Systematic review of long-term effectiveness of endoscopic gastrojejunostomy in patients presenting with gastric outlet obstruction from periampullary malignancies.

BACKGROUND: Recently, endoscopic ultrasound-guided (EUS) gastrojejunostomy (GJ) has emerged as an alternative option to surgical palliation and endoscopic duodenal stenting for malignant gastric outlet obstruction (GOO). Although early success rates are commonly reported with the technique, there is a paucity of data regarding the long-term efficacy of this approach. In this study, we investigated long-term outcomes in patients that underwent EUS-guided GJ for palliation of periampullary malignancies. METHODS: From a total of 192 studies that were reviewed, 6 studies with a follow-up time frame of a minimum of 5 months were analyzed, totaling 238 patients. Outcome variables included technical success rate, clinical success rate, adverse events, symptom recurrence, and re-intervention rates. RESULTS: The cohort of 238 patients had a technical success rate of 93.7% and a clinical success rate of 92.9%. A total of 25 patients (10.5%) experienced adverse events associated with EUS-GJ. A total of 14 patients (5.9%) experienced recurrence of GOO symptoms within 5 months. A total of 14 patients (5.9%) underwent re-intervention with the first 5 months. CONCLUSIONS: This systematic review shows that data are scarce regarding long-term effectiveness of EUS-guided GJ. Even though early success rates have been reported, further studies are needed to focus on long-term efficacy of this approach. Until such studies become available, surgical palliation should continue to be the treatment of choice for patients with malignant GOO with a prolonged life expectancy.

Posterior Cranial Vault Distractor Osteogenesis for the Treatment of Chiari Malformation Type 1: A Systematic Review of the Literature.

BACKGROUND: Although posterior cranial vault distraction osteogenesis (PVDO) is utilized routinely now for the treatment of craniosynostosis, its use as a treatment option for Chiari type 1 malformation (CM1) is limited to case reports and small retrospective case series. METHODS: The authors conducted a systematic review of the published literature for PVDO as a treatment for CM1. The primary outcomes were reported complications, symptom improvement, and reoperation rates in patients that had PVDO surgery for CM1. The authors further investigated differences between patients with CM1 with an associated genetic syndrome and craniosynostosis. RESULTS: In total, 42 patients with an average age of 41.1 months were used in our analysis. A total of 38.1% of the patients had a diagnosed syndrome, 78.6% of patients had associated craniosynostosis, and 26/42 (61.9%) total patients-reported symptom improvement. Of 26 patients that reported symptom improvement, 20 (76.9%) had associated syndromes and 6 (23.1%) did not (P=0.011). In addition, of these 26 symptom improved patients, 17 (65.4%) were associated with craniosynostosis while 9 (36.4%) did not have craniosynostosis (P=0.008). CONCLUSIONS: Posterior cranial vault distraction osteogenesis seems to be a promising new surgical intervention for treatment of CM1. Most patients saw symptom improvement after treatment (61.9%). There was a clinically and statistically significant difference in symptom improvement for patients with syndromic CM1 when compared with nonsyndromic CM1 patients.

Implementation of a Patient-Tailored Opioid Prescribing Guideline in Ventral Hernia Surgery.

INTRODUCTION: Opioids are commonly prescribed beyond what is necessary to adequately manage postoperative pain, increasing the likelihood of chronic opioid use, pill diversion, and misuse. We sought to assess opioid utilization and patient-reported outcomes (PROs) in patients undergoing ventral hernia repair (VHR) following the implementation of a patient-tailored opioid prescribing guideline. METHODS: A patient-tailored opioid prescribing guideline was implemented in March of 2018 for patients undergoing inpatient VHR in a large regional healthcare system. We retrospectively assessed opioid utilization and patient-reported outcomes among patients who did (n = 42) and did not receive guideline-based care (n = 121) between March 2018 and December 2019. PROs, operative details, and patient characteristics were extracted from the Abdominal Core Health Quality Collaborative (ACHQC) registry data, and length-of-stay and prescription information were extracted from the electronic health record system at the healthcare institution. RESULTS: The milligram morphine equivalents (MME) prescribed at discharge was lower for patients receiving guideline-based care (Median = 65, interquartile range [IQR] = 50-75) than patients receiving standard care (Median = 100, IQR = 60-150). After adjusting for patient characteristics, the odds of receiving an opioid refill after discharge did not significantly differ between patient groups (P = 0.43). Patient Reported Outcomes Measurement Information System (PROMIS) pain scores and hernia-specific quality-of-life (HerQLes) scores at follow-up also did not differ between patients receiving guideline-based care (Mean PROMIS = 57.3; Mean HerQLes = 53.1) versus those that did not (Mean PROMIS = 56.7; Mean HerQLes = 46.6). CONCLUSIONS: Patients who received tailored, guideline-based opioid prescriptions were discharged with lower opioid dosages and did not require more opioid refills than patients receiving standard opioid prescriptions. Additionally, we found no differences in pain or quality-of-life scores after discharge, indicating the opioids prescribed under the guideline were sufficient for patients.

