Laparoscopic repair reduces incidence of surgical site infections for all ventral hernias.

BACKGROUND: The role of laparoscopic repair of ventral hernias remains incompletely defined. We hypothesize that laparoscopy, compared to open repair with mesh, decreases surgical site infection (SSI) for all ventral hernia types. METHODS: MEDLINE, EMBASE, and Cochrane databases were reviewed to identify studies evaluating outcomes of laparoscopic versus open repair with mesh of ventral hernias and divided into groups (primary or incisional). Studies with high risk of bias were excluded. Primary outcomes of interest were recurrence and SSI. Fixed effects model was used unless significant heterogeneity, assessed with the Higgins I square (I(2)), was encountered. RESULTS: There were 5 and 15 studies for primary and incisional cohorts. No difference was seen in recurrence between laparoscopic and open repair in the two hernia groups. SSI was more common with open repair in both hernia groups: primary (OR 4.17, 95%CI [2.03-8.55]) and incisional (OR 5.16, 95%CI [2.79-9.57]). CONCLUSIONS: Laparoscopic repair, compared to open repair with mesh, decreases rates of SSI in all types of ventral hernias with no difference in recurrence. These data suggest that laparoscopic approach may be the treatment of choice for all types of ventral hernias.

Abdominal reoperation and mesh explantation following open ventral hernia repair with mesh.

BACKGROUND: This study sought to identify the incidence, indications, and predictors of abdominal reoperation and mesh explantation following open ventral hernia repair with mesh (OVHR). METHODS: A retrospective cohort study of all patients at a single institution who underwent an OVHR from 2000 to 2010 was performed. Patients who required subsequent abdominal reoperation or mesh explantation were compared with those who did not. Reasons for reoperation were recorded. The 2 groups were compared using univariate and multivariate analysis (MVA). RESULTS: A total of 407 patients were followed for a median (range) of 57 (1 to 143) months. Subsequent abdominal reoperation was required in 69 (17%) patients. The most common reasons for reoperation were recurrence and surgical site infection. Only the number of prior abdominal surgeries was associated with abdominal reoperation on MVA. Twenty-eight patients (6.9%) underwent subsequent mesh explantation. Only the Ventral Hernia Working Group grade was associated with mesh explantation on MVA. CONCLUSIONS: Abdominal reoperation and mesh explantation following OVHR are common. Overwhelmingly, surgical complications are themost common causes for reoperation and mesh explantation.

Outcomes with porcine acellular dermal matrix versus synthetic mesh and suture in complicated open ventral hernia repair.

BACKGROUND: Mesh reinforcement as part of open ventral hernia repair (OVHR) has become the standard of care. However, there is no consensus on the ideal type of mesh to use. In many clinical situations, surgeons are reluctant to use synthetic mesh. Options in these complicated OVHRs include suture repair or the use of biologic mesh such as porcine acellular dermal matrix (PADM). There has been a paucity of controlled studies reporting long-term outcomes with biologic meshes. We hypothesized that compared with synthetic mesh in OVHR, PADM is associated with fewer surgical site infections (SSI) but more seromas and recurrences. Additionally, compared with suture repair, we hypothesized that PADM is associated with fewer recurrences but more SSIs and seromas. METHODS: A retrospective study was performed of all complicated OVHRs performed at a single institution from 2000-2011. All data were captured from the electronic medical records of the service network. Data were compared in two ways. First, patients who had OVHR with PADM were case-matched with patients having synthetic mesh repairs on the basis of incision class, Ventral Hernia Working Group (VHWG) grade, hernia size, American Society of Anesthesiologists (ASA) class, and emergency status. The PADM cases were also matched with suture repairs on the basis of incision class, hernia grade, duration of the operation, ASA class, and emergency status. Second, we developed a propensity score-adjusted multi-variable logistic regression model utilizing internal resampling to identify predictors of primary outcomes of the overall cohort. The U.S. Centers for Disease Control and Prevention (CDC) definition of SSI was utilized; seromas and recurrences were defined and tracked similarly for all patients. Data were analyzed using the McNemar, X(2), paired two-tailed Student t, or Mann-Whitney U test as appropriate. RESULTS: A total of 449 complicated OVHR cases were reviewed for a median follow up of 61 mos (range 1-143 mos): 94 patients had PADM repairs, whereas 154 patients underwent synthetic mesh repairs, and 201 had suture repairs. The 40 PADM repairs were matched to synthetic repairs and 59 were matched to suture repairs. The PADM repairs that could not be well matched (n=54 unmatched for synthetic repairs, 35 unmatched for suture repairs) were characterized generally by larger hernias, VHWG grades of 3 or 4, and incision class 3 or 4 with longer operative durations and more ASA class 4 cases. The patients were well matched. Comparing PADM with synthetic mesh, there was no difference in SSI (20% vs. 35%; p=0.29), seromas (32.5% vs. 15%; p=0.17), mesh explantations (5% vs. 15%, p=0.28), readmissions within 90 d (37.5% vs. 45%; p=1.00), or recurrence (8.5% vs. 22.5%; p=0.15). Compared with suture repair, patients with PADM had fewer recurrences (11.9% vs. 33.9%; p<0.01) and more seromas (32.2% vs. 10.2%; p=0.02), but a similar number of SSIs (23.7% vs. 39.0%; p=0.19) and 90-d readmissions (35.6% vs. 39.0%; p=0.88). Propensity score-adjusted multi-variable logistic regression of the entire cohort corroborated the results of the case-matched patients. CONCLUSIONS: The PADM repair of complicated OVHR resulted in fewer recurrences, more seromas, and no difference in SSI compared with suture repair. Although no reduction in SSI was identified with the use of PADM rather than synthetic mesh or suture for OVHR, the meaning of this finding is unclear, as this case-controlled study was underpowered and limited by selection bias. According to our data, 280 patients would have been needed to identify a clinically significant difference in the primary outcome of SSI as well as secondary outcomes of mesh explantation and recurrence (α=0.05; ß=0.20). A randomized trial is warranted to compare PADM with synthetic mesh in complicated OVHR.

