctly execute (25%), takes too long (13%), not reimbursed (4%), concerned about closure-related complications (27%), and other (22%). Regarding prophylactic mesh, respondents stated they were not familiar with literature (11%), familiar with literature but would not use (24%), familiar with literature and interested in use (45%), familiar with literature and using (15%), and other (5%).

CONCLUSIONS

There appears to be some application of hernia prevention principles related to fascial closure; however, the use of prophylactic mesh still appears to be controversial.

Rationale and Technique for Measuring Abdominal Wall Tension in Hernia Repair

We describe a method to measure abdominal wall tension during hernia surgery and evaluate a possible correlation between hernia defect width and abdominal wall tension. After Institutional Review Board approval and informed consent, a prospective trial to measure intra-abdominal tension was undertaken (May 2013 through March 2017). Tension measurements were obtained using tensiometers. Total tension, hernia defect width, and surgeon's estimation of tension were recorded. Correlation between defect width and total abdominal wall tension was assessed using multivariate analysis and a multiple linear regression analysis. An r-squared value > 0.6 was considered significant. Fifty-nine patients underwent hernia repair with concomitant tension measurements obtained at surgery. The average patient age was 61 years (range 29–81 years), 85 per cent were white, and 56 per cent female. The average total tension was 6.7 pounds (range 0.2–22 pounds) and average defect width was 8.6 cm (range 2–25 cm). The surgeon rated the fascia to be excellent in 15 per cent, good in 58 per cent, and fair in 27 per cent. The average estimation of tension by the surgeon was 5 pounds (range 2–10 pounds). We found no correlation between hernia defect size and total abdominal wall tension and no correlation between the surgeon-estimated tension and objectively measured tension. We found no correlation between the width of the hernia defect and tension associated with approximating the midline. Further study regarding the practicality and usefulness of abdominal wall tension measurements during hernia surgery is needed.

Rationale and Technique for Measuring Abdominal Wall Tension in Hernia Repair

We describe a method to measure abdominal wall tension during hernia surgery and evaluate a possible correlation between hernia defect width and abdominal wall tension. After Institutional Review Board approval and informed consent, a prospective trial to measure intraabdominal tension was undertaken (May 2013 through March 2017). Tension measurements were obtained using tensiometers. Total tension, hernia defect width, and surgeon's estimation of tension were recorded. Correlation between defect width and total abdominal wall tension was assessed using multivariate analysis and a multiple linear regression analysis. An r-squared value > 0.6 was considered significant. Fifty-nine patients underwent hernia repair with concomitant tension measurements obtained at surgery. The average patient age was 61 years (range 29-81 years), 85 per cent were white, and 56 per cent female. The average total tension was 6.7 pounds (range 0.2-22 pounds) and average defect width was 8.6 cm (range 2-25 cm). The surgeon rated the fascia to be excellent in 15 per cent, good in 58 per cent, and fair in 27 per cent. The average estimation of tension by the surgeon was 5 pounds (range 2-10 pounds). We found no correlation between hernia defect size and total abdominal wall tension and no correlation between the surgeon-estimated tension and objectively measured tension. We found no correlation between the width of the hernia defect and tension associated with approximating the midline. Further study regarding the practicality and usefulness of abdominal wall tension measurements during hernia surgery is needed.

Prophylactic mesh used in ileal conduit formation following radical cystectomy: a retrospective cohort

PURPOSE

Given the difficulty of durable repairs, there is continued interest in hernia prevention. One emerging prevention technique for parastomal hernias is prophylactic mesh placement, whereby mesh is inserted during the index procedure as hernia prophylaxis. We evaluated our experience using prophylactic mesh when creating an ileal conduit.

METHODS

We retrospectively reviewed patients undergoing robotic cystectomy with ileal conduit from 6/2010 to 8/2017. Patient demographics and operative/perioperative outcomes were documented. We evaluated hernia recurrence using postoperative computed tomography scanning or physical exam. Prophylactic mesh was inserted at the operating surgeon's discretion using a synthetic resorbable or biologic mesh.