Effect of stapled versus layered skin closure on surgical site occurrences after abdominal wall reconstruction.

BACKGROUND: The effect of skin closure technique on surgical site occurrences (SSO) after open abdominal wall reconstruction (AWR) with retromuscular polypropylene mesh placement is largely unknown. We hypothesize that layered subcuticular skin closure with cyanoacrylate skin adhesive is protective of surgical site infection compared to standard stapled closure. METHODS: A retrospective review utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database of all patients at Prisma Health-Upstate. All patients with open abdominal wall reconstruction (AWR) of midline incisional hernia defects with retromuscular polypropylene mesh placement from January 2013 to February 2020 were included. Patient demographics, comorbidities, type of hernia repair with mesh location, method of skin closure, and SSOs were collected. Skin closure method was divided into two groups, reflecting a temporal change in practice: staples (historical control group) versus subcuticular suture with cyanoacrylate skin adhesive with/without polymer mesh tape (study group). Primary endpoint was SSI and SSO. Secondary endpoints were SSO or SSI requiring procedural intervention (SSOPI/SSIPI). Standard statistical methods were utilized. RESULTS: A total of 834 patients were analyzed, with 263 treated with stapled skin closure and 571 with subcuticular and adhesive closure. On univariate analysis, the incidence of SSI was significantly lower in the study group (11.8 vs 6.8%; p = 0.002), as was the need for SSIPI (11.8 vs 6.7%; p = 0.015). Rate of SSO was not significantly different between groups (28.1 vs 27.2%), but the rate of SSO requiring intervention was lower in the study group (14.1 vs 9.3%; p = 0.045). CONCLUSION: Layered skin closure technique, including subcuticular closure and adhesive, may reduce the risk of surgical site infection after open AWR. A prospective randomized trial is planned to confirm these findings.

Labor Dystocia in Nulliparous Women.

Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

Multicenter, Prospective, Longitudinal Study of the Recurrence, Surgical Site Infection, and Quality of Life After Contaminated Ventral Hernia Repair Using Biosynthetic Absorbable Mesh: The COBRA Study.

OBJECTIVE: The aim of the study was to evaluate biosynthetic absorbable mesh in single-staged contaminated (Centers for Disease Control class II and III) ventral hernia (CVH) repair over 24 months. BACKGROUND: CVH has an increased risk of postoperative infection. CVH repair with synthetic or biologic meshes has reported chronic biomaterial infections and high hernia recurrence rates. METHODS: Patients with a contaminated or clean-contaminated operative field and a hernia defect at least 9 cm had a biosynthetic mesh (open, sublay, retrorectus, or intraperitoneal) repair with fascial closure (n = 104). Endpoints included overall Kaplan-Meier estimates for hernia recurrence and postoperative wound infection rates at 24 months, and the EQ-5D and Short Form 12 Health Survey (SF-12). Analyses were conducted on the intent-to-treat population, and health outcome measures evaluated using paired t tests. RESULTS: Patients had a mean age of 58 years, body mass index of 28 kg/m, 77% had contaminated wounds, and 84% completed 24-months follow-up. Concomitant procedures included fistula takedown (n = 24) or removal of infected previously placed mesh (n = 29). Hernia recurrence rate was 17% (n = 16). At the time of CVH repair, intraperitoneal placement of the biosynthetic mesh significantly increased the risk of recurrences (P ≤ 0.04). Surgical site infections (19/104) led to higher risk of recurrence (P < 0.01). Mean 24-month EQ-5D (index and visual analogue) and SF-12 physical component and mental scores improved from baseline (P < 0.05). CONCLUSIONS: In this prospective longitudinal study, biosynthetic absorbable mesh showed efficacy in terms of long-term recurrence and quality of life for CVH repair patients and offers an alternative to biologic and permanent synthetic meshes in these complex situations.