Suture versus preperitoneal polypropylene mesh for elective umbilical hernia repairs.

BACKGROUND: Repair of primary ventral hernias (PVH) such as umbilical hernias is a common surgical procedure. There is a paucity of risk-adjusted data comparing suture versus mesh repair of these hernias. We compared preperitoneal polypropylene (PP) repair versus suture repair for elective umbilical hernia repair. METHODS: A retrospective review of all elective open PVH repairs at a single institution from 2000-2010 was performed. Only patients with suture or PP repair of umbilical hernias were included. Univariate analysis was conducted and propensity for treatment-adjusted multivariate logistic regression. RESULTS: There were 442 elective open PVH repairs performed; 392 met our inclusion criteria. Of these patients, 126 (32.1%) had a PP repair and 266 (67.9%) underwent suture repair. Median (range) follow-up was 60 mo (1-143). Patients who underwent PP repair had more surgical site infections (SSIs; 19.8% versus 7.9%, P < 0.01) and seromas (14.3% versus 4.1%, P < 0.01). There was no difference in recurrence (5.6% versus 7.5%, P = 0.53). On propensity score-adjusted multivariate analysis, we found that body mass index (odds ratio [OR], 1.10) and smoking status (OR, 2.3) were associated with recurrence. Mesh (OR, 2.34) and American Society of Anesthesiologists (OR, 1.95) were associated with SSI. Only mesh (OR, 3.41) was associated with seroma formation. CONCLUSIONS: Although there was a trend toward more recurrence with suture repair in our study, this was not statistically significant. Mesh repair was associated with more SSI and seromas. Further prospective randomized controlled trial is needed to clarify the role of suture and mesh repair in PVH.

Review of stoma site and midline incisional hernias after stoma reversal.

BACKGROUND: The incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias. METHODS: A systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done. RESULTS: Sixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%-33.9%) and for midline incisional hernias was 44.1% (range 8.7%-58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two. CONCLUSION: Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.

Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis.

