Quality of life following component separation versus standard open ventral hernia repair for large hernias.

INTRODUCTION: Component separation (CS) has become a viable alternative to repair large ventral defects when the fascia cannot be reapproximated. However, the impact of transecting the external oblique to facilitate closure of the abdomen on quality of life (QOL) has yet to be investigated. The study goal was to investigate QOL and outcomes after standard open ventral hernia repair (OVHR) versus CS for large ventral hernias. STUDY DESIGN: Prospective data for all CSs were reviewed and compared with matched OVHR controls. All defects were 100 to 1000 cm2 in size and repaired with mesh. Comorbidities, complications, outcomes, and Carolinas Comfort Scale (CCS) scores, were reviewed. RESULTS: Seventy-four CS patients were compared with 154 patients undergoing standard OVHR with similar defect sizes. Age (56.7±13.0 vs. 54.7 ± 12.3 years, P = .26), defect sizes (299 ± 160 vs. 304 ± 210 cm2, P = .87), and BMI (32.7 ± 6.9 vs. 34.2 ± 9.0 kg/m2, P = .26) were similar in both groups, respectively. There were no differences in major postoperative complications (P = .22), mesh infections (P = 1.00), wound infections (P = .07), or hernia recurrence (P = .09), but wound breakdown increased after CS (10% vs. 1%, P < .001) as did seroma interventions (15% vs. 4%, P = .005). Postoperative CCS scores were similar at 1 month (P = .82) and 1 year (P = .14). CONCLUSIONS: In the first comparative study of its kind, it is found that patient undergoing CS with mesh reinforcement had equal short- and long-term QOL outcomes compared with similar patients who underwent standard OVHR. Whereas wound breakdown and seroma formation are higher, the overall complication, mesh infection, and recurrence rates are similar.

Does ventral hernia defect length, width, or area predict postoperative quality of life? Answers from a prospective, international study.

BACKGROUND: The goal of this study was to determine if ventral hernia defect length, width, or area predict postoperative pain and quality of life following ventral hernia repair (VHR). METHODS: The International Hernia Mesh Registry, a prospective database from 40 institutions worldwide, was queried for patients undergoing VHR from October 2007 to June 2012. Laparoscopic and open VHR were evaluated separately. Width and length were stratified into large, ≥10 cm and small, <10 cm, along with area as large, ≥100 cm(2) and small, <100 cm(2). RESULTS: In total, 865 International Hernia Mesh Registry patients underwent VHR. Large defect width, length, and area had no association with hernia recurrence or reoperation in both open and laparoscopic VHR. There was a significant increase in operating room time and length of stay for large compared with small width, length, and area for open and laparoscopic VHR patients (P < 0.05). Large area was associated with increased seroma and ileus in open and laparoscopic VHR (P < 0.05). There was greater pain and activity limitation at 1 mo for large versus small width and area whether repaired laparoscopically or open (P < 0.05). When comparing large to small length, there was no difference in pain for all follow-up time points when repaired laparoscopically, but there is significantly increased odds of pain and activity limitation at 1, 6, and 12 mo when repaired open (P < 0.05). CONCLUSIONS: Patients undergoing laparoscopic or open VHR with large defect widths and total area have a greater chance of pain and activity limitation at 1-mo follow-up, but not long term. Large defect lengths are associated with increased early and chronic discomfort in open VHR only.

Laparoscopic versus open hernia repair: outcomes and sociodemographic utilization results from the nationwide inpatient sample.