RESULTS

During the study period, 38 patients underwent robotic-assisted cystectomy with ileal conduit formation. Average patient age was 68 years, with 28 (74%) male and 35 (92%) Caucasian patients. Three patients (8%) required conversion to open, and one patient (3%) had a concomitant colorectal resection. Thirty-one (88%) patients had postoperative computed tomography scanning. Prophylactic mesh was used in 18 patients (47%) in a retrorectus position. Of these, 15 (83%) patients had synthetic resorbable mesh and 3 (17%) patients had biologic mesh. At average follow-up of 21 months, one hernia recurred (5%) in a patient without mesh placement at the time of ileal conduit. At an average follow-up of 11 months, there have been no recurrences and no mesh-related complications in the prophylactic mesh group.

CONCLUSIONS

Using prophylactic mesh in ileal conduit, creation is feasible and may decrease the parastomal hernia formation rate. Further study of using synthetic resorbable and biologic meshes for hernia prophylaxis is warranted.

Pharmacodynamics of teicoplanin against MRSA

Objectives

The overall study aim was to identify the relevant preclinical teicoplanin pharmacokinetic (PK)/pharmacodynamic (PD) indices to predict efficacy and suppression of resistance in MRSA infection.

Methods

A hollow-fibre infection model and a neutropenic murine thigh infection model were developed. The PK/PD data generated were modelled using a non-parametric population modelling approach with Pmetrics. The posterior Bayesian estimates derived were used to study the exposure-effect relationships. Monte Carlo simulations from previously developed population PK models in adults and children were conducted to explore the probability of target attainment (PTA) for teicoplanin dosage regimens against the current EUCAST WT susceptibility range.

Results

There was a concentration-dependent activity of teicoplanin in both the in vitro and in vivo models. A total in vivo AUC/MIC of 610.4 (total AUC of 305.2 mg·h/L) for an MRSA strain with an MIC of 0.5 mg/L was needed for efficacy (2 log10 cell kill) against a total bacterial population. A total AUC/MIC ratio of ∼1500 (total AUC of ∼750 mg·h/L) was needed to suppress the emergence of resistance. The PTA analyses showed that adult and paediatric patients receiving a standard regimen were only successfully treated for the in vivo bactericidal target if the MIC was ≤0.125 mg/L in adults and ≤0.064 mg/L in children.

Conclusions

This study improves our understanding of teicoplanin PD against MRSA and defines an in vivo AUC/MIC target for efficacy and suppression of resistance. Additional studies are needed to further corroborate the PK/PD index in a variety of infection models and in patients.

Role of Prophylactic Mesh Placement for Laparotomy and Stoma Creation

Incisional and parastomal hernias are a cause of significant morbidity and have a substantial effect on quality of life and economic costs for patients and hospital systems. Although many aspects of abdominal hernias are understood, prevention is a feature that is still being realized. This article reviews the current literature and determines the utility of prophylactic mesh placement in prevention of incisional and parastomal hernias.

Pharmacodynamics of Isavuconazole for Invasive Mold Disease: Role of Galactomannan for Real-Time Monitoring of Therapeutic Response

Background.

The ability to make early therapeutic decisions when treating invasive aspergillosis using changes in biomarkers as a surrogate for therapeutic response could significantly improve patient outcome.

Methods.

Cox proportional hazards model and logistic regression were used to correlate early changes in galactomannan index (GMI) to mortality and overall response, respectively, from patients with positive baseline GMI (≥0.5) and serial GMI during treatment from a phase 3 clinical trial for the treatment of invasive mold disease. Pharmacokinetic/pharmacodynamic (PK/PD) analysis in patients with isavuconazole plasma concentrations was conducted to establish the exposure necessary for GMI negativity at the end of therapy.

Results.

The study included 158 patients overall and 78 isavuconazole patients in the PK/PD modeling. By day 7, GMI increases of >0.25 units from baseline (3/130 survivors; 9/28 who died) significantly increased the risk of death compared to those with no increase or increases <0.25 (hazard ratio, 9.766; 95% confidence interval [CI], 4.356–21.9; P < .0001). For each unit decrease by day 7 from baseline, the odds of successful therapy doubled (odds ratio, 2.154; 95% CI, 1.173–3.955). An area under the concentration-versus-time curve over half-maximal effective concentration (AUC:EC₅₀) of 108.6 is estimated to result in a negative GMI at the end of isavuconazole therapy.

Conclusions.