Standard laparoscopic versus robotic retromuscular ventral hernia repair.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) demonstrates comparable recurrence rates, but lower incidence of surgical site infection (SSI) than open repair. Delayed complications can occur with intraperitoneal mesh, particularly if a subsequent abdominal operation is required, potentially resulting in bowel injury. Robotic retromuscular ventral hernia repair (RRVHR) allows abdominal wall reconstruction (AWR) and extraperitoneal mesh placement previously only possible with open repair, with the wound morbidity of LVHR. METHODS: All LVHR and RRVHR performed in our institution between June 2013 and May 2015 contained in the Americas Hernia Society Quality Collaborative database were analyzed. Continuous bivariate analysis was performed with Student's t test. Continuous nonparametric data were compared with Chi-squared test, or Fisher's exact for small sample sizes. p values <0.05 were considered significant. RESULTS: We compared 103 LVHR with 53 RRVHR. LVHR patients were older (60.2 vs. 52.9 years; p = 0.001), but demographics were otherwise similar between groups. Hernia width was similar (6.9 vs. 6.5 cm, p = 0.508). Fascial closure was achieved more often with RRVHR (96.2 vs. 50.5 %; p < 0.001) and aided by myofascial release in 43.4 %. Mesh was placed in an intraperitoneal position in 90.3 % of LVHR and extraperitoneal in 96.2 % of RRVHR. RRVHR operative time was longer (245 vs. 122 min, p < 0.001). Narcotic requirement was similar between LVHR and RRVHR (1.8 vs. 1.4 morphine equivalents/h; p = 0.176). Seroma was more common after RRVHR (47.2 vs. 16.5 %, p < 0.001), but SSI was similar (3.8 vs. 1 %, p = 0.592). Median length of stay was shorter after RRVHR (1 vs. 2 days, p = 0.004). Direct hospital cost was similar (LVHR $13,943 vs. RRVHR $19,532; p = 0.07). CONCLUSION: RRVHR enables true AWR, with myofascial release to offset tension for midline fascial closure, and obviates the need for intraperitoneal mesh. Perioperative morbidity of RRVHR is comparable to LVHR, with shorter length of stay despite a longer operative time and extensive tissue dissection.

Risks of subsequent abdominal operations after laparoscopic ventral hernia repair.

INTRODUCTION: Laparoscopic ventral hernia repair (LVHR) with intraperitoneal mesh placement is well established; however, the fate of patients requiring future abdominal operations is not well understood. This study identifies the characteristics of LVHR patients undergoing reoperation and the sequelae of reoperation. METHODS: A retrospective review of a prospectively maintained database at a hernia referral center identified patients who underwent LVHR between 2005 and 2014 and then underwent a subsequent abdominal operation. The outcomes of those reoperations were collected. Data are presented as a mean with ranges. RESULTS: A total of 733 patients underwent LVHR. The average age was 56.5 years, BMI 33.9 kg/m2, hernia size 115 cm2 (range 1-660 cm2), and mesh size 411 cm2 (range 17.7-1360 cm2). After a mean follow-up of 19.4 months, the overall hernia recurrence rate was 8.4 %. Subsequent abdominal operations were performed in 17 % (125 patients) at a mean 2.2 years. The most common indication for reoperation was recurrent hernia (33 patients, 26.4 %), followed by bowel obstruction (18 patients, 14.4 %), hepatopancreaticobiliary (17 patients, 13.6 %) and infected mesh removal (15 patients, 12 %), gynecologic (10 patients, 8 %), colorectal (8 patients, 6.4 %), bariatric (4 patients, 3 %), trauma (1 patient, 0.8 %), and other (19 patients, 15 %). The overall incidence of enterotomy or unplanned bowel resection (EBR) at reoperation was 4 %. This occurred exclusively in those reoperated for complete bowel obstruction, and the reason for EBR was mesh-bowel adhesions. No other indication for reoperation resulted in EBR. The incidence of secondary mesh infection after subsequent operation was 2.4 %. CONCLUSION: In a large consecutive series of LVHR, the rate of abdominal reoperation was 17 %. Generally, these reoperations can be performed safely. A reoperation for bowel obstruction, however, may carry an increased risk of EBR as a direct result of mesh-bowel adhesions. Secondary mesh infection after reoperation, although rare, may also occur. Surgeons should discuss with their patients the potential long-term implications of having an intraperitoneal mesh and how it may impact future abdominal surgery.

