Early warning: End-tidal carbon dioxide is associated with central venous oxygenation under continuous cardiorespiratory monitoring in a porcine model of hemorrhagic shock and resuscitation.

BACKGROUND: End-tidal carbon dioxide (ETCO2) has previously shown promise as a predictor of shock severity and mortality in trauma. ETCO2 monitoring is non-invasive, real-time, and readily available in prehospital settings, but the temporal relationship of ETCO2 to systemic oxygen transport has not been thoroughly investigated in the context of hemorrhagic shock. METHODS: A validated porcine model of hemorrhagic shock and resuscitation was used in male Yorkshire swine (N â€‹= â€‹7). Both ETCO2 and central venous oxygenation (SCVO2) were monitored and recorded continuously in addition to other traditional hemodynamic variables. RESULTS: Linear regression analysis showed that ETCO2 was associated with ScvO2 both throughout the experiment (ߠ​= â€‹1.783, 95% confidence interval (CI) [1.552-2.014], p â€‹< â€‹0.001) and during the period of most rapid hemorrhage (ߠ​= â€‹4.896, 95% CI [2.416-7.377], p â€‹< â€‹0.001) when there was a marked decrease in ETCO2. CONCLUSIONS: ETCO2 and ScvO2 were closely associated during rapid hemorrhage and continued to be temporally associated throughout shock and resuscitation.

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.

Impact of COVID-19 on volume of elective and nonelective ventral hernia repair.

BACKGROUND: The significant decrease in elective surgery during the COVID-19 pandemic prompted fears that there would be an increase in emergency or urgent operations for certain disease states. The impact of COVID-19 on ventral hernia repair is unknown. This study aimed to compare volumes of elective and nonelective ventral hernia repairs performed pre-COVID-19 with those performed during the COVID-19 pandemic. METHODS: An analysis of a prospective database from 8 hospitals capturing patient admissions with the International Classification of Diseases, Tenth Revision Procedure Coding System for ventral hernia repair from January 2017 through June 2021 were included. During, COVID-19 was defined as on or after March 2020. RESULTS: Comparing 3,558 ventral hernia repairs pre-COVID-19 with 1,228 during COVID-19, there was a significant decrease in the mean number of elective ventral hernia repairs per month during COVID-19 (pre-COVID-19: 61 ± 5 vs during COVID-19 19: 39 ± 11; P < .001), and this persisted after excluding the initial 3-month COVID-19 surge (61 ± 5 vs 42 ± 9; P < .001). There were fewer nonelective cases during the initial 3-month COVID-19 surge (32 ± 9 vs 24 ± 4; P = .031), but, excluding the initial surge, there was no difference in nonelective volume (32 ± 9 vs 33 ± 8; P = .560). During COVID-19, patients had lower rates of congestive heart failure (elective: 9.0% vs 6.6%; P = .0047; nonelective: 17.7% vs 11.6%; P < .001) and chronic obstructive pulmonary disease (elective: 13.7% vs 10.2%; P = .017; nonelective: 17.9% vs 12.0%; P < .001) and underwent fewer component separations (10.2% vs 6.4%; P ≤ .001). Intensive care unit admissions decreased for elective ventral hernia repairs (7.7% vs 5.0%; P = .016). Length of stay, cost, and readmission were similar between groups. CONCLUSION: Elective ventral hernia repair volume decreased during COVID-19 whereas nonelective ventral hernia repairs transiently decreased before returning to baseline. During COVID-19, patients appeared to be lower risk and less complex. The possible impact of the more complex patients delaying surgery is yet to be seen.

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

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

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

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

Impact of race and ethnicity on rates of emergent ventral hernia repair (VHR): has anything changed?

BACKGROUND: Non-white patients have been shown to have higher rates of emergent VHR, though no study to date has characterized these disparities over time. METHODS: National Surgical Quality Improvement Program (NSQIP) database was queried for VHR patients between 2008 and 2019. White, black, and hispanic patients were included for analysis. Older (2008-2011) versus New (2016-2019) time-periods were compared. The primary outcome was emergent VHR proportion. Multivariable analysis identified predictors of emergent VHR, then patients in each time-period were propensity matched (PSM) to control for confounders. RESULTS: The 665,809 VHRs between 2008 and 2019 consisted of 69.2% white, 9.7% black, and 8.1% hispanic patients. Emergent VHR rates were higher (all p < 0.001) for black (6.8%) and hispanic (5.6%) patients compared to White (4.1%). Emergent VHR rates between white vs black and white vs hispanic for both old (4.6% vs 7.4% and 4.6% vs 7.4%) and new (3.6% vs 5.8% and 3.6% vs 5.1%) groups demonstrated lower rates in White patients (all p < 0.001). Ratios of emergent VHR rates over time (old to new) remained similar (black:white 1.61-1.61; hispanic:white 1.43-1.42). Multivariable analysis showed older age, higher BMI, smoking, female sex, and increasing ASA class increased odds for emergent VHR. Comparison of PSM-groups (white-PSM vs black-PSM and white-PSM vs hispanic-PSM) for both old (5.0% vs 7.0% and 3.6% vs 6.3%) and new (3.2% vs 4.8% and 3.8% vs 5.5%) time-periods showed lower emergent VHR rates in white patients (all p < 0.001). Ratios of emergent VHR rates over time increased for black patients and decreased for Hispanic patients (black:white:1.4 to 1.5, and hispanic:white:1.75 to 1.45). CONCLUSION: Black and Hispanic patients have higher rates of emergent VHR compared to White patients, and this has not improved over time. After PSM to control for confounding variables, disparities in emergent VHR rates have increased for Black patients and decreased for Hispanic patients.

