Deep learning model utilizing clinical data alone outperforms image-based model for hernia recurrence following abdominal wall reconstruction with long-term follow up.

BACKGROUND: Deep learning models (DLMs) using preoperative computed tomography (CT) imaging have shown promise in predicting outcomes following abdominal wall reconstruction (AWR), including component separation, wound complications, and pulmonary failure. This study aimed to apply these methods in predicting hernia recurrence and to evaluate if incorporating additional clinical data would improve the DLM's predictive ability. METHODS: Patients were identified from a prospectively maintained single-institution database. Those who underwent AWR with available preoperative CTs were included, and those with < 18 months of follow up were excluded. Patients were separated into a training (80%) set and a testing (20%) set. A DLM was trained on the images only, and another DLM was trained on demographics only: age, sex, BMI, diabetes, and history of tobacco use. A mixed-value DLM incorporated data from both. The DLMs were evaluated by the area under the curve (AUC) in predicting recurrence. RESULTS: The models evaluated data from 190 AWR patients with a 14.7% recurrence rate after an average follow up of more than 7 years (mean ± SD: 86 ± 39 months; median [Q1, Q3]: 85.4 [56.1, 113.1]). Patients had a mean age of 57.5 ± 12.3 years and were majority (65.8%) female with a BMI of 34.2 ± 7.9 kg/m2. There were 28.9% with diabetes and 16.8% with a history of tobacco use. The AUCs for the imaging DLM, clinical DLM, and combined DLM were 0.500, 0.667, and 0.604, respectively. CONCLUSIONS: The clinical-only DLM outperformed both the image-only DLM and the mixed-value DLM in predicting recurrence. While all three models were poorly predictive of recurrence, the clinical-only DLM was the most predictive. These findings may indicate that imaging characteristics are not as useful for predicting recurrence as they have been for other AWR outcomes. Further research should focus on understanding the imaging characteristics that are identified by these DLMs and expanding the demographic information incorporated in the clinical-only DLM to further enhance the predictive ability of this model.

Using impedance planimetry to define the end of a peroral endoscopic myotomy.

INTRODUCTION: Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic option for management of achalasia. Adequate distal myotomy is necessary for relief of symptoms, but when too long may also increase risk of reflux. The objective of this study is to evaluate clinical outcomes after POEM and final length of gastric myotomy using impedance planimetry (EndoFLIP). METHODS: A retrospective review of 34 consecutive patients undergoing POEM with EndoFLIP were included. EndoFLIP measurements, including esophagogastric junction distensibility index (DI), minimum diameter (Dmin), and cross-sectional area (CSA) were recorded at 30- and 40-mL balloon-fill pre- and post- myotomy. The myotomy was considered complete when DI ≥ 3.4 mm2/mmHg. Postoperative Eckardt score (ES) was determined at initial postoperative visit and most recent follow-up. Linear and logistic regression were used to evaluate the association between gastric myotomy length and post-myotomy EndoFLIP measurements on postoperative ES and GERD. Wilcoxon rank-sum test was used to compare gastric myotomy lengths and EndoFLIP parameters in relation to clinical success and development of GERD, and paired t-test to compare EndoFLIP measurements and ES pre- and post-myotomy. RESULTS: Final length of gastric myotomy measured 1 cm in 1 (2.9%), 1.5 cm in 11 (32.4%), 2.0 cm in 19 (55.9%), and 2.5 cm in 3 (8.8%) patients. Mean preoperative ES was 6.6 ± 2.2. All patients achieved ES < 3 postoperatively, which was maintained in 88.5% of patients at a median of 7.5 months of follow-up. Gastric myotomy length and post-myotomy EndoFLIP values were not associated with postoperative Eckardt scores or GERD. DISCUSSION: Early and late symptom relief was achieved in 100 and 88.5% of patients, respectively, at a gastric myotomy length of 1-2.5 cm. Using EndoFLIP to define a completed myotomy at DI of 3.4 mm2/mmHg yielded variable lengths of gastric myotomy.

Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice.

BACKGROUND: Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability. METHODS: A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test. RESULTS: There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001). CONCLUSION: The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.

Prospective, international analysis of quality of life outcomes in recurrent versus primary ventral hernia repairs.

