Perioperative Cerebrospinal Fluid Drain Placement Does Not Increase Venous Thromboembolism Risk After Thoracic and Fenestrated Endovascular Aortic Repair.

BACKGROUND: Venous thromboembolism (VTE) incidence after thoracic and fenestrated endovascular aortic repair (TEVAR/FEVAR) is high (up to 6-7%) relative to other vascular procedures; however, the etiology for this discrepancy remains unknown. Notably, patients undergoing TEVAR/FEVAR commonly receive cerebrospinal fluid drains (CSFDs) for neuroprotection, requiring interruption of perioperative anticoagulation and prolonged immobility. We hypothesized that CSFDs are a risk factor for VTE after TEVAR/FEVAR. METHODS: Consecutive TEVAR/FEVAR patients at a single center were reviewed (2011-2020). Cerebrospinal fluid drains (CSFDs) were placed based on surgeon preference preoperatively or for spinal cord ischemia (SCI) rescue therapy postoperatively. The primary end-point was VTE occurrence, defined as any new deep venous thrombosis (DVT) or pulmonary embolism (PE) confirmed on imaging within 30 days postoperatively. Routine postoperative VTE screening was not performed. Patients with and without VTE, and subjects with and without CSFDs were compared. Logistic regression was used to explore associations between VTE incidence and CSFD exposure. RESULTS: Eight hundred ninety-seven patients underwent TEVAR/FEVAR and 43% (n = 387) received a CSFD at some point during their care (preoperative: 94% [n = 365/387]; postoperative SCI rescue therapy: 6% [n = 22/387]). CSFD patients were more likely to have previous aortic surgery (44% vs. 37%; P = 0.028) and received more postoperative blood products (780 vs. 405 mL; P = 0.005). The overall VTE incidence was 2.2% (n = 20). 70% (14) patients with VTE had DVT, 50% (10) had PE, and 20% (4) had DVT and PE. Among TEVAR/FEVAR patients with VTE, 65% (n = 13) were symptomatic. Most VTEs (90%, n = 18) were identified inhospital and the median time to diagnosis was 12.5 (interquartile range 7.5-18) days postoperatively. Patients with VTE were more likely to have nonelective surgery (95% vs. 41%; P < 0.001), had higher American Society of Anesthesiologists classification (4.1 vs. 3.7; P < 0.001), required longer intensive care unit admission (24 vs. 12 days; P < 0.001), and received more blood products (1,386 vs. 559 mL; P < 0.001). Venous thromboembolism (VTE) incidence was 1.8% in CSFD patients compared to 3.5% in non-CSFD patients (odds ratio 0.70 [95% confidence interval 0.28-1.78, P = 0.300). However, patients receiving CSFDs postoperatively for SCI rescue therapy had significantly greater VTE incidence (9.1% vs. 1.1%; P = 0.044). CONCLUSIONS: CSFD placement was not associated with an increased risk of VTE in patients undergoing TEVAR/FEVAR. Venous thromboembolism (VTE) risk was greater in patients undergoing nonelective surgery and those with complicated perioperative courses. Venous thromboembolism (VTE) risk was greater in patients receiving therapeutic CSFDs compared to prophylactic CSFDs, highlighting the importance of careful patient selection for prophylactic CSFD placement.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Presentation and Outcomes of Elective and Nonelective Complex Endovascular Repair for Thoracoabdominal and Juxtarenal Aortic Aneurysms.

BACKGROUND: Endovascular repair of thoracoabdominal aortic aneurysms (TAAA) and juxtarenal aortic aneurysms (JAA) with fenestrated and/or branched endografts (B/FEVAR) has become common. Physician modified endografts for patients presenting with symptomatic or contained ruptures has made B/FEVAR a feasible option in nonelective settings. The purpose of this study was to describe our 10-year institutional experience with endovascular interventions for TAAA in elective and nonelective cases to evaluate differences in outcomes and the clinical risk factors associated with nonelective presentation. METHODS: A prospectively maintained database was retrospectively queried for patients undergoing B/FEVAR for TAAA and JAA at a single tertiary care academic institution between 1/2011 and 12/2020. Data collected included demographics, comorbidities, presenting symptoms, aneurysm characteristics, and clinical outcomes. Nonelective repair was defined as any patient that presented through the Emergency Department, as a hospital transfer, or as a direct admission from clinic and had aortic repair performed during the same admission. Univariate analyses were used to compare patients. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included perioperative complications and nonhome discharge. RESULTS: Between 1/201 and 12/2020, a total of 208 patients underwent B/FEVAR for TAAA (173) and JAA (35). Nonelective repair was performed in 44 (21%) patients with 39 for TAAA (23%) and 5 for JAA (14%). Nonelective patients were younger (71 ± 11 vs. 74 ± 7 years, P = 0.03), more likely to be self-pay or have Medicaid (11% vs. 2%, P = 0.02) and had a different race distribution compared to the elective cohort (P < 0.01). Thirty-day mortality was 4% (n = 6) in elective repairs and 7% (n = 3) in nonelective repairs. One-year mortality was 13% (n = 22) in elective repairs and 18% (n = 8) in nonelective repairs. There were no differences between patients receiving elective versus nonelective repair in 30-day (P = 0.40) or 1-year mortality (P = 0.47). Nonelective patients had longer median duration of stay (11 interquartile range (IQR) 6-15 vs. 5 IQR 4-8, P < 0.01), postoperative length of stay (7 IQR 5-12 vs. 4 IQR 3-7, P < 0.01), and more intensive care unit days (6 IQR 3-8 vs. 3 IQR 2-5, P < 0.01). There were no differences in other secondary outcomes between elective and nonelective patients including inpatient and access-related complications, re-interventions, and nonhome discharge (P > 0.05 for all comparisons). A composite "any complication" occurred more frequently in patients with nonelective repair (50% vs. 35%, P = 0.03). CONCLUSIONS: Endovascular repair for TAAA or JAA is a good option in patients undergoing nonelective surgical intervention, with comparable 30-day mortality, 1-year mortality, and perioperative morbidity to that of patients undergoing elective B/FEVAR.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Ventral hernia patient outcomes postoperatively housed on surgical vs non-surgical units.

