Predictors of postoperative opioid use in ventral and incisional hernia repair.

BACKGROUND: One in two ventral and incisional hernia repair (VIHR) patients have preoperative opioid prescription within a year before procedure. The study's aim was to investigate risk factors of increased postoperative prescription filling in patients with or without preoperative opioid prescription. METHODS: VIHR cases from 2013 to 2017 were reviewed. State prescription drug monitoring program data were linked to patient records. The primary endpoint was cumulative opioid dose dispensed through post-discharge day 45. Morphine milligram equivalent (MME) was used for uniform comparison. RESULTS: 205 patients were included in the study (average age 53.5 years; 50.7% female). Over 35% met criteria for preoperative opioid use. Preoperative opioid tolerance, superficial wound infection, current smoking status, and any dispensed opioids within 45 days of admission were independent predictors for increased postoperative opioid utilization (p < 0.001). CONCLUSION: Preoperative opioid use during 45-day pre-admission correlated strongly with postoperative prescription filling in VIHR patients, and several independent risk factors were identified.

Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use.

INTRODUCTION: Appropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients. METHODS: National Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors. RESULTS: One thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs. CONCLUSIONS: We conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.

Surgical Site Infections in Colorectal Resections: What is the Cost?

INTRODUCTION: Although surgical site infections (SSIs) associated with colectomy are tracked by the National Healthcare Safety Network/Center for Disease Control, untracked codes, mainly related to patients undergoing proctectomy, are not. These untracked codes are performed less often yet they may be at a greater risk of SSI due to their greater complexity. Determining the impact and predictors of SSI are critical in the development of quality improvement initiatives. METHODS: Following an institutional review board approval, National Surgery Quality Improvement Program, institutional National Surgery Quality Improvement Program, and financial databases were queried for tracked colorectal resections and untracked colorectal resections (UCR). National data were obtained for January 2019-December 2019, and local procedures were identified between January 2013 and December 2019. Data were analyzed for preoperative SSI predictors, operative characteristics, outcomes, and 30-day postdischarge costs (30dPDC). RESULTS: Nationally, 71,705 colorectal resections were identified, and institutionally, 2233 patients were identified. UCR accounted for 7.9% nationally and 11.8% of all colorectal resections institutionally. Tracked colorectal resection patients had a higher incidence of SSI predictors including sepsis, hypoalbuminemia, coagulopathy, hypertension, and American Society of Anesthesiologists class. UCR patients had a higher rate of SSIs [12.9% (P < 0.001), 15.2% (P = 0.064)], readmission, and unplanned return to the operating room. Index hospitalization and 30dPDC were significantly higher in patients experiencing an SSI. CONCLUSIONS: SSI was associated with nearly a two-fold increase in index hospitalization costs and six-fold in 30dPDC. These data suggest opportunities to improve hospitalization costs and outcomes for patients undergoing UCR through protocols for SSI reduction and preventing readmissions.

Comparative long-term effectiveness between ventral hernia repairs with biosynthetic and synthetic mesh.

BACKGROUND: Debate exists regarding the most appropriate type of mesh to use in ventral hernia repair (VHR). Meshes are broadly categorized as synthetic or biologic, each mesh with individual advantages and disadvantages. More recently developed biosynthetic mesh has characteristics of both mesh types. The current study aims to examine long-term follow-up data and directly compare outcomes-specifically hernia recurrence-of VHR with biosynthetic versus synthetic mesh. METHODS: With IRB approval, consecutive cases of VHR (CPT codes 49,560, 49,561, 49,565, and 49,566 with 49,568) performed between 2013 and 2018 at a single institution were reviewed. Local NSQIP data was utilized for patient demographics, perioperative characteristics, CDC Wound Class, comorbidities, and mesh type. A review of electronic medical records provided additional variables including hernia defect size, postoperative wound events to six months, duration of follow-up, and incidence of hernia recurrence. Longevity of repair was measured using Kaplan-Meier method and adjusted Cox proportional hazards regression. RESULTS: Biosynthetic mesh was used in 101 patients (23%) and synthetic mesh in 338 (77%). On average, patients repaired using biosynthetic mesh were older than those with synthetic mesh (57 vs. 52 years; p = .008). Also, ASA Class ≥ III was more common in biosynthetic mesh cases (70.3% vs. 55.1%; p = .016). Patients repaired with biosynthetic mesh were more likely than patients with synthetic mesh to have had a prior abdominal infection (30.7% vs. 19.8%; p = .029). Using a Kaplan-Meier analysis, there was not a significant difference in hernia recurrence between the two mesh types, with both types having Kaplan Meir 5-year recurrence-free survival rates of about 72%. CONCLUSION: Using Kaplan-Meier analysis, synthetic mesh and biosynthetic mesh result in comparable hernia recurrence rates and surgical site infection rates in abdominal wall reconstruction patients with follow-up to as long as five years.

