The Impact of Postoperative COVID-19 Infection on 30-day Outcomes of Laparoscopic Cholecystectomy.

Introduction: Preoperative Coronavirus Disease 2019 (COVID-19) infections are associated with postoperative adverse outcomes. However, there is limited data on the impact of postoperative COVID-19 infection on postoperative outcomes of common general surgery procedures.Objective: To evaluate the impact of postoperative COVID-19 diagnosis on laparoscopic cholecystectomy outcomes.Methods: Patients with symptomatic cholelithiasis, acute cholecystitis, or gallstone pancreatitis who underwent laparoscopic cholecystectomy with or without intraoperative cholangiogram were identified using the 2021 National Surgical Quality Improvement Program (NSQIP) database. Patients were categorized into two groups: patients with and without a postoperative COVID-19 diagnosis. Coarsened Exact Matching was used to match the groups based on preoperative risk factors, and outcomes were compared.Results: A total of 47,948 patients were included. In the aggregate cohort, 31% were male, and mean age was 50 years. Age, BMI, smoking, COPD, CHF, preoperative sepsis, and ASA class were significantly different between the two groups. After matching, there were no differences in characteristics. 30-day morbidity (OR = 2.7, 95% CI 1.4-5.1), pneumonia (OR = 5.0, 95% CI 1.7-15.0), DVT (OR = 8.22, 95% CI 1.0-66), reoperation (OR = 9.3, 95% CI 1.2-73.8), and readmission (OR = 4.8, 95% CI 2.3-10.1) continued to be significantly worse in the matched cohort.Conclusion: Postoperative COVID-19 infection was associated with worse outcomes after laparoscopic cholecystectomy. These findings suggest that even postoperative COVID-19 diagnosis increases the risk for adverse outcomes in patients recovering from laparoscopic cholecystectomy and may indicate that precautions should be taken and new COVID-19 infections even after surgery should be closely monitored.

Association of anesthetic modality and other variables on 1-year functional patency of cephalic-based arteriovenous fistulae.

OBJECTIVE: Some studies suggest that regional anesthesia provides better patency for arteriovenous fistula (AVF) for hemodialysis access as compared to local and general anesthesia. This study evaluates the impact of anesthetic modality on long term fistula function at 12 months. METHODS: A retrospective review of patients undergoing cephalic vein-based hemodialysis access in consecutive cases between 2014 and 2019 was conducted from five safety net hospitals. The primary endpoint was functional patency at 12 months. Subset analysis individually evaluated cephalic-based lower forearm and wrist vs upper arm AVFs. Bivariate and multivariate logistic regression models evaluated the relationship between anesthetic modality and fistula function at 12 months. RESULTS: There were 818 cephalic-based fistulas created during the study period. The overall 12-month functional patency rate was 78.7%, including an 81.3% patency for upper arm AVF and 73.3% for wrist AVF (P = .009). There was no statistically significant difference among patients with functional and nonfunctional AVFs at 12 months with respect to anesthetic modality when comparing regional, local, and general anesthesia (P = .343). Multivariate regression analysis identified that history of AVF/arteriovenous graft (odds ratio [OR], 0.24; P = .007), receiving intraoperative systemic anticoagulation (OR, 2.49; P < .001), and vein diameter (OR, 1.85; P = .039) as independently associated with AVF functional patency at 12 months. CONCLUSIONS: There was no association between anesthetic modality and functional patency of cephalic-based AVFs at 12 months. Further studies are needed to better define which patients may benefit from regional anesthesia.

Determination of Factors Associated with Upstage in Atypical Ductal Hyperplasia to Identify Low-Risk Patients Where Active Surveillance May be an Alternative.

