Impact of Intraoperative Foley Catheters on Postoperative Urinary Retention after Inguinal Hernia Surgery.

Foley catheters (FCs) are often used during inguinal hernia operations; however, the impact of intraoperative FC use on postoperative urinary retention (POUR) is not well understood. We reviewed unplanned returns to the urgent care or ED for 27,012 inguinal hernia operations across 15 Southern California Kaiser Permanente medical centers over 6.5 years. In total, 239 (0.88%) patients returned to urgent care/ED with POUR [235 (98%) men versus 4 (2%) women]. Overall, POUR increased with age (P < 0.00001). POUR was higher in open repairs using general anesthesia versus local with monitored anesthesia care (0.7% vs 0.3%, P < 0.0001). Of 5,017 laparoscopic operations, 28 per cent had FC use. Although POUR was greater for laparoscopic versus open operations (2.21 vs 0.58%, P < 0.00001), there was no difference in POUR for intraoperative FC versus no FC use in the laparoscopic approach (2.36% vs 2.15%, P = 0.33). For all laparoscopic operations, there was no difference in urinary tract infection within 7 or 30 days when comparing intraoperative FC versus no FC use (P = 0.28). POUR can be minimized by avoiding general anesthesia for open inguinal hernia repairs, but intraoperative FC use does not affect POUR or urinary tract infection rates for laparoscopic inguinal hernia repair.

An Analysis of Early Postoperative Returns after Inguinal Hernia Surgery.

Although inguinal herniorrhaphy is low risk, patients still return to the urgent care or ED. We performed a retrospective study on 19,296 inguinal hernia operations across 14 Southern California Kaiser Permanente medical centers over five years. Unplanned returns within the first postoperative week were evaluated focusing on four potentially avoidable diagnoses (AD): pain, constipation, urinary retention, and nausea/vomiting. Overall, 1370 (7%) patients returned to the urgent care/emergency department, of which 537 (39%) had an AD. There was no difference in total returns (7.1 vs 7.4%, P = 0.33) or AD returns [2.8 vs 2.6%, (P = 0.44)] for males vs females. Of the 537 total AD returns, there were 205 (38%) patients with pain, 191 (36%) with urinary retention, 112 (21%) with constipation, and 29 (5%) with nausea/vomiting. Most AD returns (78%) occurred within the first three postoperative days. Pain was greater in open operations [44 vs 26%, (P < 0.05)], and urinary retention was greater in the laparoscopic group [27 vs 55%, (P < 0.05)]. The overall rate of return was higher for laparoscopic compared with open unilateral operations [8 vs 6%, (P < 0.05)], but similar between approaches for bilateral operations [11 vs 10%, (P = 0.32)].

Gallbladder Polyps: Real or Imagined?

The finding of gallbladder polyps on imaging studies prompts further workup. Imaging results are often discordant with final pathology. The goal of this study is to compare polypoid lesions of the gallbladder found on preoperative ultrasound (US) with final pathologic diagnosis after cholecystectomy to help guide clinical decision-making. A retrospective study was conducted identifying adult patients who were diagnosed with polyps via US and who underwent cholecystectomy from 2008 through 2015. Imaging data, final pathology, and demographics were manually reviewed. A total of 2290 cholecystectomy patients had US-based polyps. Of these, 1661 patients (73%) did not have polyps on final pathology; primarily, stones or sludge were identified. Adenomyosis was diagnosed in 61 patients (2.7%). A total of 556 patients (24.2%) had pathologic polypoid lesions with the following breakdown: 463 (20.2%) cholesterol polyps, 43 other benign polyps (1.8%), 40 adenomas (1.7%), and 10 adenocarcinomas (0.4%). All patients with adenocarcinoma were older than 40 years and 91 per cent had US findings of polyps >10 mm. Ultrasound alone is an unreliable method of detecting real gallbladder polyps. This large database study found a very low risk of cancer. Size on US and patient age should be considered in the selection of appropriate surgical candidates with sonographic "polyps."

Outcomes of Unroofing with Limited Excision and Structured Postoperative Care for Pilonidal Disease.

