Ventral hernia repair in patients with abdominal loss of domain: an observational study of one institution's experience.

PURPOSE: Abdominal wall hernias are a common problem. The success of abdominal wall reconstruction decreases with increasing hernia size. This study summarizes the outcomes of one surgeon's experience using a "sandwich" technique for hernia repair in patients with loss of abdominal domain. METHODS: We reviewed our ventral hernia repair (VHR) experience from 2008 to 2015 among patients with loss of domain, as defined by a hernia defect greater than 300 cm2. The percent of herniation through the defect, defined by a hernia sac-to-abdominal cavity volume ratio, was measured on preoperative CT scans by four independent reviewers and averaged. Outcomes were compared among those with giant ventral hernias (hernia sac-to-abdominal cavity volume >30%) and those with smaller defect ratios. RESULTS: Over the study period, 21 patients underwent VHR. In 17 patients (81%), a "sandwich" technique was utilized. Ten patients had hernia sac-to-abdominal cavity defects less than 30%, and 11 had defects greater than 30%. Preoperative characteristics were similar in both groups with the exception of a higher ASA score in those with giant ventral hernias and more Ventral Hernia Working Group Grade 3 hernias in those without giant ventral hernias. Postoperative outcomes were similar in both groups. There were no mortalities. There were two recurrences (18%) in the giant VHR group and none in the smaller defect group (p = 0.16). Surgical site occurrences were noted in 48% of patients and did not differ between giant and non-giant VHR groups (50 vs 45%, p = 0.84). Average postoperative length of stay was significantly longer in the giant VHR group (31 vs. 17 days, p = 0.03). CONCLUSIONS: Our results suggest that the "sandwich" technique for VHR is a safe and durable method to restore abdominal wall integrity in those with LOD, even in patients with giant ventral hernias.

Creation of a novel risk score for surgical site infection and occurrence after ventral hernia repair.

BACKGROUND: Complex ventral hernia repair (VHR) is a common surgical operation but carries a risk of complications from surgical site infections (SSI) and occurrences (SSO). We aimed to create a predictive risk score to identify patients at increased risk for SSO or SSI within 30 days of surgery. METHODS: Data were prospectively collected on all patients undergoing VHR between January 2008 and February 2015 by a single surgeon. Multivariable logistic regression was used to identify independent factors predictive of SSO and SSI. Significant predictors of SSO and SSI were assigned point values based on their odds ratios to create a novel risk score, the Hopkins ventral hernia repair SSO/SSI risk score; predicted and actual rates of outcomes were then compared using weighted regression. RESULTS: During the study period, 362 patients underwent open VHR. Thirty-day SSO and SSI occurred in 18.5 and 10% of patients, respectively. After risk adjustment, ASA class ≥3 (1 point), operative time ≥4 h (2 points), and the absence of a postoperative wound vacuum dressing (1 point) were predictive of 30-day SSO. Predicted risk of SSO utilizing this scoring system was 9.7, 19.4, 29.1, and 38.8% for 1, 2, 3, and 4 points (AUC = 0.73). For SSI, operative time ≥4 h (1 point) and the lack of a wound vacuum dressing (1 point) were predictive. Predicted risk of SSI based on this scoring system was 12.5% for 1 point and 25% for 2 points (AUC = 0.71). Actual vs. predicted rates of SSO and SSI correlated strongly for risk model with a coefficient of determination (R 2) of 0.92 and 0.91, respectively. CONCLUSION: The novel Hopkins ventral hernia repair risk score accurately predicts risk of SSO and SSI after complex VHR. Further studies using a prospective randomized controlled trial will be needed to further validate our findings.

Effect of hernia size on operative repair and post-operative outcomes after open ventral hernia repair.