BACKGROUND: Excision is routinely recommended for atypical ductal hyperplasia (ADH) found on core biopsy given cancer upstage rates of near 20%. Identifying a cohort at low-risk for upstage may avoid low-value surgery. Objectives were to elucidate factors predictive of upstage in ADH, specifically near-complete core sampling, to potentially define a group at low upstage risk. PATIENTS AND METHODS: This retrospective, cross-sectional, multi-institutional study from 2015 to 2019 of 221 ADH lesions in 216 patients who underwent excision or active observation (≥ 12 months imaging surveillance, mean follow-up 32.6 months) evaluated clinical, radiologic, pathologic, and procedural factors for association with upstage. Radiologists prospectively examined imaging for lesional size and sampling proportion. RESULTS: Upstage occurred in 37 (16.7%) lesions, 25 (67.6%) to ductal carcinoma in situ (DCIS) and 12 (32.4%) to invasive cancer. Factors independently predictive of upstage were lesion size ≥ 10 mm (OR 5.47, 95% CI 2.03-14.77, p < 0.001), pathologic suspicion for DCIS (OR 12.29, 95% CI 3.24-46.56, p < 0.001), and calcification distribution pattern (OR 8.08, 95% CI 2.04-32.00, p = 0.003, "regional"; OR 19.28, 95% CI 3.47-106.97, p < 0.001, "linear"). Near-complete sampling was not correlated with upstage (p = 0.64). All three significant predictors were absent in 65 (29.4%) cases, with a 1.5% upstage rate. CONCLUSIONS: The upstage rate among 221 ADH lesions was 16.7%, highest in lesions ≥ 10 mm, with pathologic suspicion of DCIS, and linear/regional calcifications on mammography. Conversely, 30% of the cohort exhibited all low-risk factors, with an upstage rate < 2%, suggesting that active surveillance may be permissible in lieu of surgery.

Association of race and ethnicity with initial surgical hemodialysis access type in a safety net system.

OBJECTIVES: Prior studies have found lower arteriovenous fistula (AVF) creation rates in Black and Hispanic patients. Whether this is due to health care disparities or other differences is unclear. Our objective was to evaluate the racial/ethnic differences in initial surgical access type within a high-volume, safety net system with predominantly Black and Hispanic populations. METHODS: A retrospective review of initial hemodialysis (HD) access in consecutive cases between 2014 and 2019 was conducted from all five safety net hospitals in a health care system that primarily treats underserved patients. Patient data collected included race, ethnicity, sex, comorbidities, and initial arteriovenous (AV) access type (AV fistula [AVF] vs AV graft [AVG]). The rates of cephalic vein-based AVF (CAVF; radiocephalic, brachiocephalic) were compared with basilic and brachial vein AVF (BAVF), because the latter are performed as two stages. Bivariate and multivariate logistic regression models were adjusted for demographic and clinical variables to evaluate the relationship between race/ethnicity, surgical access type, and comorbid conditions. RESULTS: We included 1334 patients (74% Hispanic, 9% Black, 7% Asian, 2% White, 8% other) who underwent first-time surgical HD access creation. The majority were male (818 [63%]). Medical comorbidities were equal among groups, except for chronic obstructive pulmonary disease and stroke, which were higher in Black patients (P < .005 and P = .005, respectively). Overall, 1303 patients (98%) underwent AVF creation and 31 AVG creation (2%), with no difference between race/ethnicity in AVF vs AVG creation. Of the AVF cohort, 991 (76%) had a CAVF and 312 (24%) had a BAVF. Males were more likely than females to get a CAVF (65% vs 35%; P = .002). CONCLUSIONS: Within our safety net health system, where most patients are under-represented minorities, nearly all patients undergoing HD access had an AVF as their initial surgery with no difference in race/ethnicity. AVF type received differed by race, with Black patients twice as likely to undergo BAVF, which required two stages. Further studies are needed to identify the reasons for these differences.

Association of body mass index with morbidity following elective ventral hernia repair.

Background: Prior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes. Methods: Adults ≥ 18 years undergoing isolated, elective, primary VHR were identified using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest. Results: Of ~89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06-1.41), class II (AOR 1.42, 95%CI: 1.21-1.66), class III obesity (AOR 1.76, 95%CI: 1.49-2.09) and superobesity (AOR 2.25, 95 % CI: 1.71-2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was identified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay. Conclusion: BMI ≥ 32 is associated with greater morbidity following open, but not laparoscopic VHR. The relevance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving outcomes, and optimizing care. Key message: Body mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall complications following open VHR, though this association is not observed in operations performed laparoscopically.

Association of Laparoscopic Approach With Improved Short-Term Outcomes in Patients With Hematologic Malignancy Undergoing Splenectomy.