INTRODUCTION: The differences and advantages of laparoscopic (LVHR) and open ventral hernia repair (OVHR) have been debated since laparoscopic hernia repair was first described. The purpose of this study is to compare LVHR and OVHR with mesh in the United States using the Nationwide Inpatient Sample (NIS). METHODS: The NIS, a representative sample of approximately 20% of all inpatient encounters in the United States, was queried for all ventral hernia repairs with graft or prosthesis in 2009 using ICD-9-CM codes. The patients were stratified into LVHR and OVHR groups. Sociodemographic data, comorbidities, complications, and outcomes were compared between groups. RESULTS: A total of 18,223 cases were documented in the NIS sample after inclusion and exclusion criteria were met. LVHR was performed in 27.6% of cases. There were no statistically significant differences in gender or mean income by zip code of residence. Mean age (58.8 years in open group vs. 58.1 years, p = 0.014) and mean Charlson score (0.97 vs. 0.77, p < 0.0001) differed significantly between groups. OVHR more often was associated with emergent admissions (21.7 vs. 15.2%, p < 0.0001). There were significant differences comparing outcomes between groups: complication rate (OVHR: 8.24 vs. LVHR: 3.97%, p < 0.0001), average length of stay (5.2 vs. 3.5 days, p < 0.0001), total charge ($45,708 vs. $35,947, p < 0.0001), frequency of routine discharge (80.8 vs. 91.1%, p < 0.0001), and mortality rate (0.88 vs. 0.36%, p = 0.0002). After controlling for confounding variables with multivariate regression, all outcomes remained significant between groups. CONCLUSIONS: Patients who have undergone LVHR with mesh had fewer complications, shorter length of stay, lower hospital charges, more frequent routine discharge, and decreased mortality compared with those who received open repair. Patient comorbidities, selection bias, and emergency operations may limit the number of patients who receive laparoscopic ventral hernia repair. Regionalization studies may better illuminate the low rates of laparoscopic surgery.

Evaluation of an innovative, cordless ultrasonic dissector.

Ultrasonic thermal energy is commonly used for dissection and vessel ligation. This study compared HARMONIC ACE and Sonicision Cordless Ultrasonic Dissector (SCUD). The devices were used in an in vivo porcine model to coagulate 189 arteries up to 5 mm. Seal times were similar: SCUD, 5.2 ± 1.7 s; ACE, 4.9 ± 1.5 s (P = .20). Burst pressures for SCUD and AVE were 578 ± 284 and 605 ± 288 mm Hg, respectively (P = .48). Stratification by vessel diameter yielded similar results. In all, 17 applications resulted in seal failure on either the proximal or distal side, with no difference between SCUD (4.4%) and ACE (6.6%; P = .37). Histological examination of 48 specimens showed similar thermal spreads: 1.06 ± 0.05 versus 1.08 ± 0.05 mm for SCUD and ACE, respectively (P = .82). In 41 timed mesenteric transections, SCUD required 24.8 ± 4.9 s, which was significantly less than the 33.8 ± 5.4 s for ACE (P < .0001), with no bleeding in either group. SCUD and ACE showed similar vessel seal times, burst pressures, thermal spreads, and seal failure rates. SCUD was more efficient than ACE in mesenteric transection.

Microwave ablation using 915-MHz and 2.45-GHz systems: what are the differences?

OBJECTIVES: This study was conducted to evaluate differences between 915-MHz and 2.45-GHz microwave ablation (MWA) systems in the ablation of hepatic tumours. METHODS: A retrospective analysis of patients undergoing hepatic tumour MWA utilizing two different systems over a 10-month period was carried out. RESULTS: Data for a total of 48 patients with a mean age of 58 ± 1.24 years were analysed. A total of 124 tumours were ablated; 72 tumours were ablated with a 915-MHz system and 52 with a 2.45-GHz system. Mean tumour diameters were 1.7 ± 0.1 cm in the 915-MHz group and 2.5 ± 0.2 cm in the 2.45-GHz group (P < 0.01). Mean ablation time per burn was 8.1 ± 0.3 min in the 915-MHz group and 4.0 ± 0.1 min in the 2.45-GHz group (P < 0.01). The mean number of burns per lesion was 2.0 ± 0.1 in the 915-MHz group and 1.7 ± 0.1 in the 2.45-GHz group (P < 0.05). The mean ablation time per lesion was 9.7 ± 0.7 min in the 915-MHz group, and 6.6 ± 0.6 min in the 2.45-GHz group (P < 0.01). The 2.45-GHz system demonstrated a better correlation between ablation time and tumour size (r(2) = 0.6222) than the 915-MHz system; (r(2) = 0.0696). Mean total energy applied per lesion, and energy applied per cm, were greater with the 915-MHz system (P < 0.05 and P < 0.01, respectively). Total energy applied per lesion was similarly correlated for the 2.45-GHz (r(2) = 0.6263) and 915-MHz (r(2) = 0.7012) systems. Mean total energy applied per cm/min was greater with the 2.45-GHz system (P < 0.05). CONCLUSIONS: Both 915-MHz and 2.45-GHz MWA systems achieve reproducible hepatic tumour ablation. The 2.45-GHz system achieves equivalent, but more predictable and faster ablations using a single antenna system.

