Global Survey on Pancreatic Surgery During the COVID-19 Pandemic.

OBJECTIVE: The aim of this study was to clarify the role of pancreatic surgery during the COVID-19 pandemic to optimize patients' and clinicians' safety and safeguard health care capacity. SUMMARY BACKGROUND DATA: The COVID-19 pandemic heavily impacts health care systems worldwide. Cancer patients appear to have an increased risk for adverse events when infected by COVID-19, but the inability to receive oncological care seems may be an even larger threat, particularly in case of pancreatic cancer. METHODS: An online survey was submitted to all members of seven international pancreatic associations and study groups, investigating the impact of the COVID-19 pandemic on pancreatic surgery using 21 statements (April, 2020). Consensus was defined as >80% agreement among respondents and moderate agreement as 60% to 80% agreement. RESULTS: A total of 337 respondents from 267 centers and 37 countries spanning 5 continents completed the survey. Most respondents were surgeons (n = 302, 89.6%) and working in an academic center (n = 286, 84.9%). The majority of centers (n = 166, 62.2%) performed less pancreatic surgery because of the COVID-19 pandemic, reducing the weekly pancreatic resection rate from 3 [interquartile range (IQR) 2-5] to 1 (IQR 0-2) (P < 0.001). Most centers screened for COVID-19 before pancreatic surgery (n = 233, 87.3%). Consensus was reached on 13 statements and 5 statements achieved moderate agreement. CONCLUSIONS: This global survey elucidates the role of pancreatic surgery during the COVID-19 pandemic, regarding patient selection for the surgical and oncological treatment of pancreatic diseases to support clinical decision-making and creating a starting point for further discussion.

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.

OBJECTIVE: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). SUMMARY BACKGROUND DATA: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. METHODS: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. RESULTS: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. CONCLUSION: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Endoscopic Management of Pancreatic Fluid Collections.

Pancreatic fluid collections (PFCs) may develop due to inflammation secondary to acute and/or chronic pancreatitis, trauma, surgery, or obstruction from solid or cystic neoplasms. PFCs can be drained percutaneously, surgically, or endoscopically with endoscopic ultrasound-guided cyst gastrostomy and/or transpapillary drainage through endoscopic retrograde cholangiopancreatography. There has been a paradigm shift in the endoscopic management of PFCs in the past few years with newer techniques including utilization of self-expanding metal stents and multiport devices. This review is a comprehensive update on the classification of PFC, indications for drainage, optimal approach, and techniques.

Cancer Survivorship: Defining the Incidence of Incisional Hernia After Resection for Intra-Abdominal Malignancy.

BACKGROUND: Cancer survivorship focuses largely on improving quality of life. We aimed to determine the rate of ventral incisional hernia (VIH) formation after cancer resection, with implications for survivorship. METHODS: Patients without prior VIH who underwent abdominal malignancy resections at a tertiary center were followed up to 2 years. Patients with a viewable preoperative computed tomography (CT) scan and CT within 2 years postoperatively were included. Primary outcome was postoperative VIH on CT, reviewed by a panel of surgeons uninvolved with the original operation. Factors associated with VIH were determined using Cox proportional hazards regression. RESULTS: 1847 CTs were reviewed among 491 patients (59 % men), with inter-rater reliability 0.85 for the panel. Mean age was 60 ± 12 years; mean follow-up time 13 ± 8 months. VIH occurred in 41 % and differed across diagnoses: urologic/gynecologic (30 %), colorectal (53 %), and all others (56 %) (p < 0.001). Factors associated with VIH (adjusting for stage, age, adjuvant therapy, smoking, and steroid use) included: incision location [flank (ref), midline, hazard ratio (HR) 6.89 (95 %CI 2.43-19.57); periumbilical, HR 6.24 (95 %CI 1.84-21.22); subcostal, HR 4.55 (95 %CI 1.51-13.70)], cancer type [urologic/gynecologic (ref), other {gastrointestinal, pancreatic, hepatobiliary, retroperitoneal, and others} HR 1.86 (95 %CI 1.26-2.73)], laparoscopic-assisted operation [laparoscopic (ref), HR 2.68 (95 %CI 1.44-4.98)], surgical site infection [HR 1.60 (95 %CI 1.08-2.37)], and body mass index [HR 1.06 (95 %CI 1.03-1.08)]. CONCLUSIONS: The rate of VIH after abdominal cancer operations is high. VIH may impact cancer survivorship with pain and need for additional operations. Further studies assessing the impact on QOL and prevention efforts are needed.