BACKGROUND: Inpatient hospital units vary in staffing ratios, monitoring, procedural abilities, and experience with unique patients and diagnoses. The purpose of this study is to assess the impact of patient cohorting upon ventral hernia repair outcomes. METHODS: An IRB-approved retrospective review of open ventral hernia repairs between August 2013 and July 2017 was performed. The information of all patient locations during hospitalization, time at location, post-anesthesia care unit duration (PACU), and intensive care unit (ICU) duration was collected. Patient demographics, comorbidities, operative details, cost, and patient outcomes were analyzed. Multivariable analysis of log length of stay (LOS) was assessed with adjustment for clinical and operative factors. RESULTS: 235 patients underwent open ventral hernia repair. 179 patients were admitted to surgical units, 33 non-surgical units, and 23 stayed on both units. Clinical characteristics including patient age, gender, BMI, and medical comorbidities were similar between patients boarded on surgical versus non-surgical units. Hernia, wound, and operative data were also statistically similar. Patients admitted to non-surgical units for any duration experienced longer hospital stay (4 vs. 6 days, p < 0.001). Patients housed on a non-surgical unit were more likely to transfer rooms than patients on surgical units, 42.9% vs. 10.1% (p < 0.001), respectively. Multivariable analysis of natural log-transformed LOS showed any stay on a non-surgical unit increased LOS by 1.0 days (95% Cl 0.9-1.2 days, p = 0.026). There were no differences in ICU or PACU stay, cost, or postoperative complications in patients housed on surgical versus non-surgical units. CONCLUSIONS: Postoperative surgical patients had an increased length of stay when admitted to non-surgical units. More frequent room transfers occurred in patients admitted to non-surgical units. Evaluation of patient outcomes and LOS in open ventral hernia repair patients based on hospital unit is unique to this study.

Preoperative opioid use and incidence of surgical site infection after repair of ventral and incisional hernias.

BACKGROUND: Preoperative opioid use is a risk factor for complications after some surgical procedures. The purpose of this study was to investigate the influence of preoperative opiates on outcomes after ventral hernia repair. METHODS: With institutional review board approval, we conducted a retrospective review of consecutive ventral hernia repair cases during a 4-y period. RESULTS: A striking 48% of the total 234 patients met criteria for preoperative opioid use. Preoperative characteristics and operative details were similar between patient groups (preoperative opioid use versus no preoperative opioid use). Median duration of hospital stay trended toward an increase for opioid users versus nonopioid users (P = .06). Return of bowel function was delayed in opioid users compared with nonopioid users (P = .018). Incidence of superficial surgical site infection was increased among patients who used opioids preoperatively (27% vs 8.3%; P <.001) and remained so after multivariable logistic regression, (adjusted odds ratio 2.9, 95% confidence interval 1.2-6.7; P = .013). CONCLUSION: Among patients undergoing ventral hernia repair, those with preoperative opioid use experienced an increased incidence of superficial surgical site infection compared with patients without preoperative opioid use. Further study is needed to understand the relationship between opioid use and surgical site infection after ventral hernia repair.

The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair.

BACKGROUND: Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS. METHODS: With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013-July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors. RESULTS: Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4 days (SD = 3.3). Independent perioperative predictors (P's < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100 cm2), and age (8% increase per 10 years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7 days (95% CI 6%-24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (- 36%). CONCLUSIONS: Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.

Perioperative factors associated with pain following open ventral hernia repair.

