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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion?

BACKGROUND: Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution. METHODS: A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed. RESULTS: 180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m2 (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m2 and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001). CONCLUSIONS: RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.

Impact of perforator sparing on anterior component separation outcomes in open abdominal wall reconstruction.

INTRODUCTION: Anterior component separation (ACS) is a well-established, highly functional technique to achieve fascial closure in complex abdominal wall reconstruction (AWR). Unfortunately, ACS is also associated with an increased risk of wound complications. Perforator sparing ACS (PS-ACS) has more recently been introduced to maintain the subcutaneous perforators derived from the deep epigastric vessels. The aim of this study is to evaluate wound-related outcomes in patients undergoing open AWR after implementation of a PS-ACS technique. METHODS: A prospectively collected database were queried for patients who underwent open AWR and an ACS from 2006 to 2018. Patients who underwent PS-ACS were compared to patients undergoing ACS using standard statistical methods. Patients undergoing concomitant panniculectomy were included in the standard ACS group. RESULTS: In total, 252 patients underwent ACS, with 24 (9.5%) undergoing PS-ACS. Age and specific comorbidities were similar between groups (all p > 0.05) except for the PS-ACS groups having a higher rate of prior tobacco use (45.8% vs 19.6%, p = 0.003). Mean hernia defect area was 381.6 ± 267.0 cm2 with 64.3% recurrent hernias, and both were similar between groups (all p > 0.05). The PS-ACS group did have more complex wounds with more Ventral Hernia Working Group Grade 3 and 4 hernias (p = 0.04). OR time and length of stay were similar between groups (all p > 0.05). Despite increased complexity, wound complication rates were much lower in the PS-ACS group (20.8% vs 46.1%, p = 0.02), and all specific wound complications were lower but not statistically different. Hernia recurrence rate was similar between PS-ACS and ACS groups (4.2% vs 7.0%, p > 0.99) with mean follow-up of 27.7 ± 26.9 months. CONCLUSIONS: In complex AWR, preservation of the deep epigastric perforating vessels during ACS significantly lowers the rates of wound complications, despite its performance in more complex patients with an increased risk of infection. PS-ACS should be performed preferentially over a standard ACS whenever possible.

Are laparoscopic and open ventral hernia repairs truly comparable?: A propensity-matched study in large ventral hernias.

BACKGROUND: The merits of laparoscopic (LVHR) and open preperitoneal ventral hernia repair (OPPVHR) have been debated for more than 2 decades. Our aim was to determine peri-operative and long-term outcomes in large hernias. METHODS: A prospective, institutional database at a tertiary hernia center was queried for patients undergoing LVHR and OPPVHR. One-to-one propensity score matching was performed for hernia defect size and follow-up. RESULTS: Three hundred and fifty-two LVHR and OPPVHR patients were identified with defect sizes closely matched between laparoscopic (182.0 ± 110.0 cm2) and open repairs (178.3 ± 99.8 cm2), p = 0.64. LVHR and OPPVHR patients were comparable: mean age 57.2 ± 12.1 vs 56.6 ± 12.0 years (p = 0.52), BMI: 32.9 ± 6.6 vs 32.0 ± 7.4 kg/m2 (p = 0.16), diabetes 19.0% vs 19.7% (p = 0.87), and smoking history 8.7% vs 23.0% (p < 0.001), respectively. OPPVHR had higher number of recurrent hernias (14.2% vs 44.9%, p < 0.001), longer operative time (168.1 ± 64.3 vs 186.7 ± 67.7 min, p = 0.006), and more components separation (0% vs 20.3%, p < 0.001). Mean mesh size was larger (p < 0.001) in the open group (634.4 ± 243.4 cm2 vs 841.8 ± 277.6 cm2). The hernia recurrence rates were similar (10.8% vs 9.2%, p = 0.62), with average follow-up of 39.3 ± 32.5 vs 40.0 ± 35.0 months (p = 0.89). Length of stay was higher in the OVHR cohort (5.4 ± 3.0 vs 6.3 ± 3.6 days, p < 0.001), but 30-day readmission rates (4.0% vs 6.4%, p = 0.31) were similar. Overall wound infection rate (2.9% vs 8.4%, p = 0.03) was higher in the OPPVHR group, but the mesh infection rate was similar between LVHR (1.7%) and OPPVHR (0.6%) (p = 0.33). Postoperative pain (41.1% vs 41.4%, p = 0.95) and overall QOL based on the Carolinas Comfort Scale at 6 months (p = 0.73) and 5-years (p = 0.36) were similar. CONCLUSION: Laparoscopic and open preperitoneal repair for large ventral hernias have equivalent hernia recurrence rates, postoperative pain, and QOL on long-term follow-up. Patients undergoing OPPVHR were more likely to be recurrent, complex, require components separation, and more likely to develop postoperative wound complications.