Defining intraoperative hypothermia in ventral hernia repair.

BACKGROUND: Intraoperative normothermia, a single measurement of core body temperature≥36°C, is an important quality metric outlined by the World Health Organization for the reduction of surgical site infections (SSIs). Hypothermia has been linked to SSI in colorectal and trauma patients, but the effect in ventral hernia repair (VHR) is unknown. MATERIALS AND METHODS: Patients who underwent VHR at a single institution between 2005 and 2012 were included. Temperature data were matched with National Surgical Quality Improvement Program SSI data. Novel definitions of hypothermia were explored: patient temperature nadir, percentage of time spent at the nadir, mean temperature, and time spent <36°C. Multivariable regression models were performed. RESULTS: Five hundred fifty-three patients were included with temperature recorded every 8-15 min. Mean temperature nadir was 35.7°C (±1.3°C [standard deviation]) and was not associated with SSI (odds ratio [OR], 0.938; 95% confidence interval, 0.778-1.131). The percentage of readings spent at the nadir was 31% (±31%) and was not predictive of SSI (OR, 1.471; 95% CI, 0.983-2.203). As mean temperature increased, the risk of SSI increased (OR, 1.115; 95% CI, 0.559-2.225). Percentage of temperature readings<36°C was 29% (±38%) and was not associated with SSI (OR, 1.062; 95% CI, 0.628-1.796). In all models, body mass index, smoking, and length of surgery were predictive of SSI. CONCLUSIONS: Our results demonstrate no association between temperature and SSI in VHR. Efforts to reduce SSI should focus on factors such as smoking cessation, weight loss, and length of surgery. Our study suggests that maintenance of perioperative normothermia may only decrease SSIs in certain at-risk populations.

Disease-based mortality after percutaneous endoscopic gastrostomy: utility of the enterprise data warehouse.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) remains a mainstay of enteral access. Thirty-day mortality for PEG has ranged from 16 to 43 %. This study aims to discern patient groups that demonstrate limited survival after PEG placement. The Enterprise Data Warehouse (EDW) concept allows an efficient means of integrating administrative, clinical, and quality-of-life data. On the basis of this concept, we developed the Vanderbilt Procedural Outcomes Database (VPOD) and analyzed these data for evaluation of post-PEG mortality over time. METHODS: Patients were identified using the VPOD from 2008 to 2010 and followed for 1 year after the procedure. Patients were categorized according to common clinical groups for PEG placement: stroke/CNS tumors, neuromuscular disorders, head and neck cancers, other malignancies, trauma, cerebral palsy, gastroparesis, or other indications for PEG. All-cause mortality at 30, 60, 90, 180, and 360 days was determined by linking VPOD information with the Social Security Death Index. Chi-square analysis was used to determine significance across groups. RESULTS: Nine hundred fifty-three patients underwent PEG placement during the study period. Mortality over time (30-, 60-, 90-, 180-, and 360-day mortality) was greatest for patients with malignancies other than head and neck cancer (29, 45, 57, 66, and 72 %) and least for cerebral palsy or patients with gastroparesis (7 % at all time points). Patients with neuromuscular disorders had a similar mortality curve as head and neck cancer patients. Stroke/CNS tumor patients and patients with other indications had the second highest mortality, while trauma patients had low mortality. CONCLUSIONS: PEG mortality was much higher in patients with malignancies other than head and neck cancer compared to previously published rates. PEG should be used with great caution in this and other high-risk patient groups. This study demonstrates the power of an EDW-based database to evaluate large numbers of patients with clinically meaningful results.