Emergent and urgent ventral hernia repair: comparing recurrence rates amongst procedures utilizing mesh versus no mesh.

BACKGROUND: The decision for emergent and urgent ventral hernia repair (VHR) is driven by acute symptomatology, concern for incarceration and strangulation, and perforation. Although mesh has been established to reduce hernia recurrences, the potential for mesh complications may impact the decision for utilization in emergent repairs. This study evaluates hernia repair outcomes in the emergent setting with/without mesh. METHODS: An IRB-approved review of NSQIP and retrospective chart review data of emergent/urgent VHRs performed between 2013 and 2017 was conducted at a single academic institution. Six-month postoperative emergency department and surgery clinic visits, hospital readmissions, and hernia recurrences were recorded. Patients were grouped based on mesh utilization. Perioperative and outcome variables were compared using Chi-square, Fisher's exact, and t-tests. RESULTS: Among 94 patients, 41 (44%) received mesh; 53 (56%) did not. Synthetic mesh was used in 27 cases (65.9%); bioresorbable or biologic mesh was used in 14 cases (34.1%). ASA class (p = 0.016) was higher in the no-mesh group, as were emergent vs. urgent cases (p ≤ 0.001). Preoperative SIRS/Sepsis, COPD, and diabetes were increased in the no-mesh group. Hernia recurrence was significantly higher in the no-mesh group vs. the mesh group (24.5% vs. 7.3%, p = 0.03). No difference was found in wound complications between groups. ED visits occurred almost twice as often in the mesh group (42% vs. 23%, p = 0.071). Postoperative surgery clinic visits were more frequent among the mesh group (> 1 visit 61% vs. 24%, p = 0.004). CONCLUSIONS: Mesh-based hernia repairs in the urgent/emergent patient population are performed in fewer than half of patients in our tertiary care referral center. Repairs without mesh were associated with over a three-fold increase in recurrence without a difference in the risk of infectious complications. Efforts to understand the rationale for suture-based repair compared to mesh repair are needed to reduce hernia recurrences in the emergent population.

Treatment of bone loss in CKD5D: Better survival in patients with non-high bone turnover.

67% of CKD5D patients have low bone mass and present with high (HTO) or non-high (N-HTO) bone turnover. HTO has excessive resorption calling for anti-resorbers, while in N-HTO, anabolic therapy appears preferable. There are no data on this tailored approach. Adult CKD5D patients with dual energy X-ray absorptiometry (DXA) t-scores ≤ -1.0 were enrolled into this 12-month randomized controlled trial and stratified as HTO or N-HTO using values of parathyroid hormone (PTH), PTH-ratio, and TRAP5b. HTO patients were randomized into treatment with alendronate or controls, and N-HTO patients into teriparatide or controls. Clinical, lab, DXA, quantitative computed tomography bone mineral density (QCT BMD), and coronary artery calcifications (CAC) and aorta calcifications (AoC) MSQCT data were obtained at 0 and 12 months. Primary outcome was change (Δ) in BMD by QCT, secondary outcomes were changes in CAC (ΔCAC), in AoC (ΔAoC), and death. There were 80 HTO and 61 N-HTO patients. Median HTO baseline PTH was 664 and N-HTO 183. Bone loss improved in treated N-HTO (5.7 g/cm3 vs. -10.7) but not in HTO (0.2 g/cm3 vs. -3.5) patients. There were no differences in ΔAoC or ΔCAC between treatment groups in either arm. Across all patients in the study, ΔAoC was lower in Blacks than Whites. (3.6 vs. 8.8) The HTO ΔAoC was 5 Hounsfield Units higher than N-HTO. In N-HTO, there were 0 deaths, but 20% in HTO (p = 0.005). N-HTO patients (PTH range 138 - 337 pg/mL) had better survival and less ΔAoC than those with HTO. Teriparatide treatment significantly improved low bone mass in N-HTO patients. Blacks had less ΔAoC regardless of turnover or treatment.