Despite a wide variety of surgical techniques to treat chronic pilonidal disease, high rates of recurrence are common. The current study analyzes the outcome of unroofing with limited excision combined with structured postoperative wound care for pilonidal disease. We performed a retrospective review of all patients who were treated with this technique over a seven year period. Ninety-four patients aged 11 to 63 (mean age 26) received this treatment for pilonidal disease. Eighty-nine patients were treated for primary pilonidal disease and five were treated for recurrent disease after procedures such as flaps. There were 66 males (70%) and 28 females (30%). The operation was performed by unroofing the entire pilonidal sinus along with its pits and area of chronic abscess cavity. All granulation tissue was removed and the base of the sinus was completely cauterized. No wide local excisions were performed. The cavity was packed with dry gauze and the dressing was changed twice daily. Patients were seen postoperatively on a weekly basis in clinic. The area was shaved; the cavity was cleaned and often treated with silver nitrate. In the event of premature skin closure starting to form, unroofing was easily performed in the office. The median time to achieve complete healing was 53 days requiring, on average, seven visits. With a mean follow-up of 40 months, there were two recurrences (2.1%) and reoperation for two (2.1%) inappropriately healing wounds. This study demonstrates that unroofing with limited excision and structured postoperative care for pilonidal disease is a safe and effective treatment approach with a very low recurrence and complication rate.

Anal Health Care Basics.

Despite the fact that countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Unfortunately, this leads to incorrect diagnoses and treatments. When treating a patient with an anal complaint, the primary goals are to first diagnose the etiology of the symptoms correctly, then to provide an effective and appropriate treatment strategy.The first step in this process is to take an accurate history and physical examination. Specific questions include details about bowel habits, anal hygiene, and fiber supplementation. Specific components of the physical examination include an external anal examination, a digital rectal examination, and anoscopy if appropriate.Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess or fistula, fecal incontinence, and anal skin tags. However, each problem presents differently and requires a different approach for management. It is of paramount importance that the correct diagnosis is reached. Common errors include an inaccurate diagnosis of hemorrhoids when other pathology is present and subsequent treatment with a steroid product, which is harmful to the anal area.Most of these problems can be avoided by improving bowel habits. Adequate fiber intake with 30 g to 40 g daily is important for many reasons, including improving the quality of stool and preventing colorectal and anal diseases.In this Special Report, we provide an overview of commonly encountered anal problems, their presentation, initial treatment options, and recommendations for referral to specialists.

Small Bowel Obstructions in a Virgin Abdomen: Is an Operation Mandatory?

Though conventionally not considered standard of care, nonoperative management of patients with small bowel obstruction (SBO) without previous abdominal operations, so called "virgin abdomens," (VA) is presently being practiced. We aimed to determine outcomes of patients with VA undergoing operative and nonoperative management of SBO. A retrospective review of patients with SBO was performed; outcomes of patients with VA were analyzed. SBO with a VA was found in 103 patients over a 5-year period. With a mean follow-up of 4.5 years, nonoperative management was associated with successful resolution of obstruction in 61 per cent (63/103) of patients. Of those managed nonoperatively, 58/63 (92.1%) did not experience a recurrence. Of the 21 patients with a complete/high-grade SBO on imaging, 16 (76.2%) were managed operatively. Of the 64 patients with a partial/low-grade obstruction or partial obstruction/ileus on imaging, 53 (82.8%) were managed nonoperatively. These data suggest that selected patients with SBO and a VA may safely undergo nonoperative management under close surgical monitoring.

Increasing Body Mass Index Is Inversely Related to Groin Hernias.

Few studies describe the relationship between obesity and groin hernias. Our objective was to investigate the correlation between body mass index (BMI) and groin hernias in a large population. Patients with the diagnosis of inguinal or femoral hernia with and without incarceration or strangulation were identified using the Kaiser Permanente Southern California regional database including 14 hospitals over a 7-year period. Patients were stratified by BMI. There were 47,950 patients with a diagnosis of a groin hernia--a prevalence of 2.28 per cent. Relative to normal BMI (20-24.9 kg/m(2)), lower BMI was associated with an increased risk for hernia diagnosis. With increasing BMI, the risk of incarceration or strangulation increased. Additionally, increasing age, male gender, white race, history of hernia, tobacco use history, alcohol use, and higher comorbidity index increased the chance of a groin hernia diagnosis. Complications were higher for women, patients with comorbidities, black race, and alcohol users. Our study is the largest to date correlating obesity and groin hernias in a diverse United States population. Obesity (BMI ≥ 30 kg/m(2)) is associated with a lower risk of groin hernia diagnosis, but an increased risk of complications. This inverse relationship may be due to limitations of physical exam in obese patients.