BACKGROUND: Patients with hematologic malignancies undergo splenectomy for both diagnostic and therapeutic purposes. Although minimally invasive surgery continues to be increasingly utilized for a variety of abdominal operations, no large-scale data has compared the postoperative outcomes for laparoscopic vs open splenectomy in patients with hematologic malignancy. METHODS: Patients with a diagnosis of hematologic malignancy who underwent laparoscopic and open splenectomy between 2015 and 2020 were queried using the ACS-NSQIP database. 30-day outcomes of laparoscopic vs open splenectomy were compared. RESULTS: Out of 430 patients included in the study, 52.6% were male, with a mean age of 63.4 ± 13.1 years. 233 patients (54.2%) underwent laparoscopic splenectomy. On bivariate analysis, laparoscopic surgery was associated with lower rates of 30-day mortality [2.1% vs 11.7% (P < .001)] and morbidity [9.0% vs 24.4% (P < .001)]. On multivariate regression, elective operations (OR .255, 95%CI: 0.084-.778, P = .016) and laparoscopic surgery (OR .239, 95%CI: 0.075-.760, P = .015) were independently associated with lower mortality, while history of metastatic cancer (OR 3.331, 95%CI: 1.144-9.699, P = .027) was associated with higher mortality. Laparoscopic surgery (OR .401, 95%CI: 0.209-.770, P = .006) and steroid use (OR 2.714, 95%CI: 1.279-5.757, P = .009) were the only two factors independently associated with 30-day morbidity. Laparoscopic surgery was also associated with shorter hospital length of stay (median 3 [IQR:3] vs 6 [IQR:7] days). CONCLUSION: Laparoscopic splenectomy was associated with lower 30-day mortality and morbidity, and shorter length of stay in patients with hematologic malignancies. These data suggest that laparoscopic approach, when feasible, may be preferred for splenectomy in this patient population.

Racial Disparities in Surgical Outcomes of Acute Diverticulitis: Have We Moved the Needle?

INTRODUCTION: There has been increasing national attention on reducing healthcare disparities. Prior studies cite worse surgical outcomes and less use of laparoscopy for Black patients with diverticulitis. Re-evaluation of these disparities is lacking despite national initiatives to improve health equity. This study aimed to evaluate the association of race with short-term outcomes and surgical approaches in patients with acute diverticulitis. METHODS: The National Surgical Quality Improvement Program database was queried for patients who underwent nonelective surgery for acute diverticulitis from 2015 to 2019. Severity of presentation, morbidity, mortality, surgical approach, and ostomy creation were compared by race. RESULTS: Of the 13,996 patients included in the study, 82.4% were White, 7.6% were Black, 1.1% Asian, 0.61% American Indian/Alaska Native, and 0.20% Native Hawaiian/Pacific Islander (NH/PI). Overall 30-day morbidity was 44.3% and 30-day mortality was 3.9%. In a multivariate logistic regression analysis, compared to Whites, Black race was independently associated with higher 30-day morbidity (Odds Ratio: 1.24, 95% confidence interval: 1.07-1.43, P = 0.003) and NH/PI race was independently associated with higher mortality (Odds Ratio: 5.35, 95% confidence interval: 1.32-21.6, P = 0.019). There was no difference in complicated disease (abscess or perforation), use of laparoscopy, or ostomy creation among races. CONCLUSIONS: Despite national efforts to achieve equity in healthcare, disparities persist in surgical outcomes for those with diverticulitis. Black and NH/PI race are independently associated with increased morbidity and mortality, respectively. Use of laparoscopy, however, is no longer different by race suggesting some gaps may be closing.

Post-Mastectomy Patients in an Urban Safety-Net Hospital: How Do Safety-Net Hospital Breast Reconstruction Rates Compare to National Breast Reconstruction Rates?