Predictors of Liver Failure in Non-Cirrhotic Patients Undergoing Hepatectomy.

BACKGROUND: Post-hepatectomy liver failure (PHLF) is associated with high mortality following liver resection. There have been limited studies evaluating predictors of PHLF and clinically significant PHLF in non-cirrhotic patients. METHODS: This was a retrospective cohort study using the National Surgical Quality Improvement Program database (NSQIP) to evaluate 8,093 non-cirrhotic patients undergoing hepatectomy from 2014 to 2018. Primary endpoints were PHLF and clinically significant PHLF (PHLF grade B or C). RESULTS: Among all patients, 4.74% (n = 383) developed PHLF and 2.5% clinically significant PHLF (n = 203). The overall 30-day mortality was 1.35% (n = 109), 11.5% (n = 44) in patients with PHLF, and 19.2% in those with clinically significant PHLF. Factors associated with PHLF were: metastatic liver disease (OR = 1.84, CI = 1.14-2.98), trisectionectomy (OR = 3.71, CI = 2.59-5.32), right total lobectomy (OR = 4.17, CI = 3.06-5.68), transfusions (OR = 1.99, CI = 1.52-2.62), organ/space SSI (OR = 2.84, CI = 2.02-3.98), post-operative pneumonia (OR = 2.43, CI = 1.57-3.76), sepsis (OR = 2.27, CI = 1.47-3.51), and septic shock (OR = 5.67, CI = 3.43-9.36). Patients who developed PHLF or clinically significant PHLF had 2-threefold increased risk of perioperative mortality. Post-hepatectomy renal failure (OR = 8.47, CI = 3.96-18.1), older age (OR = 1.04, CI = 1.014-1.063), male sex (OR = 1.83, CI = 1.07-3.14), sepsis (OR = 2.96, CI = 1.22-7.2), and septic shock (OR = 3.92, CI = 1.61-9.58) were independently associated with 30-mortality in patients with clinically significant PHLF. CONCLUSION: PHLF in non-cirrhotic patients increased the risk of perioperative mortality and is associated with the extent of hepatectomy and infectious complications. Careful evaluation of the liver remnant, antibiotic prophylaxis, nutritional assessment, and timely management of post-operative infections could decrease major morbidity and mortality following hepatectomy.

Lung Cancer in Young Adults: A Single-Center Experience.

OBJECTIVE: This single-center retrospective review examines the unique characteristics of young patients (ages 18 to 40 years) who were diagnosed as having non-small-cell lung cancer (NSCLC) at Markey Cancer Center, the only National Cancer Institute-designated cancer center in the state of Kentucky. METHODS: This retrospective study examines adult patients with NSCLC who were between ages 18 and 40 at diagnosis. Patients diagnosed between 2012 and 2018 were included. The final cohort consisted of 35 patients. The data collected included patient demographic information, tumor topography, clinical stage, cell type, treatment information/dates, metastasis, and survival data. RESULTS: In total, 36 of 3246 total NSCLC cases treated at Markey Cancer Center from 2012 to 2018 were diagnosed in adults aged 18 to 40 (1.11%); 35 of these 36 patients were included in our cohort. The majority (22; 62.86%) presented at an advanced stage of disease (stage III or IV). Furthermore, our cohort consisted of a strong majority of female patients (24; 68.57%). The most common histological type was adenocarcinoma (14; 40.00%). The 5-year survival rate was 47% (standard error 9%). CONCLUSIONS: Lung cancer is rare in young patients; when present, often it presents at the advanced stage. Despite many diagnostic tools and treatment modalities available, long-term survival remains poor. Our experience showed a small proportion of patients with NSCLC aged 18 to 40 at diagnosis; among this unique patient population, there is a predominance of smokers, women, adenocarcinoma, and advanced disease.