Early trends in GMI are highly predictive of patient outcome. GMI increases by day 7 could be considered in context of clinical signs to trigger changes in treatment, once validated. Our data suggest that this improves survival by 10-fold and positive outcome by 3-fold. These data have important implications for individualized therapy for patients and clinical trials.

Clinical Trials Registration.

NCT00412893.

Incisional Hernia in the United States: Trends in Hospital Encounters and Corresponding Healthcare Charges

Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.

Incisional Hernia in the United States: Trends in Hospital Encounters and Corresponding Healthcare Charges

Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.

Clinical and Patient-Reported Outcomes after Absorbable Strap Fixation for Ventral Hernia Repair

INTRODUCTION

Various mesh fixation methods are employed by surgeons during ventral hernia repair. These may include tacks, straps, sutures, glue, or a combination of methods. One of these choices is an absorbable fixation device, Securestrap® (Ethicon Inc., Somerville, New Jersey), consisting of an absorbable copolymer barbed U-shaped strap with a spring-loaded deployment system.

MATERIALS AND METHODS

The International Hernia Mesh Registry is a prospective multi-center registry, designed to collect longitudinal data on hernia repair methods, products, and outcomes. Patients complete the Carolinas Comfort Scale™ (CCS) (The Charlotte-Mecklenburg Hospital Authority, Charlotte, North Carolina) pre-operatively, and at one month, six months, and 12 months post-operatively. Symptomatic patients defined as responding >1 to any CCS™ question. Statistical comparison of symptom frequency was made with the McNemar test and Kaplan Meier methods to determine the recurrence rate up to 365 days.

RESULTS

Patients were enrolled at 16 centers. Data was available on 100 of the 203 patients at six months and on 119 patients at 12 months. Demographics: mean age of 52.7 (13.2 standard deviation[ SD]); mean body mass index (BMI) of 33.2 (7.5 SD) kg/m2; 64.3% having a BMI over 30kg/m2; male patients 47.4%; 16.7% for recurrent hernias. Mesh fixation with straps alone in 48.3% of cases or straps and sutures in 51.7% of cases. Percentage of patients with symptomatic pain decreased slightly from baseline to one month (70.0 vs. 60.6, p=0.0782) and significantly from one month to six months (60.6% symptomatic vs. 23.2%; p=0.0004). From six months to twelve months, the change in percentage of symptomatic patients was not significant (23.2% vs. 28.7%; p=0.8084). Similar results were observed with symptomatic CCS™ movement limitations. Overall recurrence rate at 12 months was 4.72% (2.39%-9.22%).

CONCLUSION

Mesh fixation with straps with or without additional sutures is associated with significant improvements in patient-reported pain and movement limitation from baseline to six months post-operative.

Exposure-Response Relationships for Isavuconazole in Patients with Invasive Aspergillosis and Other Filamentous Fungi

Isavuconazole, the active moiety of the water-soluble prodrug isavuconazonium sulfate, is a triazole antifungal agent for the treatment of invasive fungal infections. The purpose of this analysis was to characterize the isavuconazole exposure-response relationship for measures of efficacy and safety in patients with invasive aspergillosis and infections by other filamentous fungi from the SECURE clinical trial. Two hundred thirty-one patients who received the clinical dosing regimen and had exposure parameters were included in the analysis. The primary drug exposure parameters included were predicted trough steady-state plasma concentrations, predicted trough concentrations after 7 and 14 days of drug administration, and area under the curve estimated at steady state (AUCss). The exposure parameters were analyzed against efficacy endpoints that included all-cause mortality through day 42 in the intent-to-treat (ITT) and modified ITT populations, data review committee (DRC)-adjudicated overall response at end of treatment (EOT), and DRC-adjudicated clinical response at EOT. The safety endpoints analyzed were elevated or abnormal alanine aminotransferase, increased aspartate aminotransferase, and a combination of the two. The endpoints were analyzed using logistic regression models. No statistically significant relationship (P > 0.05) was found between isavuconazole exposure and either efficacy or safety endpoints. The lack of association between exposure and efficacy indicates that the isavuconazole exposures achieved by clinical dosing were appropriate for treating the infecting organisms in the SECURE study and that increases in alanine or aspartate aminotransferase were not related to increase in exposures. Without a clear relationship, there is no current clinical evidence for recommending routine therapeutic drug monitoring for isavuconazole.