Rare, long-term complication after pancreatoduodenectomy-a case report of cecal volvulus.

Complications after pancreatoduodenectomy are common, and range widely in timing of presentation, relation to pancreatobiliary pathology, and necessity of operative intervention. We present a case of a 74-year-old male with history of pancreatoduodenectomy for pancreatic adenocarcinoma who presented 11 months after index operation with cecal volvulus and required emergent right hemicolectomy. Prior history of pancreatoduodenectomy with mobilization of the right colon likely predisposed him to development of this surgical emergency. Patients have altered gastrointestinal anatomy after pancreatoduodenectomy and special care is necessary to protect the afferent biliopancreatic limb during intraoperative exploration, and particularly if right colectomy is necessary.

The effect of age on short-term outcomes after pancreatic resection: a population-based study.

OBJECTIVE: To use a large population-based cohort to determine age-dependent short-term outcomes after pancreatic resection. METHODS: We identified all pancreatic resections in Texas from 1999 to 2005. Patients were stratified into 4 age groups (<60, 60-69, 70-79, and 80+ years). Bivariate and multivariate analyses were performed to determine the effect of age on mortality, discharge to home versus requiring inpatient nursing care, and length of stay. RESULTS: Three thousand seven hundred and thirty-six patients underwent pancreatic resection. Unadjusted in-hospital mortality increased with each increasing age group from 2.4% in patients <60 to 11.4% in patients 80 years and older (P < 0.0001). Likewise, postoperative lengths of stay increased with each increasing age group (P = 0.02). Age group independently predicted the need for discharge to an inpatient nursing unit rather than home (P < 0.0001), with the odds ration (OR) increasing with each increasing age group. With each increasing age group, patients were less likely to be resected at high-volume (H-V) hospitals (>10 pancreatic resections/y). Whereas low-volume (L-V) hospitals (< or =10 pancreatic resections/y) had higher mortality rates (3.2% versus 7.3%, P < 0.0001), the difference in mortality between H- and L-V hospitals was more striking in older patients. With increasing age group, mortality increased from 3.0% to 9.5% to 11.4% to 14.7% at L-V hospitals. It increased from 2.0% to 3.5% to 4.5% to 8.7% at H-V hospitals (P < 0.0001). In the multivariate model controlling for gender, race, hospital volume, year of surgery, diagnosis, risk of mortality, severity of illness, admission status, and procedure type, older age group independently predicted increased mortality. The OR for patients 60-69 years was 2.5 (P = 0.0003), the OR for patients 70-79 years was 1.8 (P = 0.02), and the OR for patients 80+ years was 4.4 (P < 0.0001) when compared with patients <60 years. CONCLUSIONS: In contrast to some previous single-institution studies, we found that increased age is an independent risk factor for mortality after pancreatic resection. For all ages, mortality rates were higher at L-V hospitals, but the difference worsened significantly with increasing age. Older patients had longer lengths of stay, were less likely to be discharged home, and more likely to require care at an inpatient nursing or acute care facility at the time of discharge.

Incidence of additional primary cancers in patients with invasive intraductal papillary mucinous neoplasms and sporadic pancreatic adenocarcinomas.

