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.

Negative Pressure Wound Therapy for Surgical-site Infections: A Randomized Trial.

OBJECTIVE: This study seeks to evaluate the efficacy of negative pressure wound therapy for surgical-site infection (SSI) after open pancreaticoduodenectomy. BACKGROUND: Despite improvement in infection control, SSIs remain a common cause of morbidity after abdominal surgery. SSI has been associated with an increased risk of reoperation, prolonged hospitalization, readmission, and higher costs. Recent retrospective studies have suggested that the use of negative pressure wound therapy can potentially prevent this complication. METHODS: We conducted a single-center randomized, controlled trial evaluating surgical incision closure during pancreaticoduodenectomy using negative pressure wound therapy in patients at high risk for SSI. We randomly assigned patients to receive negative pressure wound therapy or a standard wound closure. The primary end point of the study was the occurrence of a postoperative SSI. We evaluated the economic impact of the intervention. RESULTS: From January 2017 through February 2018, we randomized 123 patients at the time of closure of the surgical incision. SSI occurred in 9.7% (6/62) of patients in the negative pressure wound therapy group and in 31.1% (19/61) of patients in the standard closure group (relative risk = 0.31; 95% confidence interval, 0.13-0.73; P = 0.003). This corresponded to a relative risk reduction of 68.8%. SSIs were found to independently increase the cost of hospitalization by 23.8%. CONCLUSIONS: The use of negative pressure wound therapy resulted in a significantly lower risk of SSIs. Incorporating this intervention in surgical practice can help reduce a complication that significantly increases patient harm and healthcare costs.

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.

Long-term outcomes of sandwich ventral hernia repair paired with hybrid vacuum-assisted closure.

BACKGROUND: Sandwich ventral hernia repair (SVHR) may reduce ventral hernia recurrence rates, although with an increased risk of surgical site occurrences (SSOs) and surgical site infections (SSIs). Previously, we found that a modified negative pressure wound therapy (hybrid vacuum-assisted closure [HVAC]) system reduced SSOs and SSIs after ventral hernia repair. We aimed to describe our outcomes after SVHR paired with HVAC closure. METHODS: We conducted a 4-y retrospective review of all complex SVHRs (biologic mesh underlay and synthetic mesh overlay) with HVAC closure performed at our institution by a single surgeon. All patients had fascial defects that could not be reapproximated primarily using anterior component separation. Descriptive statistics were used to report the incidence of postoperative complications and hernia recurrence. RESULTS: A total of 60 patients (59.3 ± 11.4 y, 58.3% male, 75% American Society of Anesthesiologists class ≥3) with complex ventral hernias being underwent sandwich repair with HVAC closure. Major postoperative morbidity (Dindo-Clavien class ≥3) occurred in 14 (23.3%) patients, but incidence of SSO (n = 13, 21.7%) and SSI (n = 4, 6.7%) was low compared with historical reports. Median follow-up time for all patients was 12 mo (interquartile range 5.8-26.5 mo). Hernia recurrence occurred in eight patients (13.3%) after a median time of 20.6 months (interquartile range 16.4- 25.4 months). CONCLUSIONS: Use of a dual layer sandwich repair for complex abdominal wall reconstruction is associated with low rates of hernia recurrence at 1 year postoperatively. The addition of the HVAC closure system may reduce the risk of SSOs and SSIs previously reported with this technique and deserves consideration in future prospective studies assessing optimization of ventral hernia repair approaches.

Early hospital readmission for gastrointestinal-related complications predicts long-term mortality after pancreatectomy.

BACKGROUND: The purpose of this study was to investigate the prognostic significance of early (30-day) hospital readmission (EHR) on mortality after pancreatectomy. METHODS: Using a prospectively collected institutional database linked with a statewide dataset, we evaluated the association between EHR and overall mortality in all patients undergoing pancreatectomy at our tertiary institution (2005 to 2010). RESULTS: Of 595 pancreatectomy patients, EHR occurred in 21.5%. Overall mortality was 29.4% (median follow-up 22.7 months). Patients with EHR had decreased survival compared with those who were not readmitted (P = .011). On multivariate analysis adjusting for baseline group differences, EHR for gastrointestinal-related complications was a significant independent predictor of mortality (hazard ratio 2.30, P = .001). CONCLUSIONS: In addition to known risk factors, 30-day readmission for gastrointestinal-related complications following pancreatectomy independently predicts increased mortality. Additional studies are necessary to identify surgical, medical, and social factors contributing to EHR, as well as interventions aimed at decreasing postpancreatectomy morbidity and mortality.