BACKGROUND: Quality of life (QOL) has become a key outcome measure following ventral hernia repair (VHR), but recurrent and primary VHR have not been compared in this context previously. METHODS: The International Hernia Mesh Registry (2008-2019) was used to identify patients with QOL data scored by the Carolinas Comfort Scale preoperatively and postoperatively at 1 year. RESULTS: Repairs were performed in 227 recurrent and 1,122 primary VHs. Recurrent patients had a higher BMI, larger defects, and were more likely to have preoperative pain, but other comorbidities were equal. Recurrence rates at 1 year were equivalent. Recurrent patients had a greater improvement in pain (-6.3 ± 10.2 vs -4.3 ± 8.3,p = 0.002) and movement limitation (-5.5 ± 10.0 vs -3.2 ± 7.2,p < 0.001) compared to primary patients, but they had increased postoperative mesh sensation (4.6 ± 7.7 vs 2.7 ± 5.5,p < 0.001). CONCLUSIONS: Recurrent VHRs led to improved pain and movement limitation, but increased mesh sensation. These findings may be useful for preoperative counseling in the elective setting.

Defining surgical risk in octogenarians undergoing paraesophageal hernia repair.

BACKGROUND: With an aging population, the utility of surgery in elderly patients, particularly octogenarians, is of increasing interest. The goal of this study was to analyze outcomes of octogenarians versus non-octogenarians undergoing paraesophageal hernia repair (PEHR). METHODS: The Nationwide Readmission Database was queried for patients > 18 years old who underwent PEHR from 2016 to 2018. Exclusion criteria included a diagnosis of gastrointestinal malignancy or a concurrent bariatric procedure. Patients ≥ 80 were compared to those 18-79 years old using standard statistical methods, and subgroup analyses of elective and non-elective PEHRs were performed. RESULTS: From 2016 to 2018, 46,450 patients were identified with 5425 (11.7%) octogenarians and 41,025 (88.3%) non-octogenarians. Octogenarians were more likely to have a non-elective operation (46.3% vs 18.2%, p < 0.001), and those undergoing non-elective PEHR had a higher mortality (5.5% vs 1.2%, p < 0.001). Outcomes were improved with elective PEHR, but octogenarians still had higher mortality (1.3% vs 0.2%, p < 0.001), longer LOS (3[2, 5] vs 2[1, 3] days, p < 0.001), and higher readmission rates within 30 days (11.1% vs 6.5%, p < 0.001) compared to non-octogenarian elective patients. Multivariable logistic regression showed that being an octogenarian was not independently predictive of mortality (odds ratio (OR) 1.373[95% confidence interval 0.962-1.959], p = 0.081), but a non-elective operation was (OR 3.180[2.492-4.057], p < 0.001). Being an octogenarian was a risk factor for readmission within 30 days (OR 1.512[1.348-1.697], p < 0.001). CONCLUSIONS: Octogenarians represented a substantial proportion of patients undergoing PEHR and were more likely to undergo a non-elective operation. Being an octogenarian was not an independent predictor of perioperative mortality, but a non-elective operation was. Octogenarians' morbidity and mortality was reduced in elective procedures but was still higher than non-octogenarians. Elective PEHR in octogenarians is reasonable but should involve a thorough risk-benefit analysis.

The incidence and impact of enterotomy during laparoscopic and robotic ventral hernia repair: a nationwide readmissions analysis.

INTRODUCTION: Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes. METHODS: The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients. RESULTS: In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m2 (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036). CONCLUSION: Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates.

Factors Predicting Increased Length of Stay in Abdominal Wall Reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)-specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol. METHODS: A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8). RESULTS: Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (ß0.04,SE0.02), BMI (ß0.06,SE0.03), hernia defect size (ß0.003,SE0.001), active mesh infection or mesh fistula (ß1.8,SE0.72), operative time (ß0.02,SE0.002), and ASA score >4 (ß3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence (P = .06). CONCLUSIONS: Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.

Open preperitoneal ventral hernia repair: Prospective observational study of quality improvement outcomes over 18 years and 1,842 patients.