BACKGROUND: Recent small studies have reported an incidence of 23% to 39% for additional primary cancers in patients with intraductal papillary mucinous neoplasms (IPMN) of the pancreas. There have been no population-based studies evaluating this incidence rate. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database (1983 to 1991), we identified all patients with primary pancreatic cancers (sporadic and adenocarcinomas arising in IPMNs). We determined the incidence of additional primary cancers that developed either before or after the diagnosis of invasive IPMN and compared it to the incidence of additional primary cancers in patients with sporadic pancreatic adenocarcinoma. RESULTS: Nineteen thousand six hundred forty-seven patients were reported with pancreatic cancer. Ninety-five percent of cancers were sporadic and 5.0% were invasive IPMNs. Ten point three percent had one or more extra-pancreatic primary cancers in addition to their pancreatic primary (10.3% in patients with sporadic adenocarcinoma and 10.1% in patients with invasive IPMNs, p = NS). The most common sites of additional primary cancers were colorectal (20.1%), breast (19.9%), prostate (16.6%), urinary system (11.1%), and lung (9.8%). In the 2,017 patients with additional primary cancer, 86% occurred before the diagnosis of pancreatic cancer and 14% occurred after the diagnosis of pancreatic cancer. CONCLUSIONS: Our population-based analysis shows that the incidence of additional primary malignancies in patients with invasive IPMNs is 10%. Although not as high as previously reported in smaller studies, the incidence is significant and comparable to the incidence seen in patients with adenocarcinoma. Surveillance for other common malignancies in patients with IPMNs and pancreatic adenocarcinomas should be performed.

Trends and disparities in regionalization of pancreatic resection.

BACKGROUND: The current recommendation is that pancreatic resections be performed at hospitals doing >10 pancreatic resections annually. OBJECTIVE: To evaluate the extent of regionalization of pancreatic resection and the factors predicting resection at high-volume centers (>10 cases/year) in Texas. METHODS: Using the Texas Hospital Inpatient Discharge Public Use Data File, we evaluated trends in the percentage of patients undergoing pancreatic resection at high-volume centers (>10 cases/year) from 1999 to 2004 and determined the factors that independently predicted resection at high-volume centers. RESULTS: A total of 3,189 pancreatic resections were performed in the state of Texas. The unadjusted in-hospital mortality was higher at low-volume centers (7.4%) compared to high-volume centers (3.0%). Patients resected at high-volume centers increased from 54.5% in 1999 to 63.3% in 2004 (P = 0.0004). This was the result of a decrease in resections performed at centers doing less than five resections/year (35.5% to 26.0%). In a multivariate analysis, patients who were >75 (OR = 0.51), female (OR = 0.86), Hispanic (OR = 0.58), having emergent surgery (OR = 0.39), diagnosed with periampullary cancer (OR = 0.68), and living >75 mi from a high-volume center (OR = 0.93 per 10-mi increase in distance, P < 0.05 for all OR) were less likely to be resected at high-volume centers. The odds of being resected at a high-volume center increased 6% per year. CONCLUSIONS: Whereas regionalization of pancreatic resection at high-volume centers in the state of Texas has improved slightly over time, 37% of patients continue to undergo pancreatic resection at low-volume centers, with more than 25% occurring at centers doing less than five per year. There are obvious demographic disparities in the regionalization of care, but additional unmeasured barriers need to be identified.

The role of endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration in distinguishing pancreatic cystic lesions.

Distinguishing mucinous from nonmucinous cystic lesions of the pancreas often constitutes a diagnostic dilemma. The clinical management differs between such lesions; therefore it is important to make an accurate preoperative diagnosis. Various centers have reported conflicting results regarding their ability to detect mucin-producing neoplastic cells and appropriately reach a diagnosis based on endoscopic ultrasound (EUS) guided FNA. The aim of this study is to assess the ability of EUS-FNA cytology to diagnose and differentiate mucinous from nonmucinous pancreatic cystic lesions. We reviewed records of patients who underwent EUS of pancreatic cystic lesions. If FNA was performed and mucinous neoplasm was suspected, aspirate was evaluated for cytomorphology and presence of mucin. FNA results were compared to final histologic diagnosis if surgery was performed. Cytologic diagnosis was provided for 28/30 (93%). By comparing EUS-FNA diagnoses with final surgical pathology, FNA accurately diagnosed in 10/11 cases with sensitivity and specificity for detection of malignancy of 100 and 89, respectively, while the accuracy for identification of mucinous cystic neoplasms was 100%. Our results indicate that in the appropriate clinical and imaging setting, EUS-FNA cytology with analysis for mucin production by tumor cells is an important test in distinguishing pancreatic cystic lesions and guiding further management.