BACKGROUND: Breast reconstruction (BR) has documented psychological benefits following mastectomy. Yet, racial/ethnic minority groups have lower reported rates of BR. We sought to evaluate the rate, type, and outcome of BR in a racially and ethnically diverse population within a safety-net hospital system. METHODS: All patients who underwent mastectomy between October 2015 and July 2019 at Harbor-UCLA Medical Center were retrospectively examined. Rates and type of BR were analyzed according to patient characteristics (race/ethnicity, age, and body mass index), smoking status, cancer stage, and presence of diabetes mellitus. Breast reconstruction outcomes were also assessed. RESULTS: Of the 259 patients that underwent mastectomy, 87 (33.6%) received BR. Immediate BR was performed in 79 (30.5%) patients and delayed BR in 8 (3.1%). Of the 79 patients with immediate BR, 58 (73.4%) received implant-based BR and 21 (26.5%) autologous tissue. The BR failure rate was 10%, all implant-based. Increasing age and smoking negatively impacted BR rates. Black (P =.331) and Hispanic (P =.132) ethnicity were not independent predictors of decreased breast reconstruction. CONCLUSION: This study demonstrated that the rate, type, and quality of BR in this integrated safety-net hospital within a diverse population are comparable to national rates. When made available, historically underrepresented minority patients of Black and Hispanic ethnicity utilize BR.

Impact of Automated Reminder Calls in a Safety-Net Setting on Surgical Clinic No-Show Rates.

In surgical clinics, missed appointments may lead to delayed diagnosis and postponed surgical intervention. Automated reminder calls (robocalls) have replaced live staff phone calls in many systems as a cost-saving measure. This study aims to evaluate whether robocalls reduced the outpatient appointment no-show rate for surgical patients in a county hospital. Demographic and clinic data from two surgical clinics at a safety net hospital were collected over two time periods: 3-months immediately before robocalls went live and 3-months immediately after robocalls went live. No-show rates were compared between time periods. Multivariate analysis confirmed that robocalls were independently associated with reduced no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .032). In addition, new appointments were independently predictive of higher no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .048). Robocalls appear to be an effective tool for improving appointment attendance overall. Furthermore, robocalls may free limited staff to perform higher value work in the healthcare system.

Predictors of poor outcomes after cholecystectomy in gallstone pancreatitis: NSQIP analysis of 30-day morbidity and mortality.

BACKGROUND: Contemporary nationwide outcomes of gallstone pancreatitis (GSP) managed by cholecystectomy at the index hospitalization are limited. This study aims to define the rate of 30-day morbidity and mortality and identify associated perioperative risk factors in patients undergoing cholecystectomy for GSP. METHODS: Patients from the ACS-NSQIP database with GSP without pancreatic necrosis, who underwent cholecystectomy during the index hospitalization from 2017 to 2019 were selected. Factors associated with 30-day morbidity and mortality were analyzed. RESULTS: Of the 4021 patients identified, 1375 (34.5%) were male, 2891 (71.9%) were White, 3923 (97.6%) underwent laparoscopic surgery, and 52.4 years (SD ± 18.9) was the mean age. There were 155 (3.8%) patients who developed morbidity and 15 (0.37%) who died within 30 days of surgery. In bivariate regression analysis, both 30-day morbidity and mortality were associated with older age, elevated pre-operative BUN, hypertension, chronic obstructive pulmonary disease, congestive heart failure, acute kidney injury, and dyspnea. ASA of I or II and laparoscopic surgery were protective against 30-day morbidity and mortality. In multivariable regression analysis, factors independently associated with increased 30-day morbidity included preoperative SIRS/sepsis [OR: 1.68 (95% CI: 1.01-2.79), p = 0.048], and age [OR: 1.03 (95% CI: 1.01-1.04), p = 0.001]. Factors associated with increased 30-day mortality included tobacco use [OR: 8.62 (95% CI: 2.11-35.19), p = 0.003] and age [OR: 1.10 (95% CI: 1.04-1.17), p = 0.002]. CONCLUSIONS: Patients with GSP without pancreatic necrosis can undergo cholecystectomy during the index admission with very low risk of 30-day morbidity or mortality.

Music in the Operating Room: Comparing the Opinions of Surgeons, Anesthesiologists, and Nurses.

BACKGROUND: Music is part of operating room (OR) culture; however, some personnel may perceive music as a distraction. METHODS: A single institution survey of surgeons (SURG), anesthesia (ANES), and nursing (NURS) regarding attitudes on music in the OR. RESULTS: There were 222 responses (67% response rate) agreeing that music in the OR should be allowed (91%), is calming (75%), and helps with focus (63%). Most did not feel music was distracting (63%) or unsafe (80%). SURG were more likely to state that surgeons should decide (46.7%) if music should be played, whereas ANES and NURS (81%) were more likely to feel decisions should be made collaboratively (P < .001). CONCLUSION: Most OR personnel feel positively towards music. Surgeons were more likely to believe the decision to play music should be the surgeon's choice. The majority of OR staff agreed with collaborative decision-making, aligning with creating a safe OR culture.