Revascularization of intermittent claudicants leads to more chronic limb-threatening ischemia and higher amputation rates.

BACKGROUND: There is an increasing incidence of peripheral arterial disease (PAD). The most common symptomatic presentation of PAD is intermittent claudication (IC), reproducible leg pain with ambulation. The progression of symptoms beyond IC is rare, and a nonprocedural approach of smoking cessation, supervised exercise therapy, and best medical therapy can mitigate progression of IC. Despite the lack of limb- or life-threatening sequelae of IC, invasive treatment strategies of IC have experienced rapid growth. Within our health care system, PAD is treated by multiple disciplines with varying practice patterns, providing an opportunity to investigate the progression of IC based on treatment strategy. This study aims to compare PAD progression and amputation in patients with IC with and without revascularization. METHODS: This institutional review board-approved, single institute retrospective study reviewed all patients with an initial diagnosis of IC between June 11, 2003, and April 24, 2019. Revascularization was defined as endovascular or open. Time to chronic limb-threatening ischemia (CLTI) diagnosis and amputation were stratified by revascularization status using the Kaplan-Meier method. The association between revascularization status and each of CLTI progression and amputation using multivariable Cox regression, adjusting for demographic and clinical potential confounding variables was assessed. RESULTS: We identified 1051 patients who met the inclusion criteria. Of these patients, 328 had at least one revascularization procedure and 723 did not. The revascularized group was younger than the nonrevascularized group (60.3 years vs 62.1 years; P = .013). There was no significant difference in sex or comorbidities in the two groups other than a higher rate of diabetes mellitus type 2 (32.3% vs 16.3%; P < .001) and COPD (4.3% vs 1.7%; P = .017) in the revascularized group. Multivariable Cox regression found revascularization of patients with IC to be significantly associated with the progression to CLTI (hazard ratio, 2.9; 95% confidence interval, 2.0-4.2) and amputation (hazard ratio, 4.5; 95% confidence interval, 2.2-9.5). These findings were also demonstrated in propensity-matched cohorts of 218 revascularized and 340 nonrevascularized patients. CONCLUSIONS: Revascularization of patients with IC is associated with an increased rate of progression to CLTI and increased amputation rates. Given these findings, further studies are required to identify which, if any, patients with IC benefit from revascularization procedures.

Demonstration of a U.S. nationwide reduction in transfusion in general surgery and a review of published transfusion reduction methodologies.

BACKGROUND: Red blood cell transfusions in surgical procedures can be lifesaving. However, recent studies show transfusions are associated with a dose-dependent increase in postoperative morbidity and mortality; hospitals and physicians have attempted to reduce them. We sought to determine the success of these efforts and review and summarize published reduction methods employed. STUDY DESIGN/METHODS: An analysis of transfusion data from ACS-NSQIP public use files of general surgical procedures for 2012 and 2018; a retrospective review of the literature surrounding general surgical transfusion reduction from 2008 to 2018. RESULTS: The rate of general surgical transfusion in the NSQIP dataset decreased from 5.5% in 2012 to 4.0% in 2018, a 27% relative reduction in transfusion. After extensive multivariable adjustment for patient risk and operative complexity, this effect remained (Odds ratio 0.65, 95% CI 0.63-0.67, p < .001). Furthermore, there was a positive correlation between specific procedure decreases in transfusion and decreases in 30-day morbidity (rho =0.41, p = .003) and mortality (rho = 0.37, p = .007). There were 866 published studies matching our search term "red blood cell transfusion reduction." Forty-four were relevant to general surgery. Seven dominant strategies for transfusion reduction by descending frequency of report included restrictive transfusion thresholds, management of preoperative anemia, perioperative interventions, educational programs, electronic clinical decision support, waste reduction, and audits of transfusion practices. CONCLUSION: Our study demonstrates a 27% decrease in general surgery transfusion between 2012 and 2018 with associated reductions in morbidity and mortality, suggesting published employed strategies have been successful and safely implemented.

The Influence of the Opioid Epidemic on Firearm Violence in Kentucky Counties.