Negative-Pressure Wound Therapy in the Management of High-Grade Ventral Hernia Repairs.

BACKGROUND: Despite improved operative techniques, open ventral hernia repair (VHR) surgery in high-risk, potentially contaminated patients remains challenging. As previously reported by our group, the use of a modified negative-pressure wound therapy system (hybrid-VAC or HVAC) in patients with grade 2 hernias is associated with lower surgical site occurrence (SSO) and surgical site infection (SSI) rates. Accordingly, the authors aim to evaluate whether the HVAC would similarly improve surgical site outcomes following VHR in patients with grade 3 hernias. METHODS: A 4-year retrospective review (2011-2014) was conducted of all consecutive, modified ventral hernia working group (VHWG) grade 3 hernia repairs with HVAC closure performed by a single surgeon (FEE) at a single institution. Operative data and 90-day outcomes were evaluated. Overall outcomes (e.g., recurrence, reoperation, mortality) were reviewed for the study group. RESULTS: A total of 117 patients with an average age of 56.7 ± 11.9 years were classified as grade 3 hernias and underwent open VHR with subsequent HVAC closure. Fifty patients were male (42.7 %), the mean BMI was 35.2 (±9.5), and 60.7 % had a history of prior hernia repair. The average fascial defect size was 201.5 (±167.3) cm(2) and the mean length of stay was 14.2 (±9.3) days. Ninety-day outcomes showed an SSO rate of 20.7 % and an SSI rate of 5.2 %. The overall hernia recurrence rate was 4.2 % (n=6) with a mean follow-up of 11 ± 7.3 months. CONCLUSION: Modified VHWG grade 3 ventral hernias are associated with significant morbidity. In our series utilizing the HVAC system after VHR, the observed rate of SSO and SSI compared favorably to reported series. Further prospective cost-effective studies are warranted to validate these findings.

What is the Significance of Indeterminate Pulmonary Nodules in Patients Undergoing Resection for Pancreatic Adenocarcinoma?

OBJECTIVE: The significance of indeterminate pulmonary nodules (IPNs) in patients undergoing resection of pancreatic ductal adenocarcinoma (PDAC) is unknown. We sought to define the prevalence and impact of IPN in such patients. METHODS: We studied all patients who underwent surgical resection of PDAC between 1980 and 2013. IPN was defined as ≥1 well-defined lung nodule(s) less than 3 cm in diameter. Survival was assessed using univariate and multivariate Cox models. RESULTS: Of the 2306 resected patients, 374 (16.2 %) had a preoperative chest computed tomography (CT) scan. Of these patients, 183 (49 %) had ≥1 IPN. Demographic and clinicopathological characteristics were similar among patients with or without IPN (all P>0.05). Median survival was comparable among patients who did (15.6 months) or did not (18.0 months) have IPN (P=0.66). Of the 183 patients with IPN, 29 (16 %) progressed to clinically recognizable metastatic lung disease compared to 13 % without IPN (P=0.38). The presence of >1 IPN was associated with the development of lung metastasis (relative risk 1.58, 95 % CI 1.03-2.4; P=0.05). However, lung metastasis was not associated with survival (P=0.24). CONCLUSIONS: An IPN proved to be a lung metastasis in only one of six patients with PDAC undergoing surgical resection in this study. Survival was not impacted, even among patients who developed lung metastasis. Patients with PDAC who have IPN should not be precluded from surgical consideration.

Functional abdominal wall reconstruction using an innervated abdominal wall vascularized composite tissue allograft: a cadaveric study and review of the literature.

BACKGROUND: Large, composite abdominal wall defects represent complex problems requiring a multidisciplinary approach for reconstruction. Abdominal wall vascularized composite allotransplantation (AW-VCA) has been successfully performed in 21 patients, already receiving solid organ transplants, to provide immediate abdominal closure. The current study aims to establish a novel anatomic model for AW-VCA that retains motor and sensory function in an effort to preserve form and function while preventing complications. METHODS: Three fresh cadaver torsos were obtained. Dissection was started in the midaxillary line bilaterally through the skin and subcutaneous fascia until the external oblique was encountered. The thoracolumbar nerves were identified and measurements were obtained. A peritoneal dissection from the costal margin to pubic symphysis was performed and the vascular pedicle was identified for subsequent microsurgical anastomosis. RESULTS: The mean size of the abdominal wall graft harvested was 615 ± 120 cm(2). The mean time of abdominal wall procurement was ∼150 ± 12 minutes. The mean number of thoracolumbar nerves identified was 5 ± 1.4 on each side. The mean length of the skeletonized thoracolumbar nerves was 7.8 ± 1.7 cm. The cross-sectional diameter of all nerves as they entered the rectus abdominis was greater than 2 mm. CONCLUSIONS: Motor function and sensory recovery is expected in other forms of vascularized composite allotransplantation, such as the hand or face; however, this has never been tested in AW-VCA. This study demonstrates feasibility for the transplantation of large, composite abdominal wall constructs that potentially retains movement, strength, and sensation through neurotization of both sensory and motor nerves.