Is laparoscopic surgery safe for elderly patients with diverticulitis? A national database study.

PURPOSE: Laparoscopy is the preferred approach to elective surgery for diverticulitis and is increasingly common in the emergent setting. Although diverticulitis is most prevalent among older adults, little is known about the safety of laparoscopy for elderly patients with diverticulitis. This study aims to compare 30-day outcomes of a laparoscopic versus open approach for diverticulitis among elderly patients undergoing elective and urgent/emergent surgery. METHODS: Patients ≥ 65 years who underwent surgery for diverticulitis from 2015 to 2019 were identified from the ACS-NSQIP database. Elective and non-elective groups were analyzed separately. Coarsened exact matching matched laparoscopic and open patients 1:1 based on preoperative factors to minimize selection bias by creating comparable cohorts. Short-term outcomes of laparoscopic versus open surgery were compared. RESULTS: A total of 15,316 patients were included, 69.2% female and 88% White, with a mean age of 72.7 ± 6.1 years. Approximately half (50.9%) of cases were laparoscopic and 60.6% were elective. After matching, laparoscopy was associated with lower 30-day morbidity in both the elective (OR, 0.47; 95%CI, 0.38-0.58) and non-elective (OR, 0.76; 95%CI, 0.58-0.98) cohorts. Laparoscopic surgery in both cohorts was associated with fewer surgical site infections (SSIs) (elective, OR 0.43; 95%CI, 0.33-0.57; non-elective, OR, 0.66; 95%CI, 0.44-0.98) and shorter length of stay (LOS) (elective, mean difference, 1.7 days; 95%CI, 1.5-1.9; non-elective, mean difference, 1.2 days; 95%CI, 0.43-2.1). CONCLUSION: Elderly patients undergoing both elective and non-elective laparoscopic surgery for diverticulitis have less 30-day morbidity, SSIs, and shorter LOS compared to an open approach. Therefore, laparoscopy for elderly patients is safe in elective surgery and in select emergent cases as well.

Should Robotic Surgery Training Become a General Surgery Residency Requirement? A National Survey of Program Directors in Surgery.

OBJECTIVE: Robotic-assisted surgery (RAS) accounts for 15% of general surgery (GS) operations performed and is set to grow in prevalence. Currently, there are no training requirements or standard robotic curricula for GS residents. This study aimed to query GS program directors (PDs) on the necessity, extent, and potential impact of including RAS as a required component of residency training. DESIGN: Analysis of responses to a 14-question web-based survey. SETTING: Survey was distributed to PDs via the Association of Program Directors in Surgery listserv in April and May 2021. PARTICIPANTS: General surgery program directors RESULTS: Among 140 respondents, 110 (78.6%) agreed that operating at the robotic console should be a GS residency requirement, yet 93 (66.4%) indicated that RAS exposure negatively impacts the acquisition of other necessary skills. Still, 116 (82.9%) agreed that RAS training provided a net benefit to GS residents, PDs at academic programs were more supportive than those at independent programs of RAS console training requirements (68.2% versus 46.7%, p = 0.048). The median response to the ideal proportion of abdominopelvic cases performed by graduation was 20% robotic, 40% laparoscopic, and 35% open. The suggested minimum number of robotic cases that should be performed by graduation was indicated to be 30 cases by 26% of respondents, 20 by 23%, 10 by 12%, 5 by 4%, and "no minimum" by 36%. CONCLUSIONS: There is strong interest among PDs to institute RAS training requirements for GS residents. This study provides PD perspectives to help inform national conversations on whether and to what extent RAS requirements should be included in GS residency training.

Early Cholecystectomy in Gallstone Pancreatitis Patients With and Without End Organ Dysfunction: A NQSIP Analysis.