Impact of panniculectomy in complex abdominal wall reconstruction: a propensity matched analysis in 624 patients.

INTRODUCTION: In complex abdominal wall reconstruction (AWR), the role of concomitant panniculectomy has been debated due to concern for increased wound complications that impact outcomes; however, long-term outcomes and quality of life (QOL) have not been well described. The aim of our study was to evaluate the outcomes and QOL in patients undergoing AWR with panniculectomy utilizing 3D volumetric-based propensity match. METHODS: A prospective database from a tertiary referral hernia center was queried for patients undergoing open AWR. 3D CT volumetrics were analyzed and a propensity match comparing AWR patients with and without panniculectomy was created including subcutaneous fat volume (SFV). QOL was analyzed using the Carolinas Comfort Scale. RESULTS: Propensity match yielded 312 pairs, all with adequate CT imaging for volumetric analysis. The panniculectomy group had a higher BMI (p = 0.03) and were more likely female (p < 0.0001), but all other demographics and comorbidities were similar. The panniculectomy group was more likely to have undergone prior hernia repair (77% vs 64%, p < 0.001), but hernia area, SFV, and CDC wound class were similar (all p > 0.05). Requirement of component separation (61% vs 50%, p = 0.01) and mesh excision (44% vs 35%, p = 0.02) were higher in the panniculectomy group, but operative time were similar (all p ≥ 0.05). Panniculectomy patients had a higher overall wound occurrence rate (45% vs 32%, p = 0.002) which was differentiated only by a higher rate of wound breakdown (24% vs 14%, p = 0.003); all other specific wound complications were equal (all p ≥ 0.05). Hernia recurrence rates were similar (8% vs 9%, p = 0.65) with an average follow-up of 28 months. Overall QOL was equal at 2 weeks, and 1, 6, and 12 months (all p ≥ 0.05). CONCLUSIONS: Despite panniculectomy patients and their hernias being more complex, concomitant panniculectomy increased wound complications but did not negatively impact infection rates or long-term outcomes. Concomitant panniculectomy should be considered in appropriate patients to avoid two procedures.

Preperitoneal Ventral Hernia Repair: A Decade Long Prospective Observational Study With Analysis of 1023 Patient Outcomes.

