Doxycycline impacts hernia repair outcomes.

BACKGROUND: Incisional hernias occur commonly in up to 20% of all abdominal operations. Incisional hernia formation has been associated with increased levels of matrix metalloproteinases (MMPs), reduced collagen 1, and increased collagen 3 expression. Doxycycline, a nonspecific inhibitor of MMPs, has been shown to beneficially reduce MMP levels in both cancer and aneurysm models. This study evaluates the impact of doxycycline upon MMP expression, collagen subtypes, and hernia repair distraction forces in an animal model of incisional hernia repair. MATERIALS AND METHODS: Twenty-four Sprague Dawley rats underwent incisional hernia creation and subsequent repair with polypropylene mesh. Animals were administered doxycycline or saline daily beginning 1 d prior to hernia repair and survived for 1, 2, or 4 wk. Serum and tissue were evaluated for MMP content and collagen subtyping utilizing enzyme-linked immunosorbent assay and Western blot. Tensiometric properties of the native abdominal wall after hernia repair were measured with an Instron Corp. (Canton, MA) mechanical testing system. RESULTS: There were no differences in control and experimental groups 1 and 2 wk following hernia repair; 4 wk following hernia repair, doxycycline treated animals demonstrated reduced serum MMP-2 and MMP-9 levels, reduced tissue levels of MMP-2, MMP-3, and MMP-9, and increased collagen 1 to 3 ratios. Distraction forces required to disrupt the hernia repair were increased in the doxycycline treated group compared with controls. CONCLUSIONS: Doxycycline administration is associated with improved hernia repair strength with concomitant reduction of MMP levels with increased collagen 1 deposition. Longer term studies are required to better understand the impact of this treatment.

Predictors of poor outcomes in functionally dependent patients undergoing ventral hernia repair.

BACKGROUND: Preoperative functional health status has been shown previously to affect outcomes following ventral hernia repair. The objective of this study was to identify specific factors that contribute to morbidity and mortality in functionally dependent patients who undergo elective ventral hernia repair. METHODS: We reviewed all patients in the ACS NSQIP database who underwent elective ventral hernia repair from 2005 to 2009. Patients were selected based on the following CPT codes: 49560, 49561, 49565, 49566, 49568, 49570, 49572, 49585, 49587, 49652, 49653, 49654, 49655, 49656, and 49657. Only patients classified as partially or totally dependent were included in this study. Thirty-day outcomes included mortality, wound occurrences, pulmonary occurrences, venous thromboembolism, development of sepsis/shock, renal failure/insufficiency, and cardiovascular events. We analyzed risk factors using multivariate analyses. RESULTS: We identified 75,865 patients who underwent elective ventral hernia repair, of which 1,144 were classified as functionally dependent. Overall, major morbidity was observed in 211 (18.4 %) patients. There was no statistically significant difference in any measurable outcomes between laparoscopic and open hernia repairs. Increasing age proved to be an independent predictor of mortality, with an odds ratio of 1.63 (95 % confidence interval (CI) 1.27-2.12) for each 10 years of age beyond the mean. Ascites and preoperative renal failure also were identified as independent predictors of mortality, with odds ratios of 9.7 and 11.5, respectively. Preoperative pulmonary compromise was shown to be an independent predictor of both mortality and major morbidity, with odds ratios of 4.1 and 2.47, respectively. CONCLUSIONS: Elective ventral hernia repair in the functionally dependent patient population has significant morbidity and mortality. Increasing age, ascites, preoperative renal failure, and preoperative pulmonary compromise are independent predictors of 30-day mortality. Nonoperative management should be strongly considered in the presence of these risk factors. Further studies are needed to determine optimum management strategies for functionally dependent patients with ventral hernias.

Age-related decline in VIP-positive parasympathetic nerve fibers in the human submacular choroid.