Prospective, long-term comparison of quality of life in laparoscopic versus open ventral hernia repair.

OBJECTIVES: To compare laparoscopic ventral hernia repair (LVHR) versus open ventral hernia repair (OVHR) for quality of life (QOL), complications, and recurrence in a large, prospective, multinational study. INTRODUCTION: As recurrence rates have decreased for LVHR and OVHR, QOL has become an extremely important differentiating outcomes measure. METHODS: A prospective, international database was queried from September 2007 to July 2011 for LVHR and OVHR. Carolinas Comfort Scale (CCS) was utilized to quantify QOL (pain, movement limitation, and mesh sensation) preoperatively and at 1, 6, and 12 months postoperatively. RESULTS: A total of 710 repairs included 402 OVHR and 308 LVHR. Demographics were mean age 57.1 ± 13.3 years, 49.6% male, 21.7% recurrent hernias, mean body mass index of 30.3 ± 6.6, and mean defect size of 89.4 ± 130.8. Preoperatively, 56.9% had pain, and 53.2% experienced movement limitation. At 1-month follow-up, 587 (82.7%) patients were provided CCS scores; more LVHR patients experienced pain (P < 0.001) and movement limitations (P < 0.001). At 6 and 12 months, there were no differences in QOL with 466 (65.6%) and 478 (67.3%) patients responding, respectively. After controlling for confounding variables, LVHR was independently associated with more frequent discomfort [odds ratio (OR) = 1.9, confidence interval (CI): 1.2-3.1], movement limitation (OR = 1.6, CI: 1.0-2.7), and overall symptoms (OR = 1.6, CI: 1.0-2.6) at 1 month. LVHR resulted in a shorter length of stay (LOS) (P < 0.001) and fewer infections (P = 0.004), but overall complication rates were equal. Recurrence rates were also equal (P = 0.66). CONCLUSION: In the largest, prospective QOL study comparing LVHR and OVHR, LVHR is associated with a decrease in QOL in the short term. LOS and infection rates are decreased in LVHR, but overall complication and recurrence rates are equal.

Comparative study of wound complications: isolated panniculectomy versus panniculectomy combined with ventral hernia repair.

BACKGROUND: The resection of an abdominal pannus carries the risk of wound-related morbidity in obese patients. Surgeons often perform a panniculectomy (PAN) to gain better access to the abdomen to perform other operations. We evaluated the incidence of wound complications after PAN with and without a concomitant procedure (i.e., ventral hernia repair [VHR]). METHODS: We reviewed the prospective data from all patients who underwent PAN alone and PAN combined with VHR from 2007 to 2011 at a single institution. The demographic data, operative information, and postoperative wound complications and interventions were recorded and analyzed using standard statistical methods. Multivariate logistic regression analysis was performed to control for confounding factors. RESULTS: After excluding the patients who had undergone concomitant procedures involving the gastrointestinal or genitourinary tract, 185 patients were included in the present study (143 patients in the PAN-VHR group and 42 in the PAN group). The average patient age was 55.4 and 47.6 years in the two groups (P = 0.001). The average body mass index was 38.0 and 41.1 kg/m(2) (P = 0.69). Of the 143 patients in the PAN-VHR group, 81.1% were women. In the PAN group, 92.9% were women (P = 0.09). The mean length of follow-up was 6.5 and 3.3 mo in the PAN-VHR and PAN groups, respectively (P = 0.04). In the PAN-VHR group, 96.5% underwent hernia repair with mesh and 29% underwent component separation. Subcutaneous talc was used in 58.6% of the PAN-VHR patients and 38.1% of the PAN patients (P = 0.02). Wound pulse-a-vac irrigation with bacitracin solution was used in 37.1% of PAN-VHR patients and 19.1% of the PAN patients (P = 0.03). The rate of wound complications and interventions for the PAN-VHR and PAN groups were not significantly different statistically (P < 0.05) and included seroma, seroma drainage, wound breakdown or necrosis, cellulitis, wound interventions, including bedside debridement and vac placement, and reoperation. After controlling for age, gender, body mass index, talc use, and pulse-a-vac irrigation use in the multivariate logistic regression analysis, the PAN-VHR group were more likely to develop cellulitis than the PAN-alone group (P = 0.004). The rates of all other wound complications were not significantly different statistically between the two groups after adjusting for confounding factors. CONCLUSIONS: PAN is associated with a significant risk of wound-related complications. The risk of postoperative cellulitis is increased further in patients who undergo concomitant VHR. However, the risk of all other wound complications and the need for interventions was not increased by performing concomitant VHR.