INTRODUCTION: While literature widely supports early cholecystectomy for mild gallstone pancreatitis (GSP), this has not been reflected in clinical practice. Early cholecystectomy for GSP with end organ dysfunction remains controversial. OBJECTIVE: This study aims to evaluate the rate and outcomes of early cholecystectomy (<3 days from admission) in mild GSP patients with end organ dysfunction (+EOD) and without (-EOD). METHODS: Patients with GSP without necrosis were identified from 2017 to 2019 NSQIP database and categorized into GSP±EOD. Coarsened Exact Matching was used to match patients based on preoperative risk factors in each group, and outcomes were compared. RESULTS: There was a total of 3104 patients -EOD and 917 +EOD in the aggregate cohort. Early cholecystectomy was performed in 1520 (49.0%) of GSP-EOD and in 407 (44.4%) of GSP+EOD. In the matched cohorts, there were no significant differences in 30-day mortality, morbidity, or reoperation for early cholecystectomy in either group. In GSP-EOD, early cholecystectomy was associated with shorter LOS (2.9 ± 1.5 vs. 5.6 ± 3.0 days, P < .001), shorter operative time (69.7 ± 34.4 vs. 73.3 ± 36.6 min, P = .045), and more concurrent biliary procedures (52.1% vs. 35.4%, P < .001). Similarly, early cholecystectomy in GSP+EOD was associated with shorter LOS (3.3 ± 1.8 vs. 6.9 ± 6.6 days, P < .001), shorter operative time (65.9 ± 32.1 vs. 76.0 ± 40.7, P < .001), and more concurrent biliary procedure (46.0% vs. 34.9%, P = .002). CONCLUSIONS: This study supports early cholecystectomy in patients with mild GSP. Even with end organ dysfunction, early cholecystectomy appears to be safe given there is no difference in morbidity and mortality, and the potential benefit of reduced LOS.

Defining a Body Mass Index Threshold for Preventing Recurrence in Ventral Hernia Repairs.

INTRODUCTION: Body mass index (BMI) has been established as an independent risk factor for complications after abdominal hernia repairs. While various thresholds have been proposed, there is no consensus for an ideal BMI for elective hernia repair. OBJECTIVE: To identify the BMI threshold at which risk for hernia recurrence is significantly increased in patients undergoing ventral and incisional hernia repair. METHODS: This retrospective review of medical records included patients who underwent ventral or incisional hernia repairs from 2014 to 2020 at a single institution. Patients with hernia defects ≥4 cm were included. The primary outcome measure was hernia recurrence. Classification and Regression Tree (CART) analysis was used to determine the BMI threshold for recurrence. Bivariate and multivariate analyses were used to validate the threshold and to evaluate factors associated with recurrence. RESULTS: Of the 175 patients included, 9.1% had a recurrence. Classification and Regression Tree analysis identified BMI 35.3 kg/m2 as the critical threshold for hernia recurrence. In bivariate analysis, compared to patients who had no recurrence, patients with recurrence were more likely to have cirrhosis (12.5% vs 0%, P = .008), incarcerated hernias (75.0% vs 31.4%, P = .001), urgent surgery (75.0% vs 22.0%, P = <.001), biologic and no mesh use (25.0% vs 6.4% and 12.5% vs 5.7%, P = .012), and BMI >35.3 kg/m2 (75.0% vs 25.8%, P < .001). In multivariate regression, only BMI >35.3 kg/m2 was associated with recurrence [OR: 20.58 (95% CI: 2.17-194.87), P = .008]. CONCLUSION: Body mass index >35.3 kg/m2 was the only independent factor associated with hernia recurrence. This highlights the importance of determining a BMI threshold for patients undergoing ventral or incisional hernia repair.

Lower lymph node yield in axillary lymph node dissection specimens in breast cancer patients receiving neoadjuvant chemotherapy: Quality concern or treatment effect?