Superiority of Roeder's Knot for Fascial Mesh Fixation in a Cadaveric Model.

OBJECTIVE: This study compares the use of Roeder's knot (1:3:1, 1 hitch, 3 winds, and 1 locking hitch) to the surgeon's knot regarding the security of the knot and predictability of its position. METHOD: A polypropylene mesh was secured to the undersurface of the abdominal wall of a fresh frozen cadaver using tacks. Eight standardized transfascial sutures were performed. Four of them were secured with surgeon's knot and the remaining 4 were tied with Roeder's knot. A Mosquito hemostat was placed between the mesh and the stitch loop and the distance between its jaws was measured. We then created subcutaneous flap and measured the vertical distance between the knot and the anterior sheath. RESULTS: When surgeon's knot was used, the distance between the mesh and the stitch loop ranged between 4 and 6 mm. This distance could not be measured when Roeder's knot was used due to inability to place hemostat between the mesh and the stitch loop. The vertical length between the anterior sheath and the surgeon knot ranged between 3 and 13 mm while remaining consistent at 2 mm when Roeder's knot was applied. CONCLUSIONS: This study shows that Roeder's knot is superior to the regular sliding knot in securing the mesh to the abdominal wall. It can be tightened appropriately and leads to less variation when used properly. It has many other applications that stem from its ability to be advanced with different degrees of tightness based on body habitus and the operative requirements.

Effect of surgeon-patient sex discordance on ventral hernia repair outcomes.

PURPOSE: Concordance is an important dimension of the physician-patient relationship that may be linked to health care disparities. The purpose of this study was to determine if sex discordance between surgeon and patient impacts surgical outcomes. METHODS: A retrospective review of prospectively collected data obtained from the Abdominal Core Health Quality Collaborative (ACHQC) registry was performed on all patients who underwent ventral hernia repair. Surgical site occurrences (SSO), surgical site infections (SSI), surgical site occurrence requiring procedural intervention (SSOPI) and 30-day readmission rates were recorded. RESULTS: Female patients operated on by male surgeons have increased odds of having an SSI/SSO (OR 1.099, 95% CI 1.022-1.181), SSOPI (OR 1.156, 95% CI 1.031-1.297), and readmission (OR 1.259, 95% CI 1.128-1.406) when compared to male patients operated on by male surgeons. There was no significant difference in adverse outcomes between patient groups when operated on by female surgeons. CONCLUSION: Sex discordance between surgeon and patient is associated with increased odds adverse outcomes when male surgeons operate on female patients.

Effect of antiplatelet and anticoagulant therapy on bleeding complications following ventral hernia repair: An ACHQC analysis.

BACKGROUND: We investigate the effect of antiplatelet and anticoagulant medications on bleeding complications in patients undergoing ventral hernia repair. METHODS: The Abdominal Core Health Quality Collaborative registry was queried from 2013 to 2022 for patients who underwent ventral hernia repair, evaluating the association between antiplatelet or anticoagulant use and bleeding complications. RESULTS: 37,973 patients underwent ventral hernia repair: 11.5 â€‹% on antiplatelet therapy alone and 5.8 â€‹% on anticoagulation alone. Despite being held, an adjusted regression analysis showed that anticoagulation was associated with an increased risk for postoperative bleeding requiring transfusion (OR 2.4 [1.7-3.4], p â€‹< â€‹0.0001), reoperation for postoperative bleeding (OR 6.3 [3.9-10.0], p â€‹< â€‹0.0001), and readmission for bleeding complications (OR 4.9 [2.9-8.2], p â€‹< â€‹0.0001). Antiplatelet use was not a risk factor for any postoperative bleeding complication. CONCLUSION: Despite being held preoperatively, patients on anticoagulants are at an increased risk for postoperative hemorrhagic complications. Antiplatelet therapy does not pose the same risk.

Use of Preoperative Endoscopic Capsule-Based pH Testing Before Bariatric Surgery.

