Outcomes of umbilical hernia repair in cirrhotic veterans: a VASQIP study.

PURPOSE: Umbilical hernia repair (UHR) in cirrhotics with ascites is a challenging problem associated with increased morbidity and mortality. This study examines the outcomes of UHR in veterans, comparing those undergoing elective versus emergent repair. METHODS: VASQIP was queried for all UHRs during the period 2008-2015. Data collection included demographics, operative details, Model for End-stage Liver Disease (MELD) score, and postoperative outcomes. Univariate and multivariate regression analyses were performed, and a p value of ≤ 0.05 was considered significant. RESULTS: A total of 383 patients were included in the analysis. Overall, mean age was 58.9, 99.0% were males, mean body mass index (BMI) was 26.7 kg/m2, 98.2% had American Society of Anesthesiologists (ASA) classification ≥ III, and 87.7% had independent functional status. More than 1/3 the patients underwent emergent UHR (37.6%). Compared with the elective UHR group, who underwent emergent repair were older, more likely to be functionally dependent, higher MELD score. Hypoalbuminemia, emergency repair and MELD score were found to be independent predictors of poor outcomes. CONCLUSION: UHR in cirrhotic veterans has worse outcomes when performed emergently. Diagnosis should be followed by medical optimization and elective repair, rather than waiting for an emergent indication in > 1/3 of patients.

Iatrogenic Ureteral Injury and Prophylactic Stent Use in Veterans Undergoing Colorectal Surgery.

INTRODUCTION: Iatrogenic ureteral injury (IUI) is an uncommon complication in colorectal surgery. Prophylactic ureteral stenting (PUS) gained acceptance to aid in intraoperative identification of the ureter. Despite its use, the benefit of pus to avoid IUI remains debatable. We sought to analyze the rates of IUI after colorectal surgery in veterans and to compare the outcomes after PUS using a large matched cohort. METHODS: The veterans affairs surgical quality improvement program database was queried for patients who underwent colorectal surgery from 2008-2015. To analyze the outcomes of PUS, we created two matched groups using propensity-score matching accounting for demographical and clinical cofactors to assess variable outcomes. Cross-tabulation was used to calculate rates of IUI and univariate and multivariate analyses were performed to evaluate risk factors associated with IUI. RESULTS: 27,448 patients were identified and 458 underwent PUS placement (1.6%). The majority of procedures were performed electively and with an open approach. Mean age was 65 y, 96.3% were male, and colorectal cancer was the most common indication. 45 patients (0.2%) were diagnosed with IUI. IUI incidence was higher in female patients, after left-sided colorectal resection, and in those undergoing open procedures. After matching, PUS use was associated with longer length of stay and operative time and increased creatinine levels from baseline. CONCLUSION: We demonstrated that the use of PUS is independently associated with increased operative time and change in creatinine levels. Although no IUI occurred in the PUS group, this finding was not statistically significant. The risk and/or benefit ratio of PUS should be considered for each individual case, with its selective use based on the presence of risk factors for IUI, such as female patients and left-sided resections.

Outcomes of cholecystectomy in US veterans with cirrhosis: Predicting outcomes using nomogram.

BACKGROUND: This study examines the outcomes of open and laparoscopic cholecystectomy (OC/LC) in veterans with cirrhosis and develops a nomogram to predict outcomes. METHODS: We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent cholecystectomy from 2008 to 2015. Univariate and multivariate regression were used to identify predictors of morbidity and mortality. A predictive nomogram was constructed and internally validated. RESULTS: A total of 349 patients were identified. Overall, complications occurred in 18.7% of patients, and mortality was 3.8%. LC was performed in 58.9%, and 19.2% were preformed emergently. Overall, Model for End-Stage Liver Disease score was an independent factor of morbidity and mortality, while laparoscopic approach had a protective effect on morbidity. CONCLUSIONS: Although cholecystectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing cholecystectomy is proposed.

Disparities in access to cancer surgery after Medicaid expansion.

INTRODUCTION: The Affordable Care Act (ACA) expanded Medicaid eligibility to persons with income up to 138% of the federal poverty line. We investigated how Medicaid expansion (ME) impacted the access to cancer-specific surgical care in the US. METHODS: We used a nationwide population-based database (SEER) to identify patients with the 8 most prevalent cancers between 2007 and 2015. Adjusted difference-in-differences (DiD) and multivariate regression were used for statistical analysis. RESULTS: A total of 1,008,074 patients were included. Patients post-ME were diagnosed at an earlier stage (pre-ME, 27.6%; post-ME, 31.1%; P < 0.001), and lack of insurance coverage decreased from 5.5% to 2.6% (P < 0.001). Lower-SES population had improved access to surgical care (attributable benefit +3.18%; P < 0.001). ME was an independent predictor of access-to-surgery (OR, 1.45; P < 0.001), whereas African-American and Hispanic race were negative predictive factors. CONCLUSION: After ME, the population without insurance coverage decreased. This was associated with earlier cancer diagnosis and improved access to surgery in patients from economically disadvantaged communities.

Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta-analysis.

BACKGROUND AND OBJECTIVES: This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack-knife position (P-APR) vs the classic lithotomy position (C-APR). METHODS: We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random-effect model. RESULTS: The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P-APR was associated with decreased operative time (OT) (DM, -43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5-year LR (OR, 1.00; P = 0.99). CONCLUSION: The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.