BACKGROUND: Effective pain control following open ventral and incisional hernia repair (VHR) impacts all aspects of patient recovery. To reduce opioid use and enhance pain management, multimodal therapy is thought to be beneficial. The purpose of this study was to identify patient characteristics associated with perioperative patient-reported pain scores. METHODS: With IRB approval, surgical databases were searched for cases of open VHR performed over 3 years. Based on a retrospective chart review, modes of pain management and visual analog scale (VAS) pain scores were recorded in 12-h intervals to hospital discharge or to 8 days post-operation. Forward stepwise multivariable regression assessed the independent contribution of the perioperative factors to VAS pain scores. RESULTS: Included in the analyses were 175 patients that underwent VHR. Average age was 55 years (+/- 12.8), and half were female (50.9%). Factors independently associated with increased preoperative VAS pain scores included preoperative opioid use, preoperative open wound, CDC Wound Class II, and prior hernia repair(s). Patients with epidural for postoperative pain had significantly decreased VAS pain scores across the time continuum. Operative factors significantly associated with increased preoperative VAS pain score included median hernia defect size, concomitantly performed procedure(s), duration of operation, and estimated blood loss. Greater preoperative VAS pain score predicted increased pain at each postoperative time point (all p < .05). CONCLUSIONS: Preoperative pain and opioid use are associated with increased pain postoperatively. Epidural analgesia effectively results in decreased patient-reported pain. Increased operative complexity is associated with increased preoperative pain scores.

A comparison of short-term outcomes between laparoscopic and open emergent repair of perforated peptic ulcers.

BACKGROUND: We compared 30-day outcomes in patients undergoing emergent open and laparoscopic repair of perforated peptic ulcers in a large multicenter cohort. METHODS: Prospectively obtained data in the American College of Surgeons National Surgical Quality Improvement Program public use files from 2010 to 2016 were reviewed. Perioperative risks and outcomes were compared in unmatched and propensity-matched groups using parametric/non-parametric statistical tests as appropriate. RESULTS: A total of 4210 procedures were identified 345 (8.2%) laparoscopic and 3865 (91.8%) open. Laparoscopic repairs increased from 4.5% of 2010 cases to 11.4% of 2016 cases (p < .001). Open repair patients had more acute presentation including higher rates of ASA class, hypoalbuminemia, preoperative septic shock, dyspnea, and mechanical ventilation (all p < .01). Laparoscopic operations were longer than open procedures (p < .001). Mortality (8.5 vs. 3.5%), median length of stay (7 vs. 5 days), transfusion rates (13.7 vs. 7.0%), renal failure (3.7 vs. 1.2%), and respiratory failure (15.5 vs. 5.2%) were all worse in the unmatched open group (all p < .01). Propensity matching resulted in 342 laparoscopic and 626 open cases of similar ulcer type, demographics, ASA class, preoperative SIRS/sepsis, hypoalbuminemia, and wound class. Mortality was similar between matched groups (5.0 vs. 3.5%, p = .331). Median length of stay was longer in the open group (6 vs. 5 days, p < .001), which also had higher rates of prolonged ventilation/reintubation (9.6 vs. 5.3%, p = .019) and abdominal wall wound occurrences (6.2 vs. 2.3%, p = .042). Return to the operating room and 30-day readmissions did not differ between the matched groups. CONCLUSIONS: Emergent laparoscopic repair of perforated peptic ulcer is increasingly being performed, is safe relative to open repair (in patients without preoperative septic shock), and confers a modest benefit in terms of length of stay, respiratory, and abdominal wall wound complications.

Serial ultrasonographic evaluation of ovarian abnormalities with a morphology index.

OBJECTIVE: Transvaginal ultrasonography with tumor morphology index (MI) has been used to predict the risk of ovarian malignancy. Our objective was to analyze changes in serial MI scores for malignant and non-malignant ovarian tumors in a large and asymptomatic population. METHODS: Eligible subjects participated in the University of Kentucky Ovarian Cancer Screening Program and had abnormalities that included cysts, cysts with septations, complex cysts with solid areas, and solid masses. Analysis included: MI, change in MI (delta MI), delta MI per scan and per month, number and duration of scans. RESULTS: From 1987 to 2012, 38,983 women received 218,445 scans. Of the 7104 eligible subjects, 6758 tumors were observed without surgery and 472 were surgically removed. Eighty-six percent (5811) of observed tumors were resolved. There were 74 malignant and 272 non-malignant tumors. Eighty-five percent of malignancies had MI ≥5 at decision for surgery. The risk of malignancy based on MI was: MI=5 (3%), MI=6 (3.7%), MI=7 (12.6%), MI=8 (26.7%), MI=9 (27.8%), MI=10 (33.3%). The mean delta MI per month decreased for tumors that resolved (delta MI -1.0, p<0.001) or persisted without surgery (delta MI -0.7, p<0.001). For abnormalities surgically removed, the mean delta MI per month increased significantly more for malignancies than for benign tumors (delta MI +1.6 vs. +0.3, p<0.001). CONCLUSIONS: The mean MI for malignant ovarian tumors increases over time, while non-malignant tumors have a decreasing or stable MI. Serial MI analysis can improve the prediction of ovarian malignancy by reducing false-positive results, thereby decreasing the number of operations performed for benign abnormalities.