Preliminary results of surgical and quality of life outcomes of Physiomesh in an international, prospective study.

Physiomesh is a novel, lightweight, large pore, polypropylene mesh designed to have flexibility that matches the compliance of the abdominal wall in an effort to improve patient quality of life (QOL). The International Hernia Mesh Registry was queried for ventral hernia repair (VHR) and inguinal hernia repair (IHR) with Physiomesh. Demographics, operative and postoperative details, and the Carolinas Comfort Scale (CCS) as a measure of QOL were recorded. Physiomesh was used in 100 patients, 29 IHR and 71 VHR. Their average age was 56.8 +/- 13.7, and BMI was 34.0 +/- 21.0 kg/m2. For IHR, preoperative pain (CCS > or = 2) was present in 41%, but decreased at 1, 6, and 12 months postoperatively to 25.9%, 0%, and 1.6%, while movement limitation decreased from 42.9% to 18.5%, 1.6%, and 3.1%. There were no complications or recurrences. The average VHR measured 66.4 cm2; 93% underwent a laparoscopic repair. Pain was present in 59.1% preoperatively but 21% at 12 months. Movement limitations reduced from 43.2% to 15.8% at 12 months. Mesh sensation was reported in only 10.5% at 1 year. There was 1 recurrence. Physiomesh is well tolerated by patients undergoing IHR and VHR. It is associated with a very favorable long-term QOL.

Prospective, comparative study of postoperative quality of life in TEP, TAPP, and modified Lichtenstein repairs.

INTRODUCTION: The purpose of this study was to compare postoperative quality of life (QOL) in patients undergoing laparoscopic totally extraperitoneal (TEP), transabdominal preperitoneal (TAPP), or modified Lichtenstein (ML) hernia repairs. METHODS: The International Hernia Mesh Registry (2007-2010) was interrogated. 2086 patients who underwent 2499 inguinal hernia repairs were identified. A Carolinas Comfort Score was self-reported at 1-, 6-, 12-months and results were compared. Subgroups analysis and logistic regression were used to identify confounders and to control for significant variables. RESULTS: One hundred seventy-two patients met the exclusion criteria. The distribution of unilateral procedures was TEP (n = 217), TAPP (n = 331), and ML (n = 953). Average follow-up was 12 months. Use of >10 tacks, lack of prostate pathology, recurrent hernia repairs, and bilateral hernia repairs were significant predictors of postoperative pain. One month after surgery 8.9%, 16.6%, and 16.5% were symptomatic for TEP (P = 0.038 vs. ML), TAPP and ML, respectively. At 6 months and 1 year no differences were observed. The number of tacks used varied significantly, with 18.1% of TAPP and 2.3% of TEP with >10 tacks (P = 0.005). The incidence of hernia recurrences were equivalent: TEP (0.42%), TAPP (1.34%), and ML (1.27%). The number or type of tacks utilized did not impact recurrence rates. CONCLUSION: Use of >10 tacks doubles the incidence of early postoperative pain while having no effect on rates of recurrence. There was no difference in chronic postoperative pain comparing ML, TEP, and TAPP including when controlled for tack use.

Poor resident-attending intraoperative communication may compromise patient safety.

