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.

Improved survival following transarterial radioembolization of infiltrative-appearance hepatocellular carcinoma.

PURPOSE: Infiltrative-appearance hepatocellular carcinoma presents a challenge to clinicians as diagnostic criteria continue to evolve and evidence-based treatment guidelines have yet to be established. While transarterial radioembolization has shown efficacy in hepatocellular carcinoma, many studies exclude infiltrative-appearance HCC in their analysis. The purpose of this study was to describe imaging features of infiltrative-appearance hepatocellular carcinoma and evaluate effects of radioembolization on survival. METHODS: In a retrospective review, infiltrative HCC patients treated from 2008 to 2017 were identified. Patients were divided into two groups: TARE versus systemic therapy/palliative care. Demographics, dates of diagnosis/expiry, albumin, international normalized ratio (INR), sodium, alpha-fetoprotein (AFP), creatinine, Child-Pugh class, model for end-stage liver disease (MELD) score, bilirubin, radiation dose and volume were collected. Patients with bilirubin > 3 were excluded. Mann-Whitney U test and Fisher's exact test assessed differences between groups. Kaplan-Meier survival and Cox proportional hazard analyses were performed. RESULTS: Fifty-three patients were identified, 15 underwent TARE while 38 served as control. Mean age was 60, 43 patients were male. The mean overall survival was 16.2 months for the TARE group and 5.3 months for the control group (Log-rank p < 0.0001). Cox proportional regression analysis revealed significant associations between survival and albumin (HR 0.210, 0.052-0.839, p = 0.027), Child-Pugh class B (HR 0.196, 0.055-0.696, p = 0.012), sorafenib (HR 0.106, 0.031-0.360, p < 0.001), and number of affected liver lobes (HR 1.864, 1.387-2.506, p < 0.001). CONCLUSIONS: Transarterial radioembolization for infiltrative HCC improves life expectancy compared to treatment with comfort measures or systemic therapy.

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.

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.

Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management.

Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ©RSNA, 2020.

High Prevalence of Moyamoya Syndrome in Appalachia.

INTRODUCTION: Moyamoya is a chronic cerebrovascular condition of unclear etiology characterized by progressive occlusion of 1 or both internal carotid arteries with neovascular collateral formation. With both an idiopathic form (moya-moya disease) and congenital condition-associated form (moyamoya syndrome), it can cause ischemic and hemorrhagic stroke. Recent findings in Kentucky have challenged traditional estimates of its incidence in US populations. Using the Kentucky Appalachian Stroke Registry (KApSR), our aim was to further characterize its incidence as a cause of stroke and to understand the patient population in Appalachia. METHODS: A retrospective review of moyamoya patients was performed using the KApSR database. Data collected included demographics, county location, risk factors, comorbidities, and health-care encounters from January 1, 2012, to December 31, 2016. RESULTS: Sixty-seven patients were identified; 36 (53.7%) resided in Appalachian counties. The cohort accounted for 125 of 6,305 stroke admissions, representing an incidence of 1,983 per 100,000 stroke admissions. Patients presented with ischemic strokes rather than hemorrhagic strokes (odds ratio 5.50, 95% CI: 2.74-11.04, p < 0.01). Eleven patients (16.4%) exhibited autoimmune disorders. Compared to the general population with autoimmune disorder prevalence of 4.5%, the presence of autoimmunity within the cohort was significantly higher (p < 0.01). Compared to non-Appalachian patients, Appalachian patients tended to present with lower frequencies of tobacco use (p = 0.08), diabetes mellitus (p = 0.13), and hypertension (p = 0.16). CONCLUSIONS: Moyamoya accounts for a substantial number of stroke admissions in Kentucky; these patients were more likely to develop an ischemic stroke rather than a hemorrhagic stroke. Autoimmune disorders were more prevalent in moyamoya patients than in the general population. The reduced frequency of traditional stroke risk factors within the Appalachian group suggests an etiology distinct to the population.

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

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

Early Outcomes with Single-antenna High-powered Percutaneous Microwave Ablation for Primary and Secondary Hepatic Malignancies: Safety, Effectiveness, and Predictors of Ablative Failure.