IMPORTANCE: More than 350,000 ventral hernias are repaired in the United States annually, of which 75% are primary ventral hernias (eg, umbilical or epigastric hernias). Despite the volume, there is insufficient evidence to support the use of sutures vs mesh for primary ventral hernia repairs. OBJECTIVE: To compare suture vs mesh repairs for 3 outcomes: hernia recurrence, surgical site infection (SSI), and seromas. DATA SOURCES: Randomized controlled trials, case-control, and cohort studies were identified from OVID, PubMed, and reference lists from January 1, 1980, through June 1, 2012. STUDY SELECTION: English-language studies with adult patients were eligible for review if there was mention of both suture and mesh techniques used during elective repair of a primary ventral hernia. Two study authors independently reviewed the 1492 articles originally identified and selected 9 for analysis. The Downs and Black 26-item checklist was used to critically assess the risk of bias. DATA EXTRACTION: Year of publication, study design, inclusion and exclusion criteria, number of patients, follow-up duration, use of preoperative antibiotics, size of hernias repaired, age, body mass index (calculated as weight in kilograms divided by height in meters squared), American Society of Anesthesiologists grade, repair techniques, incidence of hernia recurrence, seroma, and SSI. DATA EXTRACTION AND SYNTHESIS: Three separate univariate meta-analyses for each end point followed by a multivariate meta-analysis were performed. Across all 9 studies, there were 637 mesh repairs and 1145 suture repairs. The pooled mesh repairs demonstrated a 2.7% recurrence rate, 7.7% seroma rate, and 7.3% SSI rate The pooled suture repairs demonstrated an 8.2% recurrence rate, 3.8% seroma rate, and 6.6% SSI rate. On the basis of results from the multivariate meta-analysis, recurrences (log odds ratio , −1.04; 95% CI, −1.58 to −0.52) were more common with suture repair, whereas seromas (0.84; 0.27-1.41) and SSIs (0.65; 0.12-1.18) were more common with mesh repair. CONCLUSIONS AND RELEVANCE: Mesh repair has a small reduction in recurrence rates compared with suture repairs for primary ventral hernias, but an increased risk of seroma and SSI was observed. Further high-quality studies are necessary to determine whether suture or mesh repair leads to improved outcomes for primary ventral hernias.

Outcomes of acute versus elective primary ventral hernia repair.

BACKGROUND: The morbidity and mortality associated with acute primary ventral hernia repair have not been well described. We examined the rate of surgical site infection (SSI), hernia recurrence, and mortality in acute versus elective primary ventral hernia repair and identified predictors of morbidity and mortality after primary ventral hernia repair. METHODS: A retrospective study on all patients undergoing open primary ventral hernia repair at a single institution (2000-2010) was performed. Primary outcomes were mortality at any time, SSI, and recurrence. Survival analysis for the entire, unmatched sample was conducted. We performed a risk-adjusted analysis of outcomes using two methods as follows: (1) case matching and (2) propensity score-adjusted regression model. RESULTS: We identified 497 patients; 57 (11%) underwent acute primary ventral hernia repair. For the entire cohort, survival was worse for patients undergoing acute repair (log rank, 0.03). Following case matching on age, body mass index, American Society of Anesthesiologists score, and hernia size, there was no difference in mortality, SSI, or recurrence. After propensity score adjustment, acute surgery was not a predictor for mortality or SSI; however, incarcerated hernias predicted recurrence. CONCLUSION: After risk adjustment, acute primary ventral hernia repair was not associated with higher mortality, infection, or recurrence compared with elective repair. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Development and validation of a risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair.

BACKGROUND: Current risk-assessment tools for surgical site occurrence (SSO) and surgical site infection (SSI) are based on expert opinion or are not specific to open ventral hernia repairs. We aimed to develop a risk-assessment tool for SSO and SSI and compare its performance against existing risk-assessment tools in patients with open ventral hernia repair. STUDY DESIGN: A retrospective study of patients undergoing open ventral hernia repair (n = 888) was conducted at a single institution from 2000 through 2010. Rates of SSO and SSI were determined by chart review. Stepwise regression models were built to identify predictors of SSO and SSI and internally validated using bootstrapping. Odds ratios were converted to a point system and summed to create the Ventral Hernia Risk Score (VHRS) for SSO and SSI, respectively. Area under the receiver operating characteristic curve was used to compare the accuracy of the VHRS models against the National Nosocomial Infection Surveillance Risk Index, Ventral Hernia Working Group (VHWG) grade, and VHWG score. RESULTS: The rates of SSO and SSI were 33% and 22%, respectively. Factors associated with SSO included mesh implant, concomitant hernia repair, dissection of skin flaps, and wound class 4. Predictors of SSI included concomitant repair, dissection of skin flaps, American Society of Anesthesiologists class ≥ 3, wound class 4, and body mass index ≥ 40. The accuracy of the VHRS in predicting SSO and SSI exceeded National Nosocomial Infection Surveillance and VHWG grade, but was not better than VHWG score. CONCLUSIONS: The VHRS identified patients at increased risk for SSO/SSI more accurately than the National Nosocomial Infection Surveillance scores and VHWG grade, and can be used to guide clinical decisions and patient counseling.

Outcomes of laparoscopic vs open repair of primary ventral hernias.