BACKGROUND: Prior research suggests that hierarchy in medicine may impact communication and patient safety. This study examined the factors that influence surgical trainees in expressing their opinion in the operating room and the consequences this might have on patient safety. METHODS: An anonymous survey of general surgery, gynecology, and orthopedic surgery residents and attendings was conducted at a teaching institution in 2010. Separate surveys were used for attendings and for trainees consisting of 26 and 27 questions, respectively, with 17 questions in common. The surveys assessed whether the surgical hierarchy interfered with the residents voicing concerns about patient safety. Survey data was compiled, and χ2, Fisher exact tests, and the Wilcoxon rank sum test were used depending on the normality of the data. RESULTS: Thirty-eight trainees and 23 attendings participated in the survey; 74%-78% of trainees and attendings recalled an incident where the trainee spoke up and prevented an adverse event. While all attendings reported that they encourage residents to question their intraoperative decision making, only 55% of residents agreed (P<0.01). Residents indicated that they were more likely to voice their opinion with some attendings than with others based on their personality. Both groups agreed that the hierarchical structure of general surgical residency is necessary. CONCLUSION: Our findings indicate that resident attending intraoperative communication can prevent adverse patient events. Trainees often feel impaired in voicing their concerns to their attendings. Strategies that improve resident attending communication intraoperatively are needed as they are likely to enhance patient safety.

The addition of lysostaphin dramatically improves survival, protects porcine biomesh from infection, and improves graft tensile shear strength.

BACKGROUND: Lysostaphin (LS), a naturally occurring Staphylococcal endopeptidase, has the ability to penetrate biofilm, and has been identified as a potential antimicrobial to prevent mesh infection. The goals of this study were to determine if LS adhered to porcine mesh (PM) can impact host survival, reduce the risk of long-term PM infection, and to analyze lysostaphin bound PM (LS-PM) mesh-fascial interface in an infected field. METHODS: Abdominal onlay PMs measuring 3×3 cm were implanted in select groups of rats (n=75). Group assignments were based on bacterial inoculum and presence of LS on mesh. Explantation occurred at 60 d. Bacterial growth and mesh-fascial interface tensile strength were analyzed. Standard statistical analysis was performed. RESULTS: Only one out of 30 rats with bacterial inoculum not treated with LS survived. All 30 LS treated rats survived and had normal appearing mesh, including 20 rats with a bacterial inoculum (10(6) and 10(8) CFU). Mean tensile strength for controls and LS and no inoculum samples was 3.47±0.86 N versus 5.0±1.0 N (P=0.008). LS groups inoculated with 10(6) and 10(8) CFU exhibited mean tensile strengths of 4.9±1.5 N and 6.7±1.6 N, respectively (P=0.019 and P<0.001 compared with controls). CONCLUSION: Rats inoculated with S. aureus and not treated with LS had a mortality of 97%. By comparison, LS treated animals completely cleared S. aureus when challenged with bacterial concentrations of 1×10(6) and 1×10(8) with maintenance of mesh integrity at 60 d. These findings strongly suggest the clinical use of LS-treated porcine mesh in contaminated fields may translate into more durable hernia repair.

How frequently and when do patients undergo cholecystectomy after bariatric surgery?