BACKGROUND: This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications. METHODS: Prospective, tertiary hernia center data (2004-2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. "Early" (2004-2012) and "Recent" (2013-2021) groups were based on surgery date. RESULTS: Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m2; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm2; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9-4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1-3.7], P = .02 vs 1.8 [1.1-3.1], P = .02), anterior component separation technique (1.8 [1.1-2.9], P = .02 vs 3.2[1.9-5.3], P < .01), and operative time (per minute: 1.01 [1.008-1.015], P < .01 vs 1.004 [1.001-1.007], P < .01). Diabetes (2.6 [1.7-4.0], P < .01) and tobacco (1.8 [1.1-2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1-20.1], P < .01 vs 3.4 [1.3-8.2]. P < .01) and recurrent hernias (4.9 [2.3-11.5], P < .01 vs 2.1 [1.1-4.2], P = .036). CONCLUSION: Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center's outcomes has significantly improved patient care results.

Observational study of complex abdominal wall reconstruction using porcine dermal matrix: How have outcomes changed over 14 years?

BACKGROUND: Our center has adopted many evidence-based practices to improve outcomes for complex abdominal wall reconstruction with porcine dermal matrix. This study analyzed outcomes over time using porcine dermal matrix in complex abdominal wall reconstruction. METHODS: Prospective, tertiary hernia center data was examined for patients undergoing complex abdominal wall reconstruction with porcine dermal matrix. Early (2008-2014) and Recent (2015-2021) cohorts were defined by dividing the study interval in half. Multivariable analyses of wound complications and recurrence were performed. RESULTS: Comparing 117 Early vs 245 Recent patients, both groups had high rates of previously repaired hernias (76.1% vs 67.4%; P = .110), Centers for Disease Control and Prevention class 3 or 4 wounds (76.0% vs 66.6%; P = .002), and very large hernia defects (320 ± 317 vs 282 ± 164 cm2; P = .640). Recent patients had higher rates of preoperative botulinum injection (0% vs 21.2%; P < .001), posterior component separation (15.4% vs 35.5%; P < .001), and delayed primary closure (23.1% vs 38.8%; P < .001), but lower rates of concurrent panniculectomy (32.3% vs 27.8%; P = .027) and similar anterior component separation (29.1% vs 18.2%; P = .060). Most mesh was placed preperitoneal (74.4% vs 93.3%; P < .001). Recent patients had less inlay (9.4% vs 2.1%; P < .01) and other mesh locations as fascial closure rate increased (88.0% vs 95.5%; P < .001). Over time, there was a decrease in wound complications (42.1% vs 14.3%; P < .001), length of stay (median [interquartile range]:8 [6-13] vs 7 [6-9]; P = .003), and 30-day readmissions (32.7% vs 10.3%; P < .001). Hernia recurrence decreased (10.3% vs 3.7%; P = .016) with mean follow-up of 2.8 ± 3.2 and 1.7 ± 1.7 years, respectively. Respective multivariable models(odds ratio, 95% confidence interval) demonstrated an increased risk of wound complications with diabetes (2.65, 1.16-5.98; P = .020), panniculectomy (2.63, 1.21-5.73; P = .014), and anterior component separation (5.1, 1.98-12.9; P < .001), with recurrence risk increased by wound complication (3.8, 1.4-2-7.62; P = .032). CONCLUSION: Porcine dermal matrix in complex abdominal wall reconstruction performs well with low recurrence rates. Internal assessment and implementation of evidence-based practices improved outcomes such as length of stay, wound complications, and recurrence rate.

Predicting rare outcomes in abdominal wall reconstruction using image-based deep learning models.