BACKGROUND: Ventral hernia repair (VHR) is a commonly performed operation, but analysis of patient outcomes based upon hernia size is lacking. We sought to identify differences in operative repair and post-operative morbidity and mortality after open VHR based on hernia defect size. METHODS: Patient and operative data were retrospectively reviewed on all patients undergoing open incisional VHR between January 2008 and February 2015 by a single surgeon at the Johns Hopkins Hospital. Patient variables were described by means for continuous variables and percentages for discrete variables, with differences between groups calculated by Chi-squared analysis. RESULTS: During the study period, 228 patients underwent open VHR during which intraoperative defect size was measured. Patients were split into four groups based upon defect size: less than 200 cm2, 200-300 cm2, 301-400 cm2, and over 400 cm2. Patients with large defects were more likely to present with a recurrent hernia (P = 0.007) and trended towards a history of wound infections (P = 0.07). Operative time was significantly longer as defect size increased (P < 0.001). Component separation was most frequently used in patients with defects 200-300 cm2 in size (P = 0.001), in whom primary closure was most likely to occur. While mesh was used in almost all patients, the specific location (overlay only, underlay only, or overlay with underlay) depended on hernia size (P < 0.001). Mean length of stay increased with defect size (P < 0.001). Larger defect size was associated with increased 30-day morbidity (P = 0.03) but not readmission (P = 0.53), recurrence (P = 0.99), or mortality (P = 0.99). CONCLUSION: Hernia defect size affects operative time and surgical technique for repair of a ventral hernia. Larger defect size is associated with increased post-operative morbidity and length of stay but not readmission, recurrence, or mortality. Hernia size greater than 400 cm2 should not be a limitation to operative repair.

A validated, risk assessment tool for predicting readmission after open ventral hernia repair.

BACKGROUND/PURPOSE: To present a validated model that reliably predicts unplanned readmission after open ventral hernia repair (open-VHR). STUDY DESIGN: A total of 17,789 open-VHR patients were identified using the 2011-2012 ACS-NSQIP databases. This cohort was subdivided into 70 and 30% random testing and validation samples, respectively. Thirty-day unplanned readmission was defined as unexpected readmission for a postoperative occurrence related to the open-VHR procedure. Independent predictors of 30-day unplanned readmission were identified using multivariable logistic regression on the testing sample (n = 12,452 patients). Subsequently, the predictors were weighted according to ß-coefficients to generate an integer-based Clinical Risk Score (CRS) predictive of readmission, which was validated using receiver operating characteristics (ROC) analysis of the validation sample (n = 5337 patients). RESULTS: The rate of 30-day unplanned readmission was 4.7%. Independent risk factors included inpatient status at time of open-VHR, operation time, enterolysis, underweight, diabetes, preoperative anemia, length of stay, chronic obstructive pulmonary disease, history of bleeding disorders, hernia with gangrene, and panniculectomy (all P < 0.05). ROC analysis of the validation cohort rendered an area under the curve of 0.71, which demonstrates the accuracy of this prediction model. Predicted incidence within each 5 risk strata was statistically similar to the observed incidence in the validation sample (P = 0.18), further highlighting the accuracy of this model. CONCLUSION: We present a validated risk stratification tool for unplanned readmissions following open-VHR. Future studies should determine if implementation of our CRS optimizes safety and reduces readmission rates in open-VHR patients.

The effect of TISSEEL fibrin sealant on seroma formation following complex abdominal wall hernia repair: a single institutional review and derived cost analysis.