OBJECTIVE: Microwave ablation (MWA) of liver malignancies has gained much traction over the past 5 years. However, MWA carries relatively higher rates of residual disease compared to resection. Likelihood of MWA success is multifactorial and newer devices with more reliable ablation zones are being developed to overcome these drawbacks. This manuscript is a review of our first 100 liver ablations with the newer single antenna high powered MWA system. MATERIALS AND METHODS: Retrospective chart review of patients that underwent MWA for either primary or secondary hepatic malignancies between March 2015 and July 2016 was conducted. The complete ablation rates, rate of new lesions, complications, and short-term survival were analyzed. Multiple statistical tests, including multivariate regression, were used to assess risk factors for local residual and recurrent disease. RESULTS: Fifty-three patients (median age 61 ± 9 years, 39 males) underwent 100 MWAs. Of the 100 lesions ablated, 76 were hepatocellular cancers (HCCs) and 24 were metastases. Median lesion size was 16 ± 9 mm. Seventy- five of these patients had multifocal disease targeted in the same session. Seventy patients had cirrhosis (median model for end-stage liver disease score 9 ± 3; Child-Pugh B and C in 42%). An 83% complete lesion ablation rate was seen on follow-up imaging with liver protocol magnetic resonance imaging/computed tomography (median follow-up of 1 year). The minor complication rate was 9.4% with no major complications or 30-day mortality. Despite this, evidence of new foci of hepatic disease was found in 47% of patients, the majority (80%) of which were in HCC patients (P < 0.01) and most of these new lesions were in a different hepatic segment (64%). Degree of cirrhosis (P < 0.01), presence of non-alcoholic steatohepatitis (NASH) (P = 0.01) and lesion's subcapsular location (P = 0.03) was significant predictors of residual disease. With the subset analysis of only HCC lesions larger than 1 cm, only the presence of NASH remained significant. CONCLUSION: The single probe high power MWA of malignant hepatic lesions is safe and effective with minimal morbidity. Degree of cirrhosis, NASH, and subcapsular location was associated with an increased rate of residual disease on short-term follow-up.

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

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

Validation and Extension of the Ventral Hernia Repair Cost Prediction Model.

BACKGROUND: Repair of ventral and incisional hernias remains a costly challenge for health care systems. In a previous study of a single surgeon's elective open ventral hernia repair (VHR) practice, a cost model was developed, which predicted over 70% of hospital cost variation. The purpose of the present study was to evaluate the ventral hernia cost model with multiple surgeons' elective open VHR cases and extending to include nonelective and laparoscopic VHR. MATERIALS AND METHODS: With the University of Kentucky Institutional Review Board approval, elective and emergent cases of open and laparoscopic VHR performed by multiple surgeons over 3 y were identified. Perioperative variables were obtained from the local American College of Surgeons National Surgery Quality Improvement Program database and electronic medical record review. Hospital cost data were obtained from the hospital cost accounting system. Forward multivariable regression of log-transformed costs identified independent cost drivers (P for entry < 0.05, and P for exit > 0.10). RESULTS: Of the 387 VHRs, 74% were open repairs; mean age was 55 y, and 52% of patients were female. For open, elective cases (n = 211; mean cost of $19,145), the previously reported six-factor cost model predicted 45% of the total cost variation. With all VHRs included, additional variables were found to independently drive costs, predicting 59% of the total cost variation from the base cost. The biggest cost drivers were inpatient status (+$1013), use of biologic mesh (+$1131), preoperative systemic inflammatory response syndrome/sepsis (+$894), and preoperative open wound (+$786). CONCLUSIONS: Ventral hernia repair cost variability is predictable. Understanding the independent drivers of cost may be helpful in controlling costs and in negotiating appropriate reimbursement with payers.

Parallel transjugular intrahepatic portosystemic shunt with Viatorr® stents for primary TIPS insufficiency: Case series and review of literature.

BACKGROUND: Transjugular intrahepatic portosystemic shunts (TIPS) can alleviate complications of portal hypertension such as ascites and variceal bleeding by decreasing the portosystemic gradient. In limited clinical situations, parallel TIPS may be only solution to alleviate either variceal bleeding or ascites secondary to portal hypertension when the primary TIPS fails to do so. Data specifically addressing the use of this partially polytetrafluoroethylene covered nitinol stent (Viatorr®) is largely lacking despite Viatorr® being the current gold standard for modern TIPS placement. CASE SUMMARY: All three patients had portal hypertension and already had a primary Viatorr® TIPS placed previously. All patients have undergone failed endoscopy to manage acute variceal bleeding before referral for a parallel stent (PS). PS were placed in patients presenting with recurrent variceal bleeding despite existence of a widely patent primary TIPS. Primary stent patency was verified with either Doppler ultrasound or intra-procedural TIPS stent venography. Doppler ultrasound follow-up imaging demonstrated complete patency of both primary and parallel TIPS. All three patients did well on clinical follow-up of up to six months and no major complications were recorded. A review of existing literature on the role of PS in the management of portal hypertension complications is discussed. There are three case reports of use of primary and PS Viatorr® stents placement, only one of which is in a patient with gastrointestinal variceal bleeding despite a patent primary Viatorr® TIPS. CONCLUSION: Viatorr® PS placement in the management of variceal hemorrhage is feasible with promising short term patency and clinical follow-up data.