Axillary lymph node dissection (ALND) specimens should have at least ten-lymph nodes for examination according to established guidelines. Nonetheless, recent evidence suggests that neoadjuvant chemotherapy (NAC) results in fewer nodes in the specimen. We sought to examine if NAC patients have lower lymph node yield from ALND specimens and whether the number of lymph nodes in the specimen is correlated with pathologic complete response (pCR). Using the National Cancer Database (NCDB), a study cohort of female patients with node-positive, non-metastatic invasive breast cancer diagnosed from 2012 to 2015 was identified. The axillary lymph node retrieval count was compared in NAC and non-NAC patients and then correlated with pCR. A multivariable analysis was performed to identify factors that were associated with less than ten-lymph nodes in the ALND pathologic specimen. Of 56,976 patients identified, 27,197 (48%) received neoadjuvant chemotherapy; 29,779 (52%) did not. NAC patients failed to meet the ten-lymph node minimum in the ALND specimen more often than non-NAC patients (35% vs. 27%, p < 0.001). NAC patients with fewer than ten-lymph nodes were more likely to have a pCR than those with ten or more (22% vs. 16%, p < 0.001). On multivariable analysis, pCR of the primary tumor and receptor status were found to be independent predictors of having fewer than ten-lymph nodes in the ALND specimen. Node-positive breast cancer patients that underwent NAC were more likely to not meet the ten-lymph node standard. However, NAC patients who did not meet the minimum were also more likely to have a pCR compared to NAC patients who did. This suggests lower lymph node yield may not truly be a marker of lower quality surgery but rather a potential marker of NAC treatment effect.

Short Courses of Antibiotics Are Safe in Necrotizing Soft Tissue Infections.

INTRODUCTION: Necrotizing soft tissue infections (NSTIs) carry high morbidity and mortality. While early aggressive surgical debridement is well-accepted treatment for NSTIs, the optimum duration of adjunct antibiotic therapy is unclear. An increasing focus on safety and evidence-based antimicrobial stewardship suggests a value in addressing this knowledge gap. OBJECTIVE: To determine whether shorter antibiotic courses have similar outcomes compared to longer courses in patients with NSTI following adequate source control. POPULATION: 142 consecutive patients with surgically managed NSTI were identified on retrospective chart review between December 2014 and December 2018 at two academic medical centers. RESULTS: Patients were predominately male (74%) with a median age of 52 and similar baseline characteristics. The median number of debridements to definitive source control was 2 (IQR 1-3) with the short course group undergoing a greater number of debridements control 2.57 ± 1.8 vs 1.9 ± 1.2, (P = .01). Of 142 patients, 34.5% received a short course and the remaining 65.5% received a longer course of antibiotics. There was no significant difference in the incidence of bacteremia or wound culture positivity between groups. There was also no significant difference in in-hospital mortality, 8% vs 6% (P = .74), incidence of C. difficile infection, median length of stay, or 30-day readmission. CONCLUSION: Provided adequate surgical debridement, similar outcomes in morbidity and mortality suggest antibiotic courses of 7 days or less are equally safe compared to longer courses.

Short-Term Outcomes Following Removal of Infected Hernia Mesh.

There are limited studies regarding outcomes of replacing an infected mesh with another mesh. We reviewed short-term outcomes following infected mesh removal and whether placement of new mesh is associated with worse outcomes. Patients who underwent hernia repair with infected mesh removal were identified from 2005 to 2018 American College of Surgeons-National Surgical Quality Improvement Program database. They were divided into new mesh (Mesh+) or no mesh (Mesh-) groups. Bivariate and multivariate logistic regression analyses were used to compare morbidity between the two groups and to identify associated risk factors. Of 1660 patients, 49.3% received new mesh, with higher morbidity in the Mesh+ (35.9% vs. 30.3%; P = .016), but without higher rates of surgical site infection (SSI) (21.3% vs. 19.7%; P = .465). Mesh+ had higher rates of acute kidney injury (1.3% vs. .4%; P = .028), UTI (3.1% vs. 1.3%, P = .014), ventilator dependence (4.9% vs. 2.4%; P = .006), and longer LOS (8.6 vs. 7 days, P < .001). Multivariate logistic regression showed new mesh placement (OR: 1.41; 95% CI: 1.07-1.85; P = .014), body mass index (OR: 1.02; 95% CI: 1.00-1.03; P = .022), and smoking (OR: 1.43; 95% CI: 1.05-1.95; P = .025) as risk factors independently associated with increased morbidity. New mesh placement at time of infected mesh removal is associated with increased morbidity but not with SSI. Body mass index and smoking history continue to contribute to postoperative morbidity during subsequent operations for complications.