BACKGROUND: Vertical sleeve gastrectomy is the most performed bariatric operation in the US; however, a significant number of patients suffer from persistent or new-onset reflux. No consensus for objective preoperative evaluation in these patients exists. We compared capsule-based pH testing vs GERD symptom scoring to determine extent of preoperative GERD to aid in procedure selection for bariatric surgery. STUDY DESIGN: An IRB-approved retrospective review of consecutive patients at a single institution was performed from April 2021 to December 2022. During initial consultation for bariatric surgery, a validated GERD symptom subjective survey was administered. All patients demonstrating interest in sleeve gastrectomy or had a history of reflux underwent upper endoscopy with capsule-based pH testing. RESULTS: Sixty-two patients underwent preoperative endoscopy with capsule-based pH testing and completed GERD symptom assessment survey(s). Median BMI was 43.4 kg/m 2 and 66.1% of patients were not taking a proton-pump inhibitor before performance of pH testing. There was negligible linear association between the objective DeMeester score obtained by capsule-based pH probe and GERD symptom survey scores. Median GERD symptom survey scores did not differ between patients with and without a diagnosis of GERD based on pH testing (all p values >0.11). CONCLUSIONS: An objective method for identifying severe GERD in the preoperative assessment may aid in the decision tree for procedure selection and informed consent process. Patients with significant preoperative GERD may be at higher risk for future GERD-related sleeve complications. Capsule-based pH testing may prove to be superior to subjective symptom scoring systems in this patient population.

Robotic repair of non-midline hernias.

Non-midline abdominal wall hernias present unique anatomic challenges, making repair more complex. The constraints of the peritoneal cavity, pelvis, and costal margin limit the utility of intraperitoneal mesh repair, and extra-peritoneal repairs have traditionally been performed using open techniques, often resulting in higher wound morbidity. Advances in minimally invasive surgery make visualization and dissection of such complex cases feasible, with all the attendant benefits of a minimally invasive over an open approach. In this study, we examined the use of the robotic platform to repair non-midline hernias. Retrospective review of all non-midline abdominal wall hernias was performed robotically at Prisma Health, excluding parastomal hernias. Study conducted and outcomes reported according to STROBE statement. Repair was performed in the retro-rectus (n = 3) or retro-rectus + transversus abdominis release (TAR) (n = 39), pre-peritoneal (n = 22), and intraperitoneal (n = 1). Mean hernia width was 9.4 cm, permanent synthetic mesh used for all repairs. Mean LOS was 1.5 days. Surgical-site occurrence (SSO) occurred in 49.2%, 78% of which were simple seroma. Three patients (4.6%) developed surgical-site infection (SSI). Two recurrences were identified with a mean follow-up of 11 mos. The robotic platform facilitates complex dissection to allow minimally invasive, extra-peritoneal repair of complex non-midline hernias. This approach overcomes the anatomic constraints of intraperitoneal mesh repair and the wound morbidity of open repair.

Outcomes of subsequent abdominal operations after an initial ventral hernia repair.

INTRODUCTION: Nearly 20% of ventral hernia repair (VHR) patients require a subsequent abdominal operation (SAO), and mesh position may impact the complexity and outcome of the SAO. METHODS: Retrospective review of VHR with mesh from 2006 to 2020 from an internal database and the ACHQC. Primary outcomes measured incidence, complexity, and complications of SAO relative to mesh position. RESULTS: SAO was required in 433 of 2539 (17.1%) patients, totaling 671 operations; 197/893 (22.1%) with intraperitoneal mesh (IPM) and 236/1646 (14.3%) with extraperitoneal mesh (EPM; p â€‹< â€‹0.001). SAO was directly related to VHR in 180 (232 total SAOs) and unrelated in 253 (439 total SAOs). There were no significant differences in complications after SAO between IPM and EPM, nor any difference in adhesion complexity. CONCLUSION: Incidence of SAO is higher with IPM, but surgical outcomes are similar. Due to the risk of secondary mesh infection with IPM, significantly more of these were removed at the time of SAO.

Impact of methocarbamol on opioid use after ventral incisional hernia repair.