BACKGROUND: Rapid weight loss after bariatric surgery is associated with gallstone formation, and cholecystectomy is required in up to 15% of patients. Prophylactic cholecystectomy or prophylactic ursodiol administration in the postoperative period have been suggested to address this problem. The objectives of this study were to investigate the frequency and timing of cholecystectomies after bariatric surgery and to determine the associated risk factors in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric band (LAGB), or laparoscopic sleeve gastrectomy (LSG). METHODS: Data prospectively collected in an institutional database were analyzed. Differences among the 3 procedures and the effects of ursodiol administration, patient demographic characteristics, postoperative weight loss, and individual surgeon practices on cholecystectomy rates were examined. Survival analysis and proportional hazard models were used. RESULTS: Of 1398 patients, 109 (7.8%) underwent cholecystectomy with a median follow-up of 49 (range 12-103) months. Cholecystectomy frequency was 10.6% after LRYGB, significantly higher than 2.9% after LAGB (P < .001), and 3.5% after LSG (P = .004). The frequency was highest within the first 6 months (3.7%), but declined over time to < 1% per year after 3 years. Ursodiol administration did not affect cholecystectomy rates (P = .97), and significant intersurgeon variability was noted. Excess weight loss (EWL)>25% within the first 3 months was the strongest predictor of postoperative cholecystectomy (P<.001). Cox hazards model revealed 1.25 odds ratio per 10% EWL within 3 months, and odds ratio .77 per decade of life. In addition, white patients had 1.45 times higher cholecystectomy rates than did black patients. Preoperative body mass index, gender, and surgeon did not affect cholecystectomy rates. CONCLUSION: Bariatric surgery is associated with a low frequency of postoperative cholecystectomy, which is highest early after surgery and mainly determined by the amount of EWL within the first 3 months. The results of the present study do not support routine prophylactic cholecystectomy at the time of bariatric surgery in asymptomatic patients.

Regionalization and outcomes of hepato-pancreato-biliary cancer surgery in USA.

BACKGROUND: Recent publications demonstrate regionalization of complex operations to high-volume centers (HVCs) in the USA. We hypothesize that this pattern applies to hepato-pancreato-biliary (HPB) cancer resections and improved outcomes. METHODS: The Nationwide Inpatient Sample (NIS) data were analyzed from 1995-1999(T1) to 2005-2009(T2) for all HPB oncologic resections. Division of hospitals into high-, mid-, and low-volume centers (HVC, MVC, LVC) was performed. Multivariate regression was utilized to identify predictors of LVC resection. Outcomes were compared in both eras. RESULTS: A total of 45,815 cases met the inclusion criteria (19,250 from T1 and 25,565 from T2). At T1, 32.5% of resections were performed at HVCs and 34.9% at LVCs. At T2, 60.8% were performed at HVCs versus 18.5% at LVCs. In T1, inpatient mortality at HVCs versus LVCs was 3.3% versus 8.67% (p < 0.0001) and 2.7% versus 6.5% (p < 0.0001) in T2. LOS and routine discharge were improved in HVCs, but total charges were higher. All outcomes significantly differed between HVCs and LVCs in multivariate analysis, except for LOS and total charges in T2. CONCLUSION: The most recent NIS data demonstrate better outcomes in HVCs for HPB oncologic resections. These trends reflect alignment with national recommendations to centralize complex cancer surgery, as well as improved outcomes in all centers.

Preoperative pain is the strongest predictor of postoperative pain and diminished quality of life after ventral hernia repair.

With evolution of hernia repair surgery, quality of life (QOL) became a major outcome measure in nearly 350,000 ventral hernia repairs (VHRs) performed annually in the United States. This study identified predictors of chronic pain after VHR. A prospective database of patient-reported QOL outcomes at a tertiary referral center was queried from 2007 to 2010; 512 patients met inclusion criteria. Factors including demographics, medical comorbidities, preoperative symptoms, and hernia characteristics were analyzed using advanced statistical modeling. Average age was 56.4 years, 57.6 per cent were males, mean body mass index was 33 kg/m(2), hernia defect size was 138 cm(2), and 35.5 per cent were repaired laparoscopically. Preoperatively, 69 per cent of patients had mild and 28 per cent severe pain during some activities. Pain levels were elevated in the first month postoperatively; by 6 months, patients reported significant improvement. The most significant and consistent predictor of postoperative pain was the presence of preoperative pain (odds ratio, 2.1; 95% confidence interval, 1.4 to 3.0; P = 0.0001). Older patients and men had less postoperative pain, but they also had less preoperative pain, so these factors were not independent predictors. Patients with minimal preoperative symptoms uniformly experienced resolution of pain by 6 months postoperatively. Among patients with severe preoperative pain, one-third reported long-term resolution of pain, and one-third had persistent severe pain. The former group had smaller hernias (91 vs 194 cm(2), respectively, P = 0.015). Cases of new-onset, long-term pain after VHR were rare (less than 2%). Most patients' symptoms resolve by 6 months after surgery, but those with severe preoperative pain are at risk for persistent postoperative pain.