BACKGROUND: The opioid crisis is a major public health emergency. Current data likely underestimate the full impact on mortality due to limitations in reporting and toxicology screening. We explored the relationship between opioid overdose and firearm-associated emergency department visits (ODED & FAED, respectively). METHODS: For the years 2010 to 2017, we analyzed county-level ODED and FAED visits in Kentucky using Office of Health Policy and US Census Bureau data. Firearm death certificate data were analyzed along with high-dose prescriptions from the Kentucky All Schedule Prescription Electronic Reporting records. Socioeconomic variables analyzed included health insurance coverage, race, median household earnings, unemployment rate, and high-school graduation rate. RESULTS: ODED and FAED visits were correlated (Rho = 0.29, P< 0.01) and both increased over the study period, remarkably so after 2013 (P < 0.001). FAED visits were higher in rural compared to metro counties (P < 0.001), while ODED visits were not. In multivariable analysis, FAED visits were associated with ODED visits (Std. B = 0.24, P= 0.001), high-dose prescriptions (0.21, P = 0.008), rural status (0.19, P = 0.012), percentage white race (-0.28, P = 0.012), and percentage high school graduates (-0.68, P < 0.001). Unemployment and earnings were bivariate correlates with FAED visits (Rho = 0.42, P < 0.001 and -0.32, P < 0.001, respectively) but were not significant in the multivariable model. CONCLUSIONS: In addition to recognized nonfatal consequences of the opioid crisis, firearm violence appears to be a corollary impact, particularly in rural counties. Firearm injury prevention efforts should consider the contribution of opioid use and abuse.

High Resource Utilization in Emergent Versus Elective General Surgery.

BACKGROUND: In an era of pay for performance metrics, we sought to increase understanding of factors driving high resource utilization (HRU) in emergent (EGS) versus same-day elective (SDGS) general surgery patients. METHODS: General surgery procedures from the 2016 ACS-NSQIP public use file were grouped according to the first four digits of the primary procedure CPT code. Groups having at least 100 of both elective and emergent cases were included (22 groups; 83,872 cases). HRU patients were defined as those in-hospital >7D, returned to the OR, readmitted, and/or had morbidity likely requiring an intensive care unit (ICU)stay. Independent NSQIP predictors of HRU were identified through forward regression; P for entry < 0.05, for exit > 0.10. RESULTS: Of all patients, 33% were HRU. The three highest HRU procedures (total colectomy, enterolysis, and ileostomy) comprised a higher proportion of EGS than SDGS cases (10.3 versus 2.6%, P < 0.001). The duration of operation was 40 Min lower in EGS after adjustment. Thirty-nine of the remaining 40 HRU predictors were higher in EGS including preoperative SIRS/Sepsis (50 versus 2%), ASA classification IV-V (31 versus 5%), albumin <3.5 g/dL (40 versus 12%), transfers (26 versus 2%, P's < 0.001), septuagenarians (35 versus 25%) and disseminated cancer (6.3 versus 4.8%, P's < 0.001); while sex did not differ. After adjustment, EGS patients remained more likely to be HRU (odds ratio 2.5, 95% CI 2.4 - 2.6, P < 0.001). CONCLUSIONS: EGS patients utilize significantly more resources than SDGS patients above what can be adjusted for in the clinically robust ACS-NSQIP dataset. Distinctive payment and value-based performance models are necessary for EGS.

Preoperative opioid, sedative, and antidepressant use is associated with increased postoperative hospital costs in colorectal surgery.

BACKGROUND: Opioid (OPD), sedative (SDT), and antidepressant (ADM) prescribing has increased dramatically over the last 20 years. This study evaluated preoperative OPD, SDT, and ADM use on hospital costs in patients undergoing colorectal resection at a single institution. METHODS: This study was a retrospective record review. The local ACS-NSQIP database was queried for adult patients (age ≥ 18 years) undergoing open/laparoscopic, partial/total colectomy, or proctectomy from January 1, 2013 to December 31, 2016. Individual patient medical records were reviewed to determine preoperative OPD, SDT, and AD use. Hospital cost data from index admission were captured by the hospital cost accounting system and matched to NSQIP query-identified cases. All ACS-NSQIP categorical patient characteristic, operative risk, and outcome variables were compared in medication groups using chi-square tests or Fisher's exact tests, and continuous variables were compared using Mann-Whitney U tests. RESULTS: A total of 1185 colorectal procedures were performed by 30 different surgeons. Of these, 27.6% patients took OPD, 18.5% SDT, and 27.8% ADM preoperatively. Patients taking OPD, SDT, and ADM were found to have increased mean total hospital costs (MTHC) compared to non-users (30.8 vs 23.6 for OPD, 31.6 vs 24.4 for SDT, and 30.7 vs 23.8 for ADM). OPD and SDT use were identified as independent risk factors for increased MTHC on multivariable analysis. CONCLUSION: Preoperative OPD and SDT use can be used to predict increased MTHC in patients undergoing colorectal resections.