BACKGROUND: Alternatives to opioid analgesia are needed to reduce the risk of abuse, misuse, and diversion. Musculoskeletal pain is a significant contributor to postoperative pain after ventral hernia repair (VHR). We report the impact of methocarbamol on opioid prescribing after VHR. METHODS: Review of all robotic and open VHR, Jan 2020-July 2022. Data was collected in the Abdominal Core Health Quality Collaborative (ACHQC) with additional chart review to assess for opioid refills. A 2:1 propensity score match was performed comparing opioid prescribing in patients prescribed vs not prescribed methocarbamol. RESULTS: 101 patients received methocarbamol compared with 202 without. Similar number of patients received an opioid prescription (87.1 vs 86.6%; p = 0.904). Study patients received significantly lower MME prescription at discharge (60 v 75; p = 0.021) with no difference in refills (12.5 vs 16.6%; p = 0.386). CONCLUSION: Addition of methocarbamol to a multimodal analgesic regimen after VHR facilitates reduction in prescribed opioid with no increase in refills.

A Novel Bio-Adhesive Mesh System for Medical Implant Applications: In Vivo Assessment in a Rabbit Model.

Injectable surgical sealants and adhesives, such as biologically derived fibrin gels and synthetic hydrogels, are widely used in medical products. While such products adequately adhere to blood proteins and tissue amines, they have poor adhesion with polymer biomaterials used in medical implants. To address these shortcomings, we developed a novel bio-adhesive mesh system utilizing the combined application of two patented technologies: a bifunctional poloxamine hydrogel adhesive and a surface modification technique that provides a poly-glycidyl methacrylate (PGMA) layer grafted with human serum albumin (HSA) to form a highly adhesive protein surface on polymer biomaterials. Our initial in vitro tests confirmed significantly improved adhesive strength for PGMA/HSA grafted polypropylene mesh fixed with the hydrogel adhesive compared to unmodified mesh. Toward the development of our bio-adhesive mesh system for abdominal hernia repair, we evaluated its surgical utility and in vivo performance in a rabbit model with retromuscular repair mimicking the totally extra-peritoneal surgical technique used in humans. We assessed mesh slippage/contraction using gross assessment and imaging, mesh fixation using tensile mechanical testing, and biocompatibility using histology. Compared to polypropylene mesh fixed with fibrin sealant, our bio-adhesive mesh system exhibited superior fixation without the gross bunching or distortion that was observed in the majority (80%) of the fibrin-fixed polypropylene mesh. This was evidenced by tissue integration within the bio-adhesive mesh pores after 42 days of implantation and adhesive strength sufficient to withstand the physiological forces expected in hernia repair applications. These results support the combined use of PGMA/HSA grafted polypropylene and bifunctional poloxamine hydrogel adhesive for medical implant applications.

Impact of methocarbamol on opioid use after primary ventral and inguinal hernia repair.

BACKGROUND: Multimodal analgesia is now a mainstay of perioperative care. Our aim is to assess the impact of adding methocarbamol on opioid use for patients undergoing primary ventral (umbilical and epigastric) hernia repair (PVHR) and inguinal hernia repair (IHR). METHODS: Retrospective review of patients undergoing PVHR and IHR who received methocarbamol, propensity score matched in a 2:1 fashion to patients not receiving methocarbamol. RESULTS: Fifty-two PVHR patients receiving methocarbamol were matched to 104 control patients. Study patients were prescribed fewer opioids (55.8 vs 90.4%; p < 0.001) and received lower MME (20 vs 50; p < 0.001), with no difference in refills or rescue opioids. For IHR, study patients received fewer prescriptions (67.3 vs 87.5%; p < 0.001) and received lower MME (25 vs 40; p < 0.001), with no difference in rescue opioid (5.9 vs 0%; p = 0.374). CONCLUSIONS: Methocarbamol significantly reduced opioid prescribing in patients undergoing PVHR and IHR without increasing the risk of refill or rescue opioid.

A Standardized Protocol for Opioid Prescribing After Surgery Decreases Total Morphine Equivalents Prescribed.