Pancreatic cancer in the general population: Improvements in survival over the last decade.

BACKGROUND: It is unknown whether the improved survival seen at high-volume centers has been translated to all patients with pancreatic cancer. OBJECTIVE: To use the Surveillance, Epidemiology, and End Results (SEER) database to evaluate population-based trends in surgical resection and survival. METHODS: All patients diagnosed with pancreatic cancer from 1988-1999 were identified. The survival and proportion of patients undergoing surgical resection were compared for each of three equal time periods. RESULTS: There were 24,016 patients with pancreatic cancer. 19,533 had stage data available. 9% had localized, 29% had regional, and 62% had distant disease. Resection rates increased for patients with localized and regional disease over the three time periods. Survival increased for patients with regional and distant disease. For regional pancreatic cancer patients, 2-year survival increased from 9.5% to 13.5% (p < 0.0001) and from 21.5% to 28.9% following surgical resection (p = 0.002). For resected local/regional pancreatic cancer, the year of diagnosis was and independent predictor of improved survival (p = 0.0001). CONCLUSIONS: SEER patients with regional and distant pancreatic cancer have improved survival over the past decade in both unadjusted and adjusted models. The improvement is most striking for patients with regional disease and reflects increased resection rates and improved resection techniques over time.

Management of gallstone pancreatitis.

Gallstones are the most common cause of acute pancreatitis in the western world. Most patients with ABP suffer a mild attack and are expected to make a full recovery. They can be managed supportively and undergo laparoscopic cholecystectomy with IOC during their initial hospitalization to prevent recurrence. If necessary, laparoscopic common bile duct exploration can be performed. Otherwise, postoperative ERCP can be performed to remove common bile duct stones. Patients with severe ABP require ICU admission, close clinical monitoring, and aggressive fluid resuscitation. There is a bimodal mortality in severe ABP with most late deaths caused by septic complications. Antibiotics should be used judiciously and are usually warranted only in the presence of infection or sepsis. ERCP, +/- ES, should be performed when signs of cholangitis are present. Early ERCP should be considered in patients with severe ABP who do not improve clinically. CT scanning should be performed to assess for necrosis or peripancreatic fluid collections. Patients with no fluid collections can undergo cholecystectomy once their clinical condition improves. Patients with peripancreatic fluid collections should be followed with serial CT scans. Laparoscopic cholecystectomy should be performed once resolution of the fluid collection is documented. If fluid collections do not resolve after 6 weeks, patients should undergo concurrent cholecystectomy and fluid drainage procedures. Sterile necrosis can be closely monitored and does not require necrosectomy unless the patient's clinical status deteriorates. Patients with infected necrosis should undergo necrosectomy when they are clinically stable. After recovery from an attack of severe ABP, patients require close follow-up because late complications are common. Currently, no single test can establish the diagnosis or predict the severity of ABP. A prompt diagnosis requires a high degree of suspicion and clinical acumen. Recognizing patients with severe pancreatitis is an important priority because it affects the type and timing of intervention. The management of these patients requires close clinical observation and a multidisciplinary approach between the surgeon, radiologist, gastroenterologist, and intensivist.

Interhospital transfer for acute surgical care: does delay matter?

BACKGROUND: Delays to definitive care are associated with poor outcomes after trauma and medical emergencies. It is unknown whether inter-hospital transfer delays affect outcomes for nontraumatic acute surgical conditions. METHODS: We performed a retrospective cohort study of patient transfers for acute surgical conditions within a regional transfer network from 2009 to 2013. Delay was defined as more than 24 hours from presentation to transfer request and categorized as 1 or 2+ days. The primary outcome was post-transfer death or hospice. Bivariate and multivariable logistic regression were performed. RESULTS: The cohort included 2,091 patient transfers. Delays of 2 or more days were associated with death or hospice in unadjusted analyses, but there was no difference after adjustment. Predictors of post-transfer death or hospice included older age, higher comorbidity scores, and greater severity of illness. CONCLUSIONS: Delays in transfer request were not associated with post-transfer mortality or discharge to hospice, suggesting effective triage of nontraumatic acute surgical patients.