BACKGROUND: Deep learning models with imbalanced data sets are a challenge in the fields of artificial intelligence and surgery. The aim of this study was to develop and compare deep learning models that predict rare but devastating postoperative complications after abdominal wall reconstruction. METHODS: A prospectively maintained institutional database was used to identify abdominal wall reconstruction patients with preoperative computed tomography scans. Conventional deep learning models were developed using an 8-layer convolutional neural network and a 2-class training system (ie, learns negative and positive outcomes). Conventional deep learning models were compared to deep learning models that were developed using a generative adversarial network anomaly framework, which uses image augmentation and anomaly detection. The primary outcomes were receiver operating characteristic values for predicting mesh infection and pulmonary failure. RESULTS: Computed tomography scans from 510 patients were used with a total of 10,004 images. Mesh infection and pulmonary failure occurred in 3.7% and 5.6% of patients, respectively. The conventional deep learning models were less effective than generative adversarial network anomaly for predicting mesh infection (receiver operating characteristic 0.61 vs 0.73, P < .01) and pulmonary failure (receiver operating characteristic 0.59 vs 0.70, P < .01). Although the conventional deep learning models had higher accuracies/specificities for predicting mesh infection (0.93 vs 0.78, P < .01/.96 vs .78, P < .01) and pulmonary failure (0.88 vs 0.68, P < .01/.92 vs .67, P < .01), they were substantially compromised by decreased model sensitivity (0.25 vs 0.68, P < .01/.27 vs .73, P < .01). CONCLUSION: Compared to conventional deep learning models, generative adversarial network anomaly deep learning models showed improved performance on imbalanced data sets, predominantly by increasing model sensitivity. Understanding patients who are at risk for rare but devastating postoperative complications can improve risk stratification, resource utilization, and the consent process.

Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study.

BACKGROUND: Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study. METHODS: A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated. RESULTS: Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm2 vs botulinum toxin A 289.7 ± 162.4 cm2; P = .73) (mean volume: 1,498.3 + 2,043.4 cm3 vs 2,914.7 + 6,539.4 cm3; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13). CONCLUSION: In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction.

INTRODUCTION: Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds. METHODS: A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both. RESULTS: In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm2 vs. 208 ± 155cm2; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection. CONCLUSIONS: Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

Hernia recurrence after primary repair of small umbilical hernia defects.

BACKGROUND: An evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined. METHODS: A prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications. RESULTS: Of 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant. CONCLUSIONS: With long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary.

Coated Polypropylene Mesh Is Associated With Increased Infection in Abdominal Wall Reconstruction.

BACKGROUND: Barrier-coated meshes were designed to reduce adhesion formation between mesh and the surrounding viscera. There have been questions raised but little data to determine if rapidly absorbable coatings pose an increased risk of infection. The objective of this study was to determine if a difference exists in wound and mesh infection rates between coated and uncoated polypropylene mesh in patients undergoing open ventral hernia repair. METHODS: A prospective, institutional database at a tertiary hernia center identified patients undergoing open preperitoneal ventral hernia repair (OPPVHR) with polypropylene mesh in CDC class 1 and 2 wounds. Using propensity score matching, an absorbable, coated and uncoated group were matched based on age, comorbidities, wound class, defect size, and mesh size. RESULTS: There were 265 patients each in the matched coated and uncoated mesh groups for a total of 530 patients. Postoperative wound infections (10.9% versus 4.6%, P = 0.01) and need for IV antibiotics (10.5% versus 4.3%, P = 0.01) were significantly higher in the coated group. There was an increase in mesh infection for the coated group (3.4% versus 0.4%, P = 0.02), and of those developing a mesh infection, 60.0% eventually required mesh excision. CONCLUSIONS: Coated mesh was associated with increased postoperative wound and mesh infection following OPPVHR. An uncoated mesh should be strongly considered when placed in an extraperitoneal location.

Multicenter analysis of laparoscopic versus open umbilical hernia repair with mesh: outcomes and quality of life (QoL).

INTRODUCTION: Umbilical hernia repair (UHR) is a common operation with varying surgical approaches. Laparoscopic (LUHR) and open (OUHR) operations are routinely performed, but their impact on quality of life (QoL) is not well described. Our aim was to evaluate perioperative outcomes and QoL of LUHR versus OUHR. METHODS: The prospectively collected International Hernia Mesh Registry was queried for patients undergoing UHR with mesh placement. QoL was measured using the Carolinas Comfort Scale preoperatively and 1, 6, 12, and 24 months postoperatively. Propensity match was performed controlling for hernia defect size (HDS), recurrent hernias, and BMI. RESULTS: 585 patients underwent 178 (30.4%) LUHR and 407 (69.6%) OUHR. LUHR patients had higher BMI, larger HDS, and more recurrent hernias (p < 0.05). Rates of other comorbidities were similar (p > 0.05). Tacks were used more frequently in LUHR (91.6% vs 1.7%, p < 0.001), and suture was used more often in OUHR (97.1% vs 47.8%, p < 0.001). Postoperative outcomes were similar (p > 0.05) except LUHR had higher rates of seroma (13.9% vs 4.3%, p < 0.001). Overall recurrence rates trended to favor OUHR, but not significantly (4.7% vs 8.4%, p = 0.07). The propensity match yielded 138 matched pairs. LUHR had more seromas and OUHR had higher infection rates (p < 0.05). Hernia recurrence was higher following LUHR (9.4% vs 2.9%, p = 0.02). QoL data were available for an average of 457 patients at each time period. QoL was superior in the OUHR group for pain and overall QoL at each time point and activity limitations at 6 and 12 months (p < 0.05). When examining patients who were asymptomatic preoperatively, OUHR had improved one-month overall QoL, but both groups had over 90% of patients report being asymptomatic postoperatively. CONCLUSIONS: OUHR is associated with higher rates of surgical site infections, but significantly lower rates of seroma formation and hernia recurrence compared to LUHR, while having superior QoL in both short- and long-term follow-up. Asymptomatic patients tend to have excellent QoL outcomes.