INTRODUCTION: Perioperative opioid analgesia has been extensively reexamined during the opioid epidemic. Multiple studies have demonstrated over prescription of opioids, demonstrating the need for change in prescribing practices. A standard opioid prescribing protocol was implemented to evaluate opioid prescribing trends and practices. OBJECTIVES: To evaluate opioid use after primary ventral, inguinal, and incisional hernia repair and to assess clinical factors that may impact opioid prescribing and consumption. Secondary outcomes include the number of refills, patients without opioid requirement, difference in opioid use based on patient characteristics and adherence to prescribing protocol. METHODS: This is a prospective observational study examining patients undergoing inguinal, primary ventral and incisional hernias between February and November 2019. A standardized prescribing protocol was implemented and utilized for postoperative prescribing. All data was captured in the abdominal core health quality collaborative (ACHQC) and opioid use was standardized via morphine milligram equivalents (MME). RESULTS: 389 patients underwent primary ventral, incisional, and inguinal hernia repair, with a total of 285 included in the final analysis. 170 (59.6%) of patients reported zero opioid use postoperatively. Total opioid MME prescribed and high MME consumption were significantly higher after incisional hernia repair with a greater number of refills were required. Compliance with prescribing protocol resulted in lower MME prescription, but not actual lower MME consumption. CONCLUSIONS: Implementation of a standardized protocol for opioid prescribing after surgery decreases the total MME prescribed. Compliance with our protocol significantly reduced this disparity, which has the potential for decreasing abuse, misuse, and diversion of opioids by better estimating actual postoperative analgesic requirements.

The prognostic impact of subclonal IDH1 mutation in grade 2-4 astrocytomas.

Background: Isocitrate dehydrogenase (IDH) mutations are thought to represent an early oncogenic event in glioma evolution, found with high penetrance across tumor cells; however, in rare cases, IDH mutation may exist only in a small subset of the total tumor cells (subclonal IDH mutation). Methods: We present 2 institutional cases with subclonal IDH1 R132H mutation. In addition, 2 large publicly available cohorts of IDH-mutant astrocytomas were mined for cases harboring subclonal IDH mutations (defined as tumor cell fraction with IDH mutation ≤0.67) and the clinical and molecular features of these subclonal cases were compared to clonal IDH-mutant astrocytomas. Results: Immunohistochemistry (IHC) performed on 2 institutional World Health Organization grade 4 IDH-mutant astrocytomas revealed only a minority of tumor cells in each case with IDH1 R132H mutant protein, and next-generation sequencing (NGS) revealed remarkably low IDH1 variant allele frequencies compared to other pathogenic mutations, including TP53 and/or ATRX. DNA methylation classified the first tumor as high-grade IDH-mutant astrocytoma with high confidence (0.98 scores). In the publicly available datasets, subclonal IDH mutation was present in 3.9% of IDH-mutant astrocytomas (18/466 tumors). Compared to clonal IDH-mutant astrocytomas (n = 156), subclonal cases demonstrated worse overall survival in grades 3 (P = .0106) and 4 (P = .0184). Conclusions: While rare, subclonal IDH1 mutations are present in a subset of IDH-mutant astrocytomas of all grades, which may lead to a mismatch between IHC results and genetic/epigenetic classification. These findings suggest a possible prognostic role of IDH mutation subclonality, and highlight the potential clinical utility of quantitative IDH1 mutation evaluation by IHC and NGS.

CDKN2A mutations have equivalent prognostic significance to homozygous deletion in IDH-mutant astrocytoma.

Homozygous deletion of CDKN2A/B is currently considered a molecular signature for grade 4 in IDH-mutant astrocytomas, irrespective of tumor histomorphology. The 2021 WHO Classification of CNS Tumors does not currently include grading recommendations for histologically lower-grade (grade 2-3) IDH-mutant astrocytoma with CDKN2A mutation or other CDKN2A alterations, and little is currently known about the prognostic implications of these alternative CDKN2A inactivating mechanisms. To address this, we evaluated a cohort of institutional and publicly available IDH-mutant astrocytomas, 15 with pathogenic mutations in CDKN2A, 47 with homozygous CDKN2A deletion, and 401 with retained/wildtype CDKN2A. The IDH-mutant astrocytomas with mutant and deleted CDKN2A had significantly higher overall copy number variation compared to those with retained/wildtype CDKN2A, consistent with more aggressive behavior. Astrocytoma patients with CDKN2A mutation had significantly worse progression-free (p = 0.0025) and overall survival (p < 0.0001) compared to grade-matched patients with wildtype CDKN2A, but statistically equivalent progression-free survival and overall survival outcomes to patients with CDKN2A deletion. No significant survival difference was identified between CDKN2A mutant cases with or without loss of the second allele. These findings suggest that CDKN2A mutation has a detrimental effect on survival in otherwise lower-grade IDH-mutant astrocytomas, similar to homozygous CDKN2A deletion, and should be considered for future grading schemes.