Tracking early readmission after pancreatectomy to index and nonindex institutions: a more accurate assessment of readmission.

IMPORTANCE: Readmission after pancreatectomy is common, but few data compare patterns of readmission to index and nonindex hospitals. OBJECTIVES: To evaluate the rate of readmission to index and nonindex institutions following pancreatectomy at a tertiary high-volume institution and to identify patient-level factors predictive of those readmissions. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a prospectively collected institutional database linked to statewide data of patients who underwent pancreatectomy at a tertiary care referral center between January 1, 2005, and December 2, 2010. EXPOSURE: Pancreatectomy. MAIN OUTCOMES AND MEASURES: The primary outcome was unplanned 30-day readmission to index or nonindex hospitals. Risk factors and reasons for readmission were measured and compared by site using univariable and multivariable analyses. RESULTS: Among all 623 patients who underwent pancreatectomy during the study period, 134 (21.5%) were readmitted to our institution (105 [78.4%]) or to an outside institution (29 [21.6%]). Fifty-six patients (41.8%) were readmitted because of a gastrointestinal or nutritional problem related to surgery and 42 patients (31.3%) because of a postoperative infection. On multivariable analysis, factors independently associated with readmission included age 65 years or older (odds ratio [OR], 1.80; 95% CI, 1.19-2.71), preexisting liver disease (OR, 2.28; 95% CI, 1.23-4.24), distal pancreatectomy (OR, 1.77; 95% CI, 1.11-2.84), and postoperative drain placement (OR, 2.81; 95% CI, 1.00-7.14). CONCLUSIONS AND RELEVANCE: In total, 21.5% of patients required early readmission after pancreatectomy. Even in the setting of a tertiary care referral center, 21.6% of these readmissions were to nonindex institutions. Specific patient-level factors were associated with an increased risk of readmission.

Novel wound management system reduction of surgical site morbidity after ventral hernia repairs: a critical analysis.

BACKGROUND: Prophylactic incisional negative-pressure wound therapy use after ventral hernia repairs (VHRs) remains controversial. We assessed the impact of a modified negative-pressure wound therapy system (hybrid-VAC or HVAC) on outcomes of open VHR. METHODS: A 5-year retrospective analysis of all VHRs performed by a single surgeon at a single institution compared outcomes after HVAC versus standard wound dressings. Multivariable logistic regression compared surgical site infections, surgical site occurrences, morbidity, and reoperation rates. RESULTS: We evaluated 199 patients (115 HVAC vs 84 standard wound dressing patients). Mean follow-up was 9 months. The HVAC cohort had lower surgical site infections (9% vs 32%, P < .001) and surgical site occurrences (17% vs 42%, P = .001) rates. Rates of major morbidity (19% vs 31%, P = .04) and 90-day reoperation (5% vs 14%, P = .02) were lower in the HVAC cohort. CONCLUSIONS: The HVAC system is associated with optimized outcomes following open VHR. Prospective studies should validate these findings and define the economic implications of this intervention.

2564 resected periampullary adenocarcinomas at a single institution: trends over three decades.

OBJECTIVE: This study was carried out to determine relative survival rates and trends in outcomes in patients who underwent resection of periampullary adenocarcinomas (PACs) with curative intent at a single institution over the last three decades. METHODS: From 1980 to 2011, 2564 pancreaticoduodenectomies (PDs) were performed for PACs. Pathological diagnosis, therapy and survival were retrospectively analysed. RESULTS: The primary sites included the pancreas (66%), ampulla (16%), bile duct (12%) and duodenum (6%). Operation volume increased from 11 per year in the 1980s to 135 per year in the 2000s (P < 0.001). Patients in the 1980s were younger (median age: 64 years; range: 33-90 years) than those in the 1990s (median age: 68 years; range: 31-103 years) and 2000s (median age: 68 years; range: 24-93 years) (P < 0.001). Over time, the frequency of a diagnosis of pancreatic cancer arising from intraductal papillary mucinous neoplasm increased from 2% in the 1980s to 8% in the 2000s (P < 0.001). The rate of 30-day mortality after surgery in the 1980s was 2%, which was similar to rates in the 1990s (1%) and 2000s (1%). Survival in each type of PAC did not change over time. Pancreatic cancer was associated with the worst survival (median survival: 19 months) compared with adenocarcinomas of the ampulla (median survival: 47 months), bile duct (median survival: 23 months) and duodenum (median survival: 54 months) (P < 0.001). CONCLUSIONS: There are significant differences among PACs in longterm survival following PD. Although the numbers of patients undergoing safe resection have increased, overall longterm outcomes have not improved significantly.