Cracking the Code: The Unexpected Challenge of Identifying Major Bile Duct Injuries.

The reported rate of major bile duct injury (BDI) after cholecystectomy is 0.2 to 0.5 per cent. We evaluated the accuracy of coding major BDIs integrating both Current Procedural Terminology (CPT) and ICD-9 coding. A retrospective review was conducted for more than 3.5 million members of a large managed health-care organization from January 2007 to December 2013. A total of 56,194 cholecystectomies were captured over this 6-year period. Major BDIs were defined as unintended transection of a major bile duct, Bismuth-Strasberg classification E1-E5, and requiring biliary reconstruction within one year of cholecystectomy. Based on two published study methods (CPT 47760, 47765, 47780 and ICD-9 code 998.2), 173 possible BDIs were identified. Only 13 (7.5%) were confirmed to have a major BDI. The remaining 160 cases were minor complications or were unrelated to cholecystectomy. This reflects an overall BDI rate of 0.02 per cent, an order of magnitude less than commonly published rates. There is a lack of consistent methodology to identify major bile duct injuries. This calls into question the accuracy of published rates. We suspect that some major injuries were not captured. We recommend a universal clinical registry and specific ICD codes to accurately identify this serious complication.

Outcome of abdominal wall hernia repair with biologic mesh: Permacol™ versus Strattice™.

The use of biologic mesh in abdominal wall operations has gained popularity despite a paucity of outcome data. Numerous biologic products are available with virtually no clinical comparison studies. A retrospective study was conducted to compare patients who underwent abdominal wall hernia repair with Permacol™ (crosslinked porcine dermis) and Strattice™ (noncrosslinked porcine dermis). Of 270 reviewed patients, 195 were implanted with Permacol™ and 75 with Strattice™. Ventral hernia repairs comprised the majority (85% for Permacol, 97% for Strattice™). Postoperative infection rate was lower in the Strattice™ group (5 vs 21%, P < 0.01). In the Permacol™ group only, the overall complication rates were significantly higher in patients with infected versus clean wounds (55 vs 35%, P < 0.05) and in obese patients (body mass index 40 kg/m(2) or greater [57 vs 34%], P < 0.01). Short-term complication and recurrence rates were higher when mesh was used as a fascial bridge: 51 versus 28 per cent for Permacol™, 58 versus 20 per cent for Strattice™. The hernia recurrence was similar in both groups. In this review of patients undergoing abdominal hernia repair with biologic mesh, Strattice™ mesh was associated with a lower short-term complication rate compared with Permacol™, but the hernia recurrence rate was similar.

Outcome of abdominal wall hernia repair with Permacol™ biologic mesh.

The use of biologic mesh in abdominal wall operations has gained popularity despite a paucity of outcome data. We aimed to review the experience of a large healthcare organization with Permacol™. A retrospective study was conducted of patients who underwent abdominal hernia repair with Permacol™ in 14 Southern California hospitals. One hundred ninety-five patients were analyzed over a 4-year period. Operations included ventral/incisional hernia repairs, ostomy closures, parastomal hernia repairs, and inguinal hernia repairs. In 50 per cent of the patients, Permacol™ was used to reinforce a primary fascial repair and in 50 per cent as a fascial bridge. The overall complication rate was 39.5 per cent. The complication rate was higher in patients with infected versus clean wounds, body mass index (BMI) 40 kg/m(2) or greater versus BMI less than 40 kg/m(2), in patients with prior mesh repair, and when mesh was used as a fascial bridge. With a mean follow-up of 2.1 years, morbid obesity was associated with a higher recurrence. To date this is the largest study on the use of Permacol™ in abdominal wall hernia repair. In our patient population undergoing heterogeneous operations with a majority of wounds as Class II or higher, use of Permacol™ did not eliminate wound morbidity or prevent recurrence, especially in morbidly obese patients.

Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernias.