IMPORTANCE: More primary ventral hernias (PVHs) are being repaired using the technique of laparoscopic ventral hernia repair (LVHR). Few studies exist comparing the outcomes of LVHR with the outcomes of open ventral hernia repair (OVHR) for PVHs. We hypothesize that LVHR of PVHs is associated with fewer surgical site infections (SSIs) but more hernia recurrences and more clinical cases of bulging (bulging not associated with recurrence or seroma). OBJECTIVE: To compare the outcomes of patients who underwent LVHR with the outcomes of patients who underwent OVHR. DESIGN: Retrospective study of 532 consecutive patients who underwent an elective PVH repair at a single institution from 2000 to 2010. The outcomes of the 2 procedures were compared using 2 statistical methods. Multivariable logistic regression was used to evaluate the association between outcomes and several independent factors, adjusting for treatment propensity, and the outcomes in the 2 groups of patients were compared using paired univariate analysis. SETTING: Michael E. DeBakey VA Medical Center in Houston, Texas. PARTICIPANTS: Seventy-nine patients who underwent LVHR and 79 patients who underwent OVHR. MAIN OUTCOMES AND MEASURES: The primary outcomes of interest were SSI, hernia recurrence, and bulging. The 2 groups of patients were matched by hernia size, American Society of Anesthesiologists class, age, and body mass index. RESULTS: There were 91 patients who underwent an LVHR and 167 patients who underwent an OVHR with mesh, with a median follow-up period of 56 months (range, 1-156 months). Seventy-nine patients with an LVHR were matched to 79 patients with an OVHR. No significant differences in demographic data or confounding factors were detected between the 2 groups. Compared with OVHR, LVHR was significantly associated with fewer SSIs (7.6% vs 34.1%; P < .01) but more clinical cases of bulging (21.5% vs 1.3%; P < .01) and port-site hernia (2.5% vs 0.0%). No differences in recurrence at the site of the hernia repair were observed (11.4% vs 11.4%; P = .99). Propensity score-matched multivariate analysis corroborated that LVHR is associated with more clinical cases of bulging but fewer SSIs. CONCLUSIONS AND RELEVANCE: Compared with OVHR of PVHs, LVHR of PVHs is associated with fewer SSIs but more clinical cases of bulging and with the risk of developing a port-site hernia. Further study is needed to clarify the role of LVHR of PVHs and to mitigate the risk of port-site hernia and bulging.

The prevalence of platybasia in patients with velopharyngeal incompetence.

Objectives : To estimate the prevalence of platybasia in patients with velopharyngeal incompetence (VPI) and its relation with palatal anomalies and syndromes. Design and Settings : Retrospective case analysis. Setting : A university-affiliated hospital. Patients : The VPI patients (n = 366) included five groups with either cleft lip and palate (CLP), cleft palate (CP) only, submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), or non-CP. The control group (n = 126) comprised healthy, normal-speech individuals. Outcome Measures : The cranial-base angle was measured by lateral cephalometric radiography. The prevalence of platybasia (defined as cranial base angle ≥ 137°) was estimated and the patient's syndromes were recorded. Results : The prevalence of platybasia was significantly higher in the VPI group (28.7%) than in the normal controls (2.4%) (P < .001). A significant difference (P < .01) was found in the prevalence of platybasia among the five VPI groups: 16.7%, 20.3%, 28.8%, 33.7%, and 40.3% for CLP, CP only, SMCP, OSMCP, and non-CP, respectively. No significant difference was found between the cranial-base angle of VPI patients and of controls and between the cranial-base angle of the five VPI groups. The VPI nonplatybasic patients had a significantly smaller cranial-base angle than normal controls (P < .01). Platybasia was the highest among patients with velocardiofacial syndrome (50%), followed by those with Pierre Robin syndrome (27.3%). Conclusions : Platybasia, which may cause enlargement of the nasopharyngeal space and difficulties in achieving velopharyngeal closure, can be found in high numbers of VPI patients with or without CP. This supports the belief that velopharyngeal anomaly may be part of a more complex craniofacial anomaly influenced by the cranial-base flexure.

Patient Satisfaction, chronic pain, and functional status following laparoscopic ventral hernia repair.