Laparoscopic parastomal hernia repair delays recurrence relative to open repair.

BACKGROUND: Mesh repair of parastomal hernia is widely accepted as superior to non-mesh repair, yet the most favorable surgical approach is a subject of continued debate. The aim of this study was to compare the clinical outcomes of open versus laparoscopic parastomal hernia repair. METHODS: An IRB-approved retrospective review was conducted comparing laparoscopic (LPHR) or open (OPHR) parastomal hernia repair performed between 2009 and 2017 at our facilities. Patient demographics, preoperative characteristics, operative details, and clinical outcomes were compared by surgical approach. Subgroup analysis was performed by location of mesh placement. Repair longevity was measured using Kaplan-Meier method and Cox proportional hazards regression. Intention to treat analysis was used for this study based on initial approach to the repair. RESULTS: Sixty-two patients (average age of 61 years) underwent repair (31 LPHR, 31 OPHR). Patient age, gender, BMI, ASA Class, and comorbidity status were similar between OPHR and LPHR. Stoma relocation was more common in OPHR (32% vs 7%, p = .022). Open sublay subgroup was similar to LPHR in terms of wound class and relocation. Open "Other" and Sublay subgroups resulted in more wound complications compared to LPHR (70% and 48% vs 27%, p = .036). Operative duration and hospital length of stay were less with LPHR (p < .001). After adjustment for prior hernia repair, risk of recurrence was higher for OPHR (p = .022) and Open Sublay and Other subgroups compared to LPHR (p = .005 and p = .027, respectively). CONCLUSIONS: Laparoscopic repair of parastomal hernias is associated with shorter operative duration, decreased length of stay, fewer short-term wound complications, and increased longevity of repair compared to open repairs. Direct comparison of repair longevity between LPHR and OPHR with mesh using Kaplan-Meier estimate is unique to this study. Further study is warranted to better understand methods of parastomal hernia repair associated with fewer complications and increased durability.

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.

Totally extraperitoneal approach for open complex abdominal wall reconstruction.

BACKGROUND: Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes. METHODS: This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations. RESULTS: One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30-39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively. CONCLUSIONS: TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.

Hepatic Steatosis is Associated with an Increased Risk of Postoperative Infections and Perioperative Transfusion Requirements in Patients Undergoing Hepatectomy.

BACKGROUND: To determine the impact of hepatic steatosis on perioperative outcomes of patients undergoing hepatectomy. METHODS: We analyzed all hepatectomy patients with normal and fatty liver texture, between 2014 and 2018 using NSQIP. Main endpoints included perioperative transfusions (within 72 h) and infectious complications. RESULTS: A total of 8,237 patients underwent hepatectomy during the study period. The overall rate of fatty liver texture (FLG) was 31% (2,557). Operative duration was significantly longer; inflow occlusion was more common (Pringle maneuver), and the need of transfusions was significantly higher in the FLG compared to the normal liver group (NLG) (p = < 0.001). On multivariate analysis, patients in the FLG had increased risk of developing infectious complications (OR 1.22 [95%IC 1.05-1.41]) and transfusion requirements within 72 h after hepatectomy (OR 1.43 [95% CI 1.24-1.63]). CONCLUSIONS: Hepatic steatosis is an independent risk factor for the development of infectious complications and increased perioperative transfusion requirements in patients undergoing hepatectomy. Those requiring transfusions within 72 h had also an increased risk of infections after hepatectomy.

Contemporary Outcomes of Peripheral Bypass Compared with Amputation in Octogenarians.