Laparoscopic versus robotic inguinal hernia repair: a single-center case-matched study.

INTRODUCTION: Robotic inguinal hernia repair (RIHR) is becoming increasingly common and is the minimally invasive alternative to laparoscopic inguinal hernia repair (LIHR). Thus far, there is little data directly comparing LIHR and RIHR. The purpose of this study will be to compare outcomes for LIHR and RIHR at a single center. METHODS: A prospective institutional hernia database was queried for patients who underwent transabdominal LIHR or RIHR from 2012 to 2020. The patients were then matched based on the surgeon performing the operation (single, expert hernia surgeon) and laterality of repair. Standard descriptive statistics were used. RESULTS: There were 282 patients who met criteria for the study, 141 LIHR and 141 RIHR; 32.6% of patients in each group had a bilateral repair (p = 1.00). LIHR patients were slightly younger (54.4 ± 15.6 vs 58.6 ± 13.8; p = 0.03) but similar in terms of BMI (27.1 ± 5.1 vs 29.1 ± 2.1; p = 0.70) and number of comorbidities (2.9 ± 2.5 vs 2.6 ± 2.2; p = 0.59). Operative time was found to be longer in the RIHR group, but when evaluating RIHR at the beginning of the study versus the end of the study, there was a 50-min decrease in operative time (p < 0.01). Recurrence rates were low for both groups (0.7% vs 1.4%; p = 0.38) with mean follow-up time 13.0 ± 13.3 months. There was only one wound infection, which was in the robotic group. No patients required return to the operating room for complications relating to their surgery. There were no 30-day readmissions in the LIHR group and three 30-day readmissions in the RIHR group (p = 0.28). CONCLUSION: LIHR and RIHR are both performed with low morbidity and have comparable overall outcomes. The total charges were increased in the RIHR group. Either LIHR or RIHR may be considered when performing inguinal hernia repair and should depend on surgeon and patient preference; continued evaluation of the outcomes is warranted.

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

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

Hernia recurrence after primary repair of small umbilical hernia defects.

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

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.

Nationwide Readmissions Analysis of Minimally Invasive Versus Open Ventral Hernia Repair: A Retrospective Population-Based Study.

INTRODUCTION: Minimally invasive ventral hernia repair (MISVHR) has been performed for almost 30 years; recently, there has been an accelerated adoption of the robotic platform leading to renewed comparisons to open ventral hernia repair (OVHR). The present study evaluates patterns and outcomes of readmissions for MISVHR and OVHR patients. METHODS: The Nationwide Readmissions Database (NRD) was queried for patients undergoing OVHR and MISVHR from 2016 to 2018. Demographic characteristics, complications, and 90-day readmissions were determined. A subgroup analysis was performed to compare robotic ventral hernia repair (RVHR) vs laparoscopic hernia repair (LVHR). Standard statistical methods and logistic regression were used. RESULTS: Over the 3-year period, there were 25 795 MISVHR and 180 635 OVHR admissions. Minimally invasive ventral hernia repair was associated with a lower rate of 90-day readmission (11.3% vs 17.3%, P < .01), length of stay (LOS) (4.0 vs 7.9 days, P < .01), and hospital charges ($68,240 ± 75 680 vs $87,701 ± 73 165, P < .01), which remained true when elective and non-elective repairs were evaluated independently. Postoperative infection was the most common reason for readmission but was less common in the MISVHR group (8.4% vs 16.8%, P < .01). Robotic ventral hernia repair increased over the 3-year period and was associated with decreased LOS (3.7 vs 4.1 days, P < .01) and comparable readmissions (11.3% vs 11.2%, P = .74) to LVHR, but was nearly $20,000 more expensive. In logistic regression, OVHR, non-elective operation, urban-teaching hospital, increased LOS, comorbidities, and payer type were predictive of readmission. CONCLUSIONS: Open ventral hernia repair was associated with increased LOS and increased readmissions compared to MISVHR. Robotic ventral hernia repair had comparable readmissions and decreased LOS to LVHR, but it was more expensive.

A case of recurrent pneumatosis intestinalis.

Pneumatosis intestinalis (PI), defined as free gas in the bowel wall, is associated with autoimmune conditions, drugs, pulmonary disease and many other etiologies. Patients with findings of PI may have variable clinical presentations, ranging from asymptomatic to acute abdomen necessitating urgent surgery. Here, we present the case of an individual with recurrent PI whose suspected etiologies ultimately varied from benign to lethal between visits. We discuss the clinical management of each case, perform post-hoc application of a proposed treatment algorithm, and highlight areas for future research.