BACKGROUND: Ventral hernia repairs are one of the most common surgeries performed. Symptoms are the most common motivation for repair. Unfortunately, outcomes of repair are typically measured in recurrence and infection rather than patient focused results. We correlated factors associated with decreased patient satisfaction, chronic pain, and diminished functional status following laparoscopic ventral hernia repair (LVHR) METHODS: A retrospective study of 201 patients from two affiliated institutions was performed. Patient satisfaction, chronic abdominal pain, pain scores, and Activities Assessment Scale results were obtained in 122 patients. Results were compared with univariate and multivariate analysis. RESULTS: Thirty-two (25.4%) patients were dissatisfied with their LVHR while 21 (17.2%) patients had chronic abdominal pain and 32 (26.2%) patients had poor functional status following LVHR. Decreased patient satisfaction was associated with perception of poor cosmetic outcome (OR 17.3), eventration (OR 10.2), and chronic pain (OR 1.4). Chronic abdominal pain following LVHR was associated with incisional hernia (OR 9.0), recurrence (OR 4.3), eventration (OR 6.0), mesh type (OR 1.9), or ethnicity (OR 0.10). Decreased functional status with LVHR was associated with mesh type used (OR 3.7), alcohol abuse (OR 3.4), chronic abdominal pain (OR 1.3), and age (OR 1.1). CONCLUSIONS: One-fourth of patients have poor quality outcome following LVHR. These outcomes are affected by perception of cosmesis, eventration, chronic pain, hernia type, recurrence, mesh type, and patient characteristics/co-morbidities. Closing central defects and judicious mesh selection may improve patient satisfaction and function. Focus on patient-centered outcomes is warranted.

The contribution of flexible endoscopy for diagnosis of acute bacterial rhinosinusitis.

This prospective controlled study ascertained the contribution of flexible endoscopy (FE) for diagnosis of acute bacterial rhinosinusitis (ABRS) in a group of consecutive adult patients who had symptoms suggestive of ABRS and in whom sinus radiography (SRG) and FE were accomplished. We adopted for analysis the 2007 updated European guidelines on rhinosinusitis and computed the sensitivity and specificity of FE against SRG. Positive diagnosis was entertained when FE showed purulent material within sinus drainage area and/or SRG demonstrated air-fluid level, complete opacification, or at least 6 mm mucosal thickening. Of a total of 179 patients initially included in this study, 104 had clinical criteria compatible with guidelines for ABRS. Of them, 43 (41.3%) had positive FE and SRG, 17 (16.3%) had positive FE and negative SRG, and vice versa in 9 (8.7%); both modalities were negative in 35 (33.7%). FE yielded sensitivity of 82.7 ± 5.24% (95% CI: 72.41-92.97%) and specificity of 67.3 ± 6.50% (95% CI: 54.56-80.06%). Age, gender, symptom duration, pre-referral antibiotics, and treatment by primary/secondary physician were not associated with positive or negative diagnosis of ABRS. Of 75 patients who were excluded from the analysis, 33 (44%) had positive diagnosis of ABRS established by FE and/or SRG. The finding that clinical criteria had moderate predictive value (66.3%) highlights the need for objective measures for diagnosis of ABRS. In absence of feasible gold standard and considering that guidelines do not recommend SRG for routine diagnosis, FE serves as an indispensable ancillary tool for establishing ABRS.

Sex and race are associated with the absence of epicardial coronary artery obstructive disease at angiography in patients with acute coronary syndromes.

BACKGROUND: A substantial minority of patients with acute coronary syndromes (ACS) do not have a diameter stenosis of any major epicardial coronary artery on angiography ("no obstruction at angiography") of > or = 50%. We examined the frequency of this finding and its relationship to race and sex. HYPOTHESIS: Among patients with myocardial infarction, younger age, female sex and non-white race are associated with the absence of obstructive coronary artery disease at angiography. METHODS: We reviewed the results of all angiograms performed from May 19, 2006 to September 29, 2006 at 1 private (n = 793) and 1 public (n = 578) urban academic medical center. Charts were reviewed for indication and results of angiography, and for demographics. RESULTS: The cohort included 518 patients with ACS. There was no obstruction at angiography in 106 patients (21%), including 48 (18%) of 258 patients with myocardial infarction. Women were more likely to have no obstruction at angiography than men, both in the overall cohort (55/170 women [32%] vs 51/348 men [15%], P < 0.001) and in the subset with MI (29/90 women [32%] vs 19/168 men [11%], P < 0.001). Black patients were more likely to have no obstruction at angiography relative to any other subgroup (24/66 [36%] vs 41/229 [18%] Whites, 31/150 [21%] Hispanics, and 5/58 [9%] Asians, P = 0.001). Among women, Black patients more frequently had no obstruction at angiography compared with other ethnic groups (16/27 [59%] vs 17/59 [29%] Whites, 17/60 [28%] Hispanics, and 3/19 [6%] Asians, P = 0.001). CONCLUSIONS: A high proportion of a multiethnic sample of patients with ACS were found to have no stenosis > or = 50% in diameter at coronary angiography. This was particularly common among women and Black patients.