BACKGROUND: Chronic limb threatening ischemia in octogenarians presents unique treatment challenges in patients with multiple comorbidities and variable functional status. Endovascular interventions offer a better risk profile; however, this is not always a feasible option for anatomic or disease-specific reasons. This study compares outcomes of peripheral bypass versus amputation in octogenarians. METHODS: The American College of Surgeon's National Surgical Quality Improvement Program database was queried from 2013 to 2016 for patients >80 years undergoing femoral-popliteal bypass (FPB), femoral-tibial bypass, or popliteal-tibial bypass with vein or prosthetic graft versus above-knee amputation (AKA) or below-knee amputation. Patients presenting with systemic inflammatory response syndrome, sepsis, septic shock, or a leukocytosis >11,000 were excluded. Patient demographics, risk factors, and 30-day unadjusted outcomes were analyzed. Multivariate regression analysis was then performed to compare risk adjusted 30-day morbidity and mortality. RESULTS: The bypass group contained 2226 patients compared with 1253 patients in the amputation group. AKA represented 59.9% of the amputation group. The largest portion of bypasses were FPBs at 58.6%. Total preoperative functional dependence was 1.3% for bypass versus 18.2% for amputation (P-value, <0.01). Risk factors for amputation over bypass included age, minority race, American Society of Anesthesiologists class IV-V, diabetes, congestive heart failure, dialysis, preoperative open wound, facility of origin, and functional dependence. Unadjusted 30-day mortality was 3.6% for bypasses and 7.7% for amputations (P-value, <0.01), with an in-hospital mortality of 2.0% vs. 3.2% and a mortality after discharge of 1.6% vs. 4.5%, respectively (P-value <0.01). Unadjusted morbidity was not significantly different between the 2 groups (18.7% bypass vs. 17.8% amputation, P-value, 0.52). After multivariate risk adjustment, there was no statistically significant difference in mortality or morbidity between the groups. CONCLUSIONS: Contemporary risk-adjusted 30-day morbidity and mortality for bypass versus amputation in octogenarians show no significant difference. These data demonstrate that aggressive surgical limb salvage can be safe in well-selected patients in this age group.

Naloxone Continuous Infusion for Spinal Cord Protection in Endovascular Aortic Surgery Leads to Higher Opioid Administration and More Pain.

OBJECTIVE: Compare total perioperative opioid use in patients receiving naloxone continuousinfusion (NCI) for spinal cord ischemia prophylaxis, versus patients not receiving NCI, in endovascular aortic repair. DESIGN: Single-center, retrospective cohort review. SETTING: Academic medical center. PARTICIPANTS: Patients undergoing elective thoracic, thoracoabdominal, or abdominal aortic endovascular repair. INTERVENTIONS: Patients were separated based on the use of naloxone continuous infusion as part of a spinal protection protocol. Primary endpoint was opioid requirements, in milligram morphine equivalents (MME), during the first 48 hours or during NCI. Secondary endpoints included: postoperative pain scores during the same interval; opioid requirements during hours 48 to 72; and pain scores during hours 48 to 72. MEASUREMENTS AND MAIN RESULTS: Ninety-five procedures were included; 43 received naloxone continuous infusion and 52 patients were in the non-naloxone group. Opioid use from a linear mixed model was elevated across the entire continuum in the naloxone group (18 MMEs, 95% CI 13-24), with the greatest difference seen at the 24-to-48-hour interval (51 MMEs, 95% CI 26-75) after adjustment for age, incisions, and prehospital opioid use. In the naloxone group, pain score estimates were elevated at each postoperative interval of evaluation, with similar adjustment. Across the continuum this was 0.7 higher (95% CI 0.2-1.3); the zero-six-hour and six-to-12-hour intervals were 0.9 (95% CI 0.4-1.4) and 1.2 higher (95% CI 0.7-1.7). CONCLUSIONS: Patients receiving anloxone continuous infusion to prevent spinal cord ischemia required greater quantities of opioids and had higher postoperative pain, compared with patients not requiring naloxone.

Is supplemental regional anesthesia associated with more complications and readmissions after ankle fracture surgery in the inpatient and outpatient setting?

BACKGROUND: There is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off. METHODS: Retrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014-16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA). RESULTS: 9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p<0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p<0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007). CONCLUSIONS: Patients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern. LEVEL OF EVIDENCE: III.