OBJECTIVES: The aim of this study was to examine the outcomes of over a decade's experience utilizing preperitoneal ventral hernia repair (PP-VHR). BACKGROUND: PP-VHR was first described by our group in 2006, and there have been no subsequent reports of outcomes with this technique. METHODS: A prospective study of all PP-VHR from January, 2004 to April, 2016 was performed. Multivariate stepwise logistic regression and Cox proportional-hazard models were used to identify predictors of wound complications and hernia recurrence, respectively. RESULTS: There were 1023 PP-VHRs. Mean age was 57.2 ±â€Š12.6 years, BMI 33.7 ±â€Š11.4 kg/m, defect size 210.0 ±â€Š221.4 cm; 23.7% had diabetes, 13.9% were smokers, 68.7% were recurrent, and 23.6% incarcerated. Component separation was required in 43.6%, and a panniculectomy was performed in 30.0%. Wound complication was present in 27.3% of patients, with 1.7% having a mesh infection. In all, there were 53 (5.2%) hernia recurrences and 36 (3.9%) in the synthetic repairs, with a mean follow-up of 27.0 ±â€Š26.4 months. On multivariate regression (odds ratio or hazard ratio, 95% confidence interval), diabetes (1.9, 1.4-3.0), panniculectomy (2.6, 1.8-3.9), and operations requiring biologic mesh were predictors of wound complications, whereas recurrent hernia repair (2.69, 1.14-6.35), biologic mesh (3.1, 1.67-5.75), and wound complications (3.01, 1.69-5.39) were predictors of hernia recurrence. CONCLUSIONS: An open PP-VHR is a very effective means to repair large, complex, and recurrent hernias resulting in a low recurrence rate. Mesh choice in VHR is important and was associated with hernia recurrence and wound complications in this population.

The association of penicillin allergy with outcomes after open ventral hernia repair.

BACKGROUND: Up to 11% of patients report a penicillin allergy (PA), with 1-2% demonstrating a true IgE mediated allergy upon testing. PA patients often receive non-beta-lactam antibiotic surgical prophylaxis (non-BLP). This study evaluates the relationship of PA to outcomes after open ventral hernia repair (OVHR). METHODS: A prospective institutional database was queried for patients undergoing OVHR. Demographics, operative characteristics, and outcomes were evaluated by the reported PA and the administration of beta-lactam prophylaxis (BLP). RESULTS: Allergy histories were reviewed in 1178 patients. PA was reported in 21.6% of patients, with 55.5% reporting rash or hives, 15.0% airway compromise or anaphylaxis, and 29.5% no specific reaction. BLP was administered to 76.3% of patients, including 22.1% of PA patients and 89.9% of patients without PA. PA patients were more often female (64.6% PA patients vs. 56% non-PA, p = 0.01), with higher rates of chronic steroids, MRSA, anxiety, asthma, COPD, chronic pain, and sleep apnea (p < 0.03 all values). PA patients had higher rates of contaminated cases, including mesh infection and fistula. Of the 683 clean cases, 82.1% received BLP. Of the 117 clean contaminated cases (CDC wound class 2), 82.9% received BLP, which was associated with reduced long-term readmission for hernia complications (21.5 vs. 55%, p = 0.002, OR 0.27, CI 0.09-0.83). In the 120 CDC wound class 3 and 4 patients, 65.8% received BLP. In multivariate analysis, BLP was associated with lower rates of reoperation (OR 0.31, CI 0.12-0.76) and recurrence (OR 0.32, CI 0.11-0.86). BLP was given to 22.1% of the PA patients with no adverse reactions noted. CONCLUSION: PA patients had more comorbidities and complex ventral hernias. When controlling for contamination and MRSA history, BLP is associated with improved outcomes particularly in contaminated cases. PA may be a risk factor for patient complexity, and further studies are warranted to determine if allergy testing can be warranted in known or anticipated contaminated cases.

The impact of component separation technique versus no component separation technique on complications and quality of life in the repair of large ventral hernias.