The regionalization of ventral hernia repair: occurrence and outcomes over a decade.

Ventral hernia repairs (VHRs) have always been considered standard general surgery cases. Recently, there has been a call for "Centers of Excellence." We sought to investigate outcomes and trends between high- and low-volume centers. The Nationwide Inpatient Sample (NIS) data were analyzed from 1998-1999 (T1) and 2008-2009 (T2) for all VHRs. Hospitals were stratified into high-, medium-, and low-volume centers (HVC/MVC/LVC). Demographics, comorbidities, and outcomes were compared. Surgical cases totaled 22,771 in T1 and 37,044 in T2. In T1, 34.3 per cent were performed in HVC versus 64.2 per cent in T2 (P < 0.0001). LVC cases decreased between eras: 32.6 versus 16.1 per cent (P < 0.0001). Comorbidities and emergent admissions increased with time (P < 0.0001). Mortality was similar in both eras and between volume centers. Length of stay was less in LVC in T2 only (4.2 vs 4.8 days, P < 0.0001). Total charges were higher in HVCs in both eras (P < 0.0001). These remained significant in T2 in multivariate regression (MVR). Hospital volume was not associated with most complications or death in either era with MVR. Charlson comorbidity score, age, and emergent admission were predictors of complications and death. Regionalization has occurred for VHRs. However, most complication and mortality rates are unrelated to volume and are linked to comorbidities, age, and emergencies.

Postoperative quality of life after open transinguinal preperitoneal inguinal hernia repair using memory ring or three-dimensional devices.

A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m(2). MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different (P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD (P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation (P = 0.02); 28.7 versus 14.8 per cent had movement limitations (P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.

Application of subcutaneous talc after axillary dissection in a porcine model safely reduces drain duration and prevents seromas.

BACKGROUND: Talc, the most common pleurodesis agent, has recently been shown to prevent seromas and decrease drain duration when placed subcutaneously after large subcutaneous dissection accompanying open ventral hernia repair. We hypothesized that talc would decrease drain duration and prevent seromas after axillary dissection without local or systemic side effects. STUDY DESIGN: Six pigs underwent full, bilateral axillary dissection (n 12 dissections). Three animals each had aerosolized small particle (SP) talc and large particle (LP) talc sprayed unilaterally (TALC) before closure, with the contralateral axillary dissection serving as the control (NOTALC). Functional status, wound complications, and drain duration were recorded. Local neurovascular structures and systemic organs were harvested at 28 days, processed with hematoxylin and eosin, and examined under normal and polarized light microscopy by blinded physicians. RESULTS: All pigs were back to baseline functional status by 72 hours. Two seromas (33%) were noted in the NOTALC dissections vs 0 in the TALC group (0%). Drain duration was significantly decreased in TALC vs NOTALC dissections (8.3 ± 2.7 vs 12.0 ± 3.2 days, p = 0.03), as was total drain volume (222.5 ± 127.1 mL vs 334.2 ± 137.9 mL, p = 0.02). Gross and histologic evaluation revealed neurovascular structures to be intact. Minimal splenic deposition of talc within macrophages without evidence of injury was identified in all specimens, with fewer deposits in the large particle talc group. Serum laboratory examination at time of harvest revealed all animals to have normal values. CONCLUSIONS: Direct application of talc throughout the wound after axillary dissection in pigs decreased drain duration and drain volume and prevented seroma formation. Gross, histologic, and serum laboratory evaluation demonstrated no talc-related local or systemic complications. Aerosolized talc is an effective and safe pretreatment to prevent seromas and hasten drain removal after axillary dissection.

Radiofrequency ablation offers a reliable surgical modality for the treatment of Barrett's esophagus with a minimal learning curve.