Adenocarcinoma of the Ileal Conduit in a Patient Born With Classic Bladder Exstrophy.

Bladder exstrophy is a rare birth defect that typically requires patients to undergo multiple surgical procedures throughout the course of their childhood. Many ultimately undergo operations that use segments of bowel for the reconstruction and/or augmentation of the urinary tract, which imparts an increased risk of malignancy in these patients. We present the case of a 59-year-old man with a history of bladder exstrophy managed with ureterosigmoidostomies revised to an ileal conduit who developed a large adenocarcinoma in the ileal conduit that extended into small bowel, sigmoid colon, and ureter.

Superior mesenteric artery syndrome: spectrum of CT findings with multiplanar reconstructions and 3-D imaging.

OBJECTIVE: This article reviews the causes, clinical presentation, and CT diagnosis of superior mesenteric artery (SMA) syndrome. CONCLUSION: In conjunction with an appropriate clinical history, several CT findings can suggest the diagnosis of SMA syndrome. These findings include narrowing of the aortomesenteric angle and distance, distension of the stomach and duodenum, and dilatation of the left renal vein with left-sided venous collaterals.

Double Hamoudi: A case report.

INTRODUCTION: Solid pseudopapillary neoplasms are rare pancreatic neoplasms with low malignant potential and favorable prognosis that are typically seen in young women. PRESENTATION OF CASE: We report a case of two large solid pseudopapillary neoplasms in a 23-year old woman who was treated successfully with a total pancreatectomy. CONCLUSION: To the best of our knowledge, this is the first report of two discrete solid pseudopapillary neoplasms in the same patient.

Predicting the risk of perioperative mortality in patients undergoing pancreaticoduodenectomy: a novel scoring system.

OBJECTIVE: To develop and validate a risk score to predict the 30- and 90-day mortality after a pancreaticoduodenectomy or total pancreatectomy on the basis of preoperative risk factors in a high-volume program. DESIGN: Data from a prospectively maintained institutional database were collected. In a random subset of 70% of patients (training cohort), multivariate logistic regression was used to develop a simple integer score, which was then validated in the remaining 30% of patients (validation cohort). Discrimination and calibration of the score were evaluated using area under the receiver operating characteristic curve and Hosmer-Lemeshow test, respectively. SETTING: Tertiary referral center. PATIENTS: The study comprised 1976 patients in a prospectively maintained institutional database who underwent pancreaticoduodenectomy or total pancreatectomy between 1998 and 2009. MAIN OUTCOME MEASURES: The 30- and 90-day mortality. RESULTS: In the training cohort, age, male sex, preoperative serum albumin level, tumor size, total pancreatectomy, and a high Charlson index predicted 90-day mortality (area under the curve, 0.78; 95% CI, 0.71-0.85), whereas all these factors except Charlson index also predicted 30-day mortality (0.79; 0.68-0.89). On validation, the predicted and observed risks were not significantly different for 30-day (1.4% vs 1.0%; P = .62) and 90-day (3.8% vs 3.4%; P = .87) mortality. Both scores maintained good discrimination (for 30-day mortality, area under the curve, 0.74; 95% CI, 0.54-0.95; and for 90-day mortality, 0.73; 0.62-0.84). CONCLUSIONS: The risk scores accurately predicted 30- and 90-day mortality after pancreatectomy. They may help identify and counsel high-risk patients, support and calculate net benefits of therapeutic decisions, and control for selection bias in observational studies as propensity scores.

Obturator nerve transfer as an option for femoral nerve repair: case report.