PURPOSE: The authors evaluated the ability of a fibrin sealant (TISSEEL™: Baxter Healthcare Corp, Deerfield, IL, USA) to reduce the incidence of post-operative seroma following abdominal wall hernia repair. METHODS: We performed a 4-year retrospective review of patients undergoing abdominal wall hernia repair, with and without TISSEEL, by a single surgeon (FEE) at The Johns Hopkins Hospital. Demographics, surgical risk factors, operative data and 30-day outcomes, including wound complications and related interventions, were compared. The quantity and cost of Tisseel per case was reviewed. RESULTS: A total of 250 patients were evaluated: 127 in the TISSEEL group and 123 in the non-TISSEEL control group. The average age for both groups was 56.6 years (P = 0.97). The majority of patients were female (TISSEEL 52.8%, non-TISSEEL 56.1%, P = 0.59) and ASA Class III (TISSEEL 56.7%, non-TISSEEL 58.5%, P = 0.40). There was no difference in the average defect size for both groups (TISSEEL 217 ± 187.6 cm(2), non-TISSEEL 161.3 ± 141.5 cm(2), P = 0.36). Surgical site occurrences occurred in 18.1% of the TISSEEL and 13% of the non-TISSEEL group (P = 0.27). There was a trend towards an increased incidence of seroma in the TISSEEL group (TISSEEL 11%, non-TISSEEL 4.9%, P = 0.07). A total of $124,472.50 was spent on TISSEEL, at an average cost of $995.78 per case. CONCLUSIONS: In the largest study to date, TISSEEL™ application offered no advantage for the reduction of post-operative seroma formation following complex abdominal hernia repair. Moreover, the use of this sealant was associated with significant costs.

Causes of uveitis in the general practice of ophthalmology. UCLA Community-Based Uveitis Study Group.

PURPOSE: Most uveitis case series have come from tertiary care centers, and the relative frequencies of disorders they report may reflect referral bias. We sought information about the types of uveitis encountered in the general practice of ophthalmology. METHODS: We prospectively examined 213 consecutive cases of general uveitis, defined as intraocular inflammation other than cytomegalovirus retinopathy, seen by a group of community-based comprehensive ophthalmologists. This group of cases was compared with 213 consecutive cases of general uveitis examined by a uveitis specialist at a university referral center in the same community. All cases were categorized by anatomic site of inflammation and disease course, and, if possible, they were assigned a specific diagnosis. Cases of cytomegalovirus retinopathy and masquerade syndrome seen during the same intervals were recorded separately. RESULTS: The distribution of general uveitis cases by anatomic site of disease was significantly different between the community-based practices (anterior, 90.6%; intermediate, 1.4%; posterior 4.7%; panuveitis, 1.4%) and the university referral practice (anterior, 60.6%; intermediate, 12.2%; posterior, 14.6%; panuveitis, 9.4%; P < .00005). A cause or clinical syndrome could be assigned to 47.4% of cases in the community-based practices, and to 57.8% of cases in the university referral practice (P = .03). HLA-B27-associated anterior uveitis, cytomegalovirus retinopathy, and toxoplasmic retinochoroiditis were among the five most common forms of uveitis in both practice settings. CONCLUSION: The relative frequencies with which various forms of uveitis are seen in a tertiary referral center do not necessarily reflect the experience of ophthalmologists from the community in which the center is located. Anterior uveitis and disorders of sudden onset constitute a greater proportion of cases seen by community-based comprehensive ophthalmologists.

An association between acute retinal necrosis syndrome and HLA-DQw7 and phenotype Bw62, DR4.

Human leukocyte antigen (HLA) typing was performed on 27 white patients with acute retinal necrosis syndrome. Antigens for the HLA-A, -B, -C, -DR and -DQ loci were determined, and frequencies were compared with racially matched controls. There was a statistically significant increase in the frequency of HLA-DQw7 (11 of 20 [55%] of patients vs 294 of 1546 [19%] of controls, P = .0004, relative risk 5.20) that remained significant at the P = .05 level when the P value was multiplied by the number of antigens tested. The HLA phenotype Bw62, DR4 is also more frequent than in normal control populations (4 of 25 [16%] of patients vs 26 of 1023 [2.6%] of controls, relative risk 7.49). These results support an association between the acute retinal necrosis syndrome and certain HLA specificities and suggest a possible immunogenetic predisposition to the syndrome in some patients.

Radiation therapy for Graves' ophthalmopathy: a retrospective analysis.