BACKGROUND: Component Separation (CST) typically involves incision of one or more fascial planes to generate myofascial advancement flaps to assist with fascial closure in ventral hernia repair (VHR). The aim of this study was to compare peri-operative outcomes and quality of life (QOL) after CST versus patients without CST (No-CST) in large, preperitoneal VHR (PPVHR). METHODS: A prospective, single institution hernia study examined all patients undergoing PPVHR with synthetic mesh. Emergency and contaminated operations were excluded. A case-control cohort was identified using propensity score matching for CST and No-CST. QOL was assessed using the Carolinas Comfort Scale. RESULTS: The algorithm matched 113 CST cases to 113 No-CST cases. The groups (CST vs No-CST) were similar regarding age, BMI, diabetes, smoking, defect size, mesh size, and follow-up. In univariate analysis, there was no difference in recurrence between the CST and no-CST groups (0.9% vs 0.9%, p = 1.0) or mesh infection (0.9% vs 0.0%, p = 1.0). CST did have more wound complications (29.2% vs 16.1%, p = 0.019). When controlling for panniculectomy and diabetes with multivariate logistic regression, CST continued to have had an increased risk for wound complications (OR 2.27, CI 1.16-4.47). QOL was routinely assessed. The groups were similar pre-operatively with 76.3% of CST patients and 77.8% of No-CST patients having pain (p = 1.0). At 1, 6, 12, 24, and 36 months post-operatively, the groups had equal QOL. CONCLUSION: The use of CST versus No-CST in the repair of large VHs results in an increased risk of wound complications but does not increase the hernia recurrence rate. In the largest QOL comparative study to date, CST's generation of myofascial advancement flaps does not negatively impact patient QOL in the repair of large ventral hernias in the short or long term.

Three-dimensional hernia analysis: the impact of size on surgical outcomes.

INTRODUCTION: BMI and hernia defect size are strongly associated with outcomes after open ventral hernia repair (OVHR). The impact of abdominal subcutaneous fat (SQV), intra-abdominal volume (IAV), hernia volume (HV), and ratio of HV to intra-abdominal volume (HV:IAV, representing visceral eventration) is less clearly elucidated. This study examines the interaction of multiple markers of adiposity and hernia size in OVHR. METHODS: OVHR with preoperative CT scans were identified. 3D volumetric software measured HV, SQV, IAV, and HV:IAV was calculated. A principal component analysis was performed to create new component variables for collinear variables. Hernia PC was composed primarily of hernia dimensions, EAV (extra-abdominal volume PC) included SQV and BMI, and IAV PC included IAV. RESULTS: A total of 1178 OVHR patients had a preoperative CT scan. Their demographics included a mean age of 58.5 ± 12.4 years, BMI of 34.2 ± 7.7 kg/m2, and 57.8% were female. The mean defect area was 150.8 ± 136.7 cm2, and 66.0% were recurrent, Patients had mean SQV of 6719.4 ± 3563.9 cm3, HV of 966.9 ± 1303.5 cm3, IAV of 4250.2 ± 2118.1 cm3, and a HV:IAV of 0.29 ± 0.46. In multivariate analysis, Hernia PC was associated with panniculectomy (OR 1.52, CI 1.37-1.69) and component separation (OR 1.34, CI 1.21-1.49) and was negatively associated with fascial closure (OR 0.78, CI 0.69-0.88). Hernia PC was also associated with reoperation, readmission, and development of wound complications (OR 1.18, CI 1.08-1.30; OR 1.15, CI 1.04-1.27; OR 1.28, CI 1.16-1.41, respectively). EAV PC was associated with performance of a panniculectomy (OR 1.33, CI 1.20-1.48), readmission (OR 1.18, CI 1.06-1.32), and wound complications (OR 1.41, CI 1.27-1.57). IAV PC was not associated with adverse outcomes. CONCLUSION: Values of hernia area, volume, IAV, HV:IAV, BMI, and SQV are collinear markers of patient obesity and hernia proportions. They are distinct enough to be represented by three principal component variables, indicating more nuanced discrete influences on variability of surgical outcomes other than BMI.

Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair.

INTRODUCTION: Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR. METHODS: OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables. RESULTS: There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7 kg/m2, age of 58.5 ± 12.4 years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24 h respiratory support with ezPAP, CPAP, or biPAP (RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1 kg/m2, p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4 years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9 cm2, p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7 cm3, p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI. CONCLUSION: The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.

Correction to: Impact of age on morbidity and mortality following bariatric surgery.

This article was updated to correct the spelling of Nicholas Dugan's first name: it is correct as displayed here.