Clinical, imaging, and cytopathological features of solid pseudopapillary tumor of the pancreas: a clinicopathologic study of three cases and review of the literature.

Solid pseudopapillary tumors are rare pancreatic neoplasms of uncertain pathogenesis that rarely metastasize and usually occur in young women. We describe the clinical, imaging, and cytopathological features of solid pseudopapillary tumor of the pancreas. We reviewed the clinical presentation, imaging, morphologic/immunochemical features, and follow-up of three women (age range 26-44). Cases 1, 2, and 3 presented with abdominal wall abscess, multiple endocrine neoplasia, and solid/cystic mass in the pancreatic head, respectively, and computed tomography of abdomen revealed solid/cystic masses with heterogeneous enhancement in body, tail and head of the pancreas, respectively. Case 2 also exhibited a left adrenal mass. Case 3 underwent endoscopic ultrasound of the pancreas, which showed a complex solid/cystic mass with septations. Sampling consisted of fine-needle aspiration (percutaneous or endosonography-guided), and additionally, core biopsy of the pancreatic mass and adrenal lesion in case 2. Aspirates and core biopsy revealed vascular structures with attached monotonous neoplastic cells in papillary-like arrays. Tumor cells had bland nuclear features with grooves, cytoplasmic periodic acid Schiff-positive hyaline globules, and associated myxoid/stromal fragments. Immunochemistry expressed alpha-1-antitrypsin, alpha-1-antichymotrypsin, vimentin, and focal neuron-specific enolase. Cases 1 and 3 underwent pancreatectomy with follow-up consisting of yearly imaging and no recurrences. Case 2 proved metastatic disease to adrenal gland and no follow-up was available. In the setting of typical clinical and imaging findings, an accurate preoperative diagnosis of pancreatic solid pseudopapillary tumor can be established by aspiration cytology and immunochemistry with or without concomitant core biopsy, on the basis of which clinicians decide treatment. This tumor can behave in a malignant fashion.

Previous Methicillin-Resistant Staphylococcus aureus Infection Independent of Body Site Increases Odds of Surgical Site Infection after Ventral Hernia Repair.

BACKGROUND: Methicillin-resistant Staphylococcus aureus infections can be difficult to manage in ventral hernia repair (VHR). We aimed to determine whether a history of preoperative MRSA infection, regardless of site, confers increased odds of 30-day surgical site infection (SSI) after VHR. STUDY DESIGN: A retrospective cohort study of patients undergoing VHR with class I to III wounds between 2005 and 2012 was performed using Vanderbilt University Medical Center's Perioperative Data Warehouse. Preoperative MRSA status, site of infection, and 30-day SSI were determined. Univariate and multivariate analyses adjusting for confounding factors were performed to determine whether a history of MRSA infection was independently associated with SSIs. RESULTS: A total of 768 VHR patients met inclusion criteria, of which 46% were women. There were 54 (7%) preoperative MRSA infections (MRSA positive); 15 (28%) soft tissue, 9 (17%) bloodstream, 4 (7%) pulmonary, 3 (6%) urinary, and 5 (9%) other. Overall SSI rate was 10% (n = 80), SSI rate in the MRSA-positive group was 33% (n = 18), compared with 9% (n = 62) in controls (p < 0.001). Multivariate analysis demonstrated that a history of MRSA infection significantly increased odds of 30-day SSI after VHR by 2.3 times (95% CI, 1.1-4.8; p = 0.035). Other factors associated with postoperative SSI were performance of myofascial release, increasing BMI, length of operation, open repair, and clean-contaminated wound classification. CONCLUSIONS: A history of site-independent MRSA infection confers significantly increased odds of 30-day SSI after VHR. Additional investigation is needed to determine perioperative treatment regimens that might decrease odds of SSI in VHR, and optimal prosthetic types and techniques for this population.

Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery.

BACKGROUND: Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations. STUDY DESIGN: A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times. RESULTS: Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01). CONCLUSIONS: In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.

Prospective evaluation of surgeon physical examination for detection of incisional hernias.

BACKGROUND: Surgeon physical examination is often used to monitor for hernia recurrence in clinical and research settings, despite a lack of information on its effectiveness. This study aims to compare surgeon-reviewed CT with surgeon physical examination for the detection of incisional hernia. STUDY DESIGN: General surgery patients with an earlier abdominal operation and a recent viewable CT scan of the abdomen and pelvis were enrolled prospectively. Patients with a stoma, fistula, or soft-tissue infection were excluded. Surgeon-reviewed CT was treated as the gold standard. Patients were stratified by body mass index into nonobese (body mass index <30) and obese groups. Testing characteristics and real-world performance, including positive predictive value and negative predictive value, were calculated. RESULTS: One hundred and eighty-one patients (mean age 54 years, 68% female) were enrolled. Hernia prevalence was 55%. Mean area of hernias was 44.6 cm(2). Surgeon physical examination had a low sensitivity (77%) and negative predictive value (77%). This difference was more pronounced in obese patients, with sensitivity of 73% and negative predictive value 69%. CONCLUSIONS: Surgeon physical examination is inferior to CT for detection of incisional hernia, and fails to detect approximately 23% of hernias. In obese patients, 31% of hernias are missed by surgeon physical examination. This has important implications for clinical follow-up and design of studies evaluating hernia recurrence, as ascertainment of this result must be reliable and accurate.

Comparative Evaluation of Dynamic Abdominal Sonography for Hernia and Computed Tomography for Characterization of Incisional Hernia.

IMPORTANCE: Previous work has demonstrated that dynamic abdominal sonography for hernia (DASH) is accurate for the diagnosis of incisional hernia. The usefulness of DASH for characterization of incisional hernia is unknown. OBJECTIVE: To determine whether DASH can be objectively used to characterize incisional hernias by measurement of mean surface area (MSA). DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted. A total of 109 adults with incisional hernia were enrolled between July 1, 2010, and March 1, 2012. Patients with a stoma, fistula, or soft-tissue infection were excluded. INTERVENTIONS: DASH was performed by a surgeon to determine the maximal transverse and craniocaudal dimensions of the incisional hernia. A separate surgeon, blinded to the DASH results, performed the same measurements using computed tomography (CT). MAIN OUTCOMES AND MEASURES: The MSA was calculated, and the difference in MSA by DASH and CT was compared using the Wilcoxon signed rank test. Subset analysis was performed with patients stratified into nonobese, obese, and morbidly obese groups. We hypothesized that there was no significant difference between MSA as measured by DASH compared with CT. RESULTS: A total of 109 patients were enrolled (mean age, 56 years; mean body mass index, 32.2 [calculated as weight in kilograms divided by height in meters squared]; and 67.0% women). The mean (SD) MSA measurements were similar between the modalities: DASH, 41.8 (67.5) cm2 and CT, 44.6 (78.4) cm2 (P = .82). The MSA measurements determined by DASH and CT were also similar for all groups when stratified by body mass index. There were 15 patients who had a hernia 10 cm or larger in transverse dimension. The mean body mass index of this group was 39.2, and the MSA measurements by DASH and CT were similar (P = .26). CONCLUSIONS AND RELEVANCE: DASH can be used to objectively characterize hernias by MSA, with accuracy demonstrated in the obese population and in patients whose hernias were very large (≥10 cm in diameter). DASH offers the advantages of real-time imaging and no ionizing radiation and may obviate the need for the patient to schedule additional imaging appointments.