A retrospective analysis of 29 patients with Graves' ophthalmopathy treated from 1973-1986 was undertaken to evaluate the use of radiation therapy (RT). Most patients presented with advanced disease; 20 had been treated with steroids and 8 had undergone prior surgery with orbital decompression. Post-RT evaluation was performed by the patients' Radiation Oncologist, Ophthalmologist, and Endocrinologist with a median follow-up period of 45 months. The overall assessment of the patients' disease was judged as improved with respect to the majority of signs and symptoms in 48%. Soft tissue changes were relieved in 78% and proptosis reduced in 52%. Ophthalmoplegia responded poorly and was improved in only 24%. After RT, 26/29 (90%) of patients have had no further steroid requirements. Thirteen patients underwent surgery for residual signs/symptoms post radiation therapy, indicating that combined modality may be necessary in many patients with advanced disease.

Ytterbium acetate as a particulate-phase digesta-flow marker.

The ability of ytterbium acetabe (Yb acetate) to fulfil the requirements of a particulate-phase digesta-flow marker in a dual-phase marker system, and of the indigestible acid-detergent-fibre fraction of the feed (IADF) to act as a digesta flow marker, were examined using six mature wether sheep given a diet of dried grass (1 kg dry matter (DM)/d). CrEDTA was continuously infused (240 mg chromium/d) into the rumen of all sheep and Yb acetate was also continuously infused (100 mg Yb/d) into the rumen of three of the sheep. At this level of infusion the equilibrium concentration of Yb in rumen, duodenal and ileal digesta and in faeces could be reliably measured by atomic absorption spectrometry. Estimates of faecal DM excretion based on either Yb or IADF did not differ (P greater than 0.05) from that determined by total collection, whereas estimates based on Cr were significantly (P less than 0.05) lower. Urinary excretion accounted for 3.1% of the infused Cr but no Yb was detected in urine. Estimates of ileal DM flow, assuming total marker recovery, were similar (P greater than 0.05) with all three markers, whereas the estimate of duodenal DM flow based on IADF was lower (P less than 0.05) than the estimates based on either Cr or Yb. Compared with the infusion of Cr alone, the infusion of Cr and Yb had no effect (P greater than 0.05) on nutrient flows at the duodenum, ileum and in faeces nor on microbial degradative activity volatile fatty acid production and N metabolism in the rumen. Polyester bag and in vitro studies showed that pre-labelling the dried grass with up to 285 mg Yb/g DM did not affect its susceptibility to microbial degradation. The Yb in rumen, duodenal and ileal digesta was predominantly (greater than 90%) associated with the particulate matter but was not uniformly distributed and its concentration increased as particle size decreased. The use of CrEDTA and Yb acetate as a dual-phase marker system proved more reliable in estimating 'true' duodenal flow than the use of the individual markers when the digesta sample was unrepresentative.

Pain reduction with transcutaneous electrical nerve stimulation after foot surgery.

The authors provide statistical evaluation of the effect of transcutaneous electrical nerve stimulation (TENS) on postoperative pain. A comparison was made to intramuscular (I.M.) and oral (P.O.) analgesic medications required by patients after foot surgery, both with and without the benefit of a TENS unit. Sixty-five postoperative patients who had TENS applied were randomly selected, and their I.M. and P.O. analgesic medications were recorded. This group was compared to a group with the same number of patients from 1 year previously. Patients in the second group were of similar ages and had similar procedures, but without the use of TENS. Compiled data were organized by age and osseous procedure group and compared in both bar and linear graphs. Significant reduction was seen in P.O. analgesic medications for all procedures and ages, and to a lesser extent for I.M. analgesics with an overall patient analgesic medication reduction of 74.9%.

The effect of movement amplitude and target diameter on reaction time: comments on Siegel (1977).

Siegel's (1977) interpretation that his reaction time results were solely a function of response factors (movement amplitude and target diameter) was discussed and criticized. It was argued that Siegel's interpretation was inappropriate because stimulus factors (eccentric and visual angle) and response factors were confounded. It was also argued that the surprising U-shaped relation between reaction time and movement amplitude was probably the result of the confounding between stimulus and response factors.