The current data available describing the relationship of obesity and abdominal wall hernias is sparse. The objective of this study was to investigate the current prevalence of noninguinal abdominal wall hernias and their correlation with body mass index (BMI) and other demographic risk factors. Patients with umbilical, incisional, ventral, epigastric, or Spigelian hernias with or without incarceration were identified using the regional database for 14 hospitals over a 3-year period. Patients were stratified based on their BMI. Univariate and multivariate analyses were performed to distinguish other significant risk factors associated with the hernias. Of 2,807,414 patients, 26,268 (0.9%) had one of the specified diagnoses. Average age of the patients was 52 years and 61 per cent were male. The majority of patients had nonincarcerated umbilical hernias (74%). Average BMI was 32 kg/m2. Compared with patients with a normal BMI, the odds of having a hernia increased with BMI: BMI of 25 to 29.9 kg/m2 odds ratio (OR) 1.63, BMI of 30 to 39.9 kg/m2 OR 2.62, BMI 40 to 49.9 kg/m2 OR 3.91, BMI 50 to 59.9 kg/m2 OR 4.85, and BMI greater than 60 kg/m2 OR 5.17 (P<0.0001). Age older than 50 years was associated with a higher risk for having a hernia (OR, 2.12; 95% [CI], 2.07 to 2.17), whereas female gender was associated with a lower risk (OR, 0.53; 95% CI, 0.52 to 0.55). Those with incarcerated hernias had a higher average BMI (32 kg/m2 vs 35 kg/m2; P<0.0001). Overall, BMI greater than 40 kg/m2 showed an increased chance of incarceration, and a BMI greater than 60 kg/m2 had the highest chance of incarceration, OR 12.7 (P<0.0001). Age older than 50 years and female gender were also associated with a higher risk of incarceration (OR, 1.28; 95% CI, 1.02 to 1.59 and OR, 1.80; CI, 1.45 to 2.24). Increasing BMI and increasing age are associated with a higher prevalence and an increased risk of incarceration of noninguinal abdominal wall hernias.

Early jejunojejunostomy obstruction after laparoscopic gastric bypass: case series and treatment algorithm.

BACKGROUND: To review our experience with early jejunojejunostomy obstruction (JJO) at a large academic teaching hospital and provide a management algorithm. Early JJO is a known and often overlooked complication of laparoscopic Roux-en-Y gastric bypass. METHODS: From 2003 to 2007, 1097 patients underwent laparoscopic Roux-en-Y gastric bypass at our institution. Data, including patient demographics, co-morbidities, intraoperative data, peri- and postoperative complications, and outcomes, were prospectively recorded and retrospectively reviewed. RESULTS: Early post-laparoscopic Roux-en-Y gastric bypass JJO occurred in 13 patients (1.2%). The average time to presentation was 15 days (range 5-27). Patients presented with a combination of nausea, vomiting, and abdominal pain; all underwent computed tomography to confirm the diagnosis. The causes of JJO included dietary noncompliance (46%), anastomotic edema (23%), narrowing of the jejunojejunostomy at surgery (23%), and luminal clot (8%). Management was determined using our proposed treatment algorithm. Three patients (23%) required operative intervention, with the remainder successfully treated conservatively. CONCLUSION: From our experience, we propose a treatment algorithm for standardized management of early JJO, reserving reoperation for those who are acutely ill on presentation or those in whom conservative management fails. A review of our series using this algorithm has suggested that most patients can be successfully treated nonoperatively; however, bariatric surgeons must maintain a low threshold for surgical re-intervention in cases in which rapid recovery is not seen.

Succinylcholine: a drug to avoid in bariatric surgery.

Succinylcholine is a paralytic agent regularly utilized in anesthesia. There are numerous adverse effects of succinylcholine ranging from mild to fatal; one such effect is succinylcholine myalgia. We report the case of a 34-year-old woman who received succinylcholine while undergoing laparoscopic Roux-en-Y gastric bypass and later developed succinylcholine myalgia leading to a prolonged hospital stay and subsequent pneumonia. In the presence of suitable alternative paralytic agents, succinylcholine should be avoided in patients undergoing bariatric surgery. The use of a designated anesthesia team familiar with bariatric operations can help maximize peri-operative management and minimize complications.

Laparoscopic gastric bypass at a large academic medical center: lessons learned from the first 1000 cases.

Bariatric surgery is an effective and durable treatment for morbid obesity in properly selected patients. Surgical outcomes and patient management methods should routinely be reviewed to improve patient care and maintain long-term effectiveness of the bariatric operation. Over a 5-year period, 1096 laparoscopic Roux-en-Y gastric bypass operations were performed at our institution. A comprehensive prospective database was maintained, which included data for comorbidities, operative techniques, perioperative management, complications