OBJECTIVE: Nerve transfers have proved to be an important addition to the armamentarium in the repair of brachial plexus lesions, but have been used sparingly for lower extremity nerve repair. Here, we present what is believed to be the first description of a successful transfer of the obturator nerve to the femoral nerve. CLINICAL PRESENTATION: A 45-year-old woman presented with a complete femoral nerve lesion after removal of a large (15-cm) schwannoma of the retroperitoneum involving the lumbar plexus. INTERVENTION: The obturator nerve was transferred to the distal stump of the femoral nerve in the retroperitoneal space at the inguinal ligament three months post-injury. At 2 years post-repair, the patient demonstrated 4 out of 5 return (Medical Research Council grade) of quadriceps function and was able to walk nearly normally. CONCLUSION: In cases in which there are extensive gaps in the femoral nerve, transfer of the obturator nerve provides an option to traditional nerve graft repair.

Adjuvant therapy in pancreatic cancer: Phase I trial of radiation dose escalation with concurrent full-dose gemcitabine.

PURPOSE: To determine the maximal tolerated dose of radiation delivered to the primary tumor bed, in combination with full-dose gemcitabine (1000 mg/m(2) weekly x 3), after resection of pancreatic cancer. METHODS AND MATERIALS: Patients with resected pancreatic carcinoma and poor prognostic features, a positive resection margin, or involved lymph nodes were eligible. Radiotherapy (RT) was directed at the preoperative tumor volume with a conformal technique. Regional lymph node basins were not included. The initial starting radiation dose was 24 Gy in 1.6-Gy fractions. Escalation was achieved by increasing the fraction size in 0.2-Gy increments, keeping the duration of RT to 3 weeks. Gemcitabine was given i.v. for 30-40 min at a dose of 1000 mg/m(2) before RT on Days 1, 8, and 15 of a 28-day cycle. After completion of RT and chemotherapy, an additional cycle of gemcitabine was delivered. RESULTS: Between November 1997 and October 2001, 32 patients were entered: 30 after Whipple resection (positive margins in 2, positive nodes in 22, and both in 6), 1 after distal pancreatectomy, and 1 after incomplete resection of a tumor involving the body (both patients with positive margins and nodes). Treatment was well tolerated. Of the 32 patients, 27 completed all protocol therapy and 29 maintained their pretreatment weight within 5%. Five patients experienced dose-limiting toxicity, four with Grade 3 vomiting requiring hospitalization and one fatal toxicity secondary to pneumonia/sepsis. At the final radiation dose level (42 Gy), 2 patients experienced GI dose-limiting toxicity. At the 39-Gy-dose level, 5 of 6 patients were without dose-limiting toxicity. Isolated local or regional progression was documented in 1 patient. Distant progression was documented in 26 of 32 patients (6 with concurrent local or regional progression). The median survival was 16.5 months (95% confidence interval 12.3-19.9) CONCLUSION: The results of our study indicate that the maximal tolerated radiation dose, administered using conformal techniques targeted to the tumor bed, is 39 Gy. In this high-risk population, data on locoregional control suggest that the reduction in radiation dose and field size minimizes toxicity and does not result in excess failures at these sites.

Surgical resection following radiation therapy with concurrent gemcitabine in patients with previously unresectable adenocarcinoma of the pancreas.

The combination of gemcitabine with concurrent radiation therapy (Gem/RT) is a promising new approach that is being investigated in patients with unresectable pancreatic cancer. However, substantial toxicity with this combination has also been observed. This review was conducted to determine whether Gem/RT could be safely delivered in the neoadjuvant setting, based on our experience with this combined therapy in a cohort of patients with previously unresectable pancreatic cancer, who subsequently underwent surgical resection. Between July 1996 and June 2001, a total of 67 patients with locally unresectable pancreatic cancer, without distant metastatic disease, received Gem/RT at our institution. Seventeen patients (25%) underwent exploratory surgery following Gem/RT, and nine underwent standard Whipple resection. Thus 9 (52%) of 17 patients who had exploratory operations or 9 (13%) of 67 patients, underwent surgical resection. Thirty-day mortality after resection was 0%, and there were no major surgical complications. Median length of hospital stay was 14 days (range 11 to 19 days). With a median follow-up of 32 months, median survival for the resected patients was 17.6 months (95% confidence interval 12.6 to 37.3 months). Median survival for the remaining 58 patients was 11.9 months (95% confidence interval 9.6 to 14.7 months, P=0.013). We conclude that surgical resection may be safely performed after Gem/RT in a select group of patients initially considered to have unresectable pancreatic cancer. The use of Gem/RT in a neoadjuvant setting is currently being investigated in a multi-institutional phase II trial.