Radiofrequency ablation (RFA) has gained popularity as treatment for Barrett's esophagus. Inclusive series of patients from initiation of our Barrett's Therapy Program were studied. Review of patients undergoing RFA for Barrett's was performed from September 2008 to May 2011. Patients' outcomes were recorded and analyzed using standard statistical methods. Seventy patients were treated. Average age was 61 (28-70); 80 per cent were male. Seventy-four per cent had dysplasia; 44 low-grade and eight high-grade. A total of 75.7 per cent of patients had long and 24.3 per cent had short segment Barrett's. Procedures per patient ranged from one to seven. Number of treatments in long- and short-segment groups were not different (P = 0.11). The maximum number of treatments in the short-segment group was five with a median of three (44.3%). For long segment, the maximum of RFA procedures was seven, with a median of three (30.8%). Average procedure time was 20.8 minutes for long and 17.9 minutes for short segment. Mean follow-up was 16.1 (2-38) months. Complete response was accomplished in 81 per cent. There were 93.3 per cent of complete responders in the short-segment group versus 75 per cent in the long (P = 0.24). Complications included dysphagia (1), transient chest and cervical pain (1), and abdominal pain (1). Comparing the first 25 per cent of the RFA procedures to the later 75 per cent or first 50 per cent to second 50 per cent, there was no difference in operative time or complications. Two patients recurred, both in the long-segment group. RFA is a safe and effective means to eradicate Barrett's. By measure of treatment time, complication rate, and efficacy of therapy, there is minimal or no "learning curve" for experienced endoscopists.

Colonoscopy is superior to neostigmine in the treatment of Ogilvie's syndrome.

BACKGROUND: Colonic pseudo-obstruction in critically ill patients may lead to devastating colonic perforation. Neostigmine is often the first-line intervention, because colonoscopy is more invasive and labor intensive. METHODS: A retrospective 10-year review at a tertiary medical center identified 100 patients with Ogilvie's syndrome, in whom treatment course and clinical and radiographic response were evaluated. RESULTS: Colonoscopy was significantly more successful than neostigmine (defined as no further therapy) after 1 or 2 interventions (75.0% vs 35.5%, P = .0002, and 84.6% vs 55.6%, P = .0031, respectively). One colonoscopy was more effective than 2 neostigmine administrations (75.0% vs 55.6%, P = .044). Clinical response (poor, fair, or good) was significantly better after colonoscopy than neostigmine after 1 or 2 interventions (P = .0028 and P = .00079). Cecal diameters decreased significantly more after colonoscopy than neostigmine (from 10.2 ± .5 cm to 7.1 ± .4 cm vs from 10.5 ± .5 cm to 8.8 ± .5 cm, P = .026). Neostigmine administration before colonoscopy did not affect outcomes. There were 3 perforations (3.7%): 1 each after colonoscopy, neostigmine, and no intervention. Neostigmine dose or repetition did not affect radiographic (P = .41) or clinical (P = .31) response. CONCLUSIONS: Colonoscopy is superior to neostigmine for Ogilvie's syndrome and should be considered first-line therapy, although neostigmine is useful in select patients and repeat interventions.

Application of subcutaneous talc in hernia repair and wide subcutaneous dissection dramatically reduces seroma formation and postoperative wound complications.

Wound complications after large ventral hernia repairs when combined with wide subcutaneous dissection (OVHR/WSD) are common (33 to 66%). We evaluate a novel technique of applying talc to wound subcutaneous tissues to decrease wound complications. We accessed our prospectively collected surgical outcomes database for OVHR/WSD procedures performed. Patients were divided into those that did and did not receive subcutaneous talc (TALC vs NOTALC). Demographics intraoperative and outcomes data were collected and analyzed. The study included 180 patients (n = 74 TALC, n = 106 NOTALC). Demographics were all similar, but hernias were larger in the TALC group. TALC patients had their drains removed earlier (14.6 vs 25.6 days; P < 0.001) with dramatic reduction in postoperative seromas requiring intervention (20.8 to 2.7%; P < 0.001) and cellulitis (39.0 to 20.6%; P = 0.007). Short-term follow-up demonstrates significantly higher recurrence rates in the NOTALC group with each recurrence related to infection. The use of talc in the subcutaneous space of OVHR/WSD results in significantly earlier removal of subcutaneous drains, fewer wound complications, and a decrease in early hernia recurrence. Use of talc in the subcutaneous space at the time of wound closure is an excellent technique to decrease wound complications in large subcutaneous dissections.