Delayed primary closure (DPC) of the skin and subcutaneous tissues following complex, contaminated abdominal wall reconstruction (AWR): a propensity-matched study.

BACKGROUND: Wound complications following abdominal wall reconstruction (AWR) in a contaminated setting are common and significantly increase the risk of hernia recurrence. The purpose of this study was to examine the effect of short-term negative pressure wound therapy (NPWT) followed by operative delayed primary closure (DPC) of the skin and subcutaneous tissue after AWR in a contaminated setting. METHODS: A prospective institutional hernia database was queried for patients who underwent NPWT-assisted DPC after contaminated AWR between 2008 and 2020. Primary outcomes included wound complication rate and reopening of the incision. A non-DPC group was created using propensity-matching. Standard descriptive statistics were used, and a univariate analysis was performed between the DPC and non-DPC groups. RESULTS: In total, 110 patients underwent DPC following AWR. The hernias were on average large (188 ± 133.6 cm2), often recurrent (81.5%), and 60.5% required a components separation. All patients had CDC Class 3 (14.5%) or 4 (85.5%) wounds and biologic mesh placed. Using CeDAR, the wound complication rate was estimated to be 66.3%. Postoperatively, 26.4% patients developed a wound complication, but only 5.5% patients required reopening of the wound. The rate of recurrence was 5.5% with mean follow-up of 22.6 ± 27.1 months. After propensity-matching, there were 73 patients each in the DPC and non-DPC groups. DPC patients had fewer overall wound complications (23.0% vs 43.9%, p = 0.02). While 4.1% of the DPC group required reopening of the incision, 20.5% of patients in the non-DPC required reopening of the incision (p = 0.005) with an average time to healing of 150 days. Hernia recurrence remained low overall (2.7% vs 5.4%, p = 0.17). CONCLUSIONS: DPC can be performed with a high rate of success in complex, contaminated AWR patients by reducing the rate of wound complications and avoiding prolonged healing times. In patients undergoing AWR in a contaminated setting, a NPWT-assisted DPC should be considered.

Closed-Incision Negative Pressure Therapy Decreases Wound Morbidity in Open Abdominal Wall Reconstruction With Concomitant Panniculectomy.

INTRODUCTION: Patients undergoing abdominal wall reconstruction (AWR) with concomitant panniculectomy (CP) may be at higher risk for wound complications due to the need for large incisions and tissue undermining. The aim of this study was to evaluate whether the use of closed-incision negative pressure therapy (ciNPT) decreases wound complications in AWR patients undergoing CP. METHODS: Beginning in February 2018, all patients at this institution who underwent AWR with CP received ciNPT. These patients were identified from a prospectively maintained institutional database. A standard dressing (non-NPT) group was then created in a 1:1 fashion by identifying patients who had AWR with CP immediately before the beginning of ciNPT use (2016-2018). A univariate comparison was made between the ciNPT and non-NPT groups. The primary outcome was wound complication rate; however, other perioperative outcomes, such as requirement for reoperation, were also tracked. Standard statistical methods and logistic regression were used. RESULTS: In total, 134 patients met criteria, with 67 patients each in the ciNPT and non-NPT groups. When comparing patients in the ciNPT and non-NPT groups, they were demographically similar, including body mass index, smoking, and diabetes (P < 0.05). Hernias was large on average (289.5 ± 158.2 vs 315.3 ± 197.3 cm2, P = 0.92) and predominantly recurrent (58.5% vs 72.6%, P = 0.14). Wound complications were much lower in the ciNPT group (15.6% vs 35.5%, P = 0.01), which was mainly driven by a decrease in superficial wound breakdown (3.1% vs 19.7%, P < 0.01). Patients in the ciNPT group were less likely to require a return trip to the operating room for wound complications (0.0% vs 13.3%, P < 0.01). In logistic regression, the use of ciNPT continued to correlate with reduced wound complication rates (P = 0.02). CONCLUSIONS: In AWR with CP, the use of ciNPT significantly decreased the risk of postoperative wound complications, particularly superficial wound breakdown, and lessened the need for wound-related reoperation.

Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair.

INTRODUCTION: Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair. METHODS: A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software. RESULTS: Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm3, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm2, p < 0.001). In multivariate analysis, HSV increase of 100cm3 (OR 1.17 CI 1.02-1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence. CONCLUSIONS: Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.

Biologic mesh is non-inferior to synthetic mesh in CDC class 1 & 2 open abdominal wall reconstruction.

BACKGROUND: Biologic mesh has historically been used in contaminated abdominal wall reconstructions (AWRs). No study has compared outcomes of biologic and synthetic in clean and clean-contaminated hernia ventral hernia repair. METHODS: A prospective AWR database identified patients undergoing open, preperitoneal AWR with biologic mesh in CDC class 1 and 2 wounds. Using propensity score matching, a matched cohort of patients with synthetic mesh was created. The objective was to assess recurrence rates and postoperative complications. RESULTS: Fifty-eight patients were matched in each group. Patient in the biologic group had higher rates of immunosuppression, history of transplantation, and inflammatory bowel disease (p ≤ 0.05). Operative variables were comparable for biologic vs synthetic, including defect size (230.5 ± 135.4 vs 268.7 ± 194.5 cm2, p = 0.62), but the synthetic mesh group had larger meshes placed (575.6 ± 247.0 vs 898.8 ± 246.0 cm2 p < 0.0001). Wound infections (15.5% vs 8.9%, p = 0.28) were equivalent, and recurrence rates (1.7% vs 3.4%, p = 1.00) were similar on follow up (19.3 ± 23.3 vs 23.3 ± 29.7 months, p = 0.56). CONCLUSIONS: In matched, lower risk, complex AWR patients with large hernia defects, biologic and synthetic meshes have equal outcomes.

Nationwide increase in component separation without concomitant rise in readmissions: A nationwide readmissions database analysis.

BACKGROUND: The use of component separation technique (CST) in complex abdominal wall reconstruction (AWR) increases the rate of primary musculofascial closure but can be associated with increased wound complications, which may require readmission. This study examines 3-year trends in readmissions for patients undergoing AWR with or without CST. METHODS: The Nationwide Readmissions Database was queried for patients undergoing elective AWR from 2016-2018. CST, demographic characteristics, and 90-day complications and readmissions were determined. CST versus non-CST readmissions were compared, including matched subgroups. Standard statistics and logistic regression were used. RESULTS: Over the 3-year period, 94,784 patients underwent AWR. There was an annual increase in the prevalence of CST: 4.0% in 2016; 6.1% in 2017; 6.7% in 2018 (P < .01), which is a 67.5% upsurge during that time. Most cases (82.3%) occurred at urban teaching hospitals, which had more comorbid patients (P < .01). The yearly 90-day readmission rate did not change: 16.0%, 18.2%, and 16.9% (P = .26). Readmissions were higher for CST patients than non-CST patients (17.1% vs 15.7%), but not in the matched subgroup (17.0% vs 16.4%; P = .41). Most commonly, readmissions were for infection (28.3%); 14.3% of readmitted patients underwent reoperation. Smoking, morbid obesity, diabetes, chronic lung disease, urban-teaching hospital status, and increased length of stay increased the chance of readmission (all P < .05). CONCLUSION: From 2016 to 2018, the use of CST increased 67.5% nationwide without an increase in readmissions. As we look toward clinical targets to reduce risk of readmission, modifiable health conditions, such as smoking, morbid obesity, and diabetes should be targeted during the prehabilitation process.