PURPOSE: An age-related decline in macular choroidal blood flow (ChBF) occurs in humans. Vasodilatory nerve fibers containing vasoactive intestinal polypeptide (VIP) innervate choroidal blood vessels. The current study was conducted to examine the possibility that an age-related loss of these fibers might occur in the submacular choroid in humans, and thus contribute to a decline in ChBF. METHODS: Macular choroid punches were collected from 35 healthy human donors ranging from 21 to 93 years of age. Choroidal samples were immunolabeled using anti-VIP and the peroxidase-antiperoxidase METHOD: VIP-positive nerve fiber abundance was quantified in up to 12 fields per punch. Fifty macular punches were analyzed, and results for eye pairs were averaged. Choroidal vessel diameter (ChVD) was measured for these same fields. The relationship between age and vessel diameter or VIP-positive fiber abundance was analyzed. Multivariate statistical models were generated correcting for gender, variables related to the tissue specimens, and potential procedural sources of variability. RESULTS: The fully adjusted multivariate models showed a significant age-related reduction in both the VIP-positive fiber abundance (P = 0.0003, adjusted R(2) = 0.51) and ChVD (P < 0.0001, adjusted R(2) = 0.63), with slopes of -0.45 and -0.19, respectively. Adjusting for the same variables, VIP-positive fiber abundance showed a significant direct correlation with ChVD. CONCLUSIONS: The results indicate a significant age-related decline in VIP-positive nerve fibers and vessel diameter in the submacular choroid in disease-free human donor eyes. These findings suggest that a decline in the neural control of ChBF and vessel diameter may explain the reductions in ChBF and its adaptive control observed clinically with aging.

Financial implications of ventral hernia repair: a hospital cost analysis.

INTRODUCTION: Complicated ventral hernias are often referred to tertiary care centers. Hospital costs associated with these repairs include direct costs (mesh materials, supplies, and nonsurgeon labor costs) and indirect costs (facility fees, equipment depreciation, and unallocated labor). Operative supplies represent a significant component of direct costs, especially in an era of proprietary synthetic meshes and biologic grafts. We aim to evaluate the cost-effectiveness of complex abdominal wall hernia repair at a tertiary care referral facility. METHODS: Cost data on all consecutive open ventral hernia repairs (CPT codes 49560, 49561, 49565, and 49566) performed between 1 July 2008 and 31 May 2011 were analyzed. Cases were analyzed based upon hospital status (inpatient vs. outpatient) and whether the hernia repair was a primary or secondary procedure. We examined median net revenue, direct costs, contribution margin, indirect costs, and net profit/loss. Among primary hernia repairs, cost data were further analyzed based upon mesh utilization (no mesh, synthetic, or biologic). RESULTS: Four-hundred and fifteen patients underwent ventral hernia repair (353 inpatients and 62 outpatients); 173 inpatients underwent ventral hernia repair as the primary procedure; 180 inpatients underwent hernia repair as a secondary procedure. Median net revenue ($17,310 vs. 10,360, p < 0.001) and net losses (3,430 vs. 1,700, p < 0.025) were significantly greater for those who underwent hernia repair as a secondary procedure. Among inpatients undergoing ventral hernia repair as the primary procedure, 46 were repaired without mesh; 79 were repaired with synthetic mesh and 48 with biologic mesh. Median direct costs for cases performed without mesh were $5,432; median direct costs for those using synthetic and biologic mesh were $7,590 and 16,970, respectively (p < .01). Median net losses for repairs without mesh were $500. Median net profit of $60 was observed for synthetic mesh-based repairs. The median contribution margin for cases utilizing biologic mesh was -$4,560, and the median net financial loss was $8,370. Outpatient ventral hernia repairs, with and without synthetic mesh, resulted in median net losses of $1,560 and 230, respectively. CONCLUSIONS: Ventral hernia repair is associated with overall financial losses. Inpatient synthetic mesh repairs are essentially budget neutral. Outpatient and inpatient repairs without mesh result in net financial losses. Inpatient biologic mesh repairs result in a negative contribution margin and striking net financial losses. Cost-effective strategies for managing ventral hernias in a tertiary care environment need to be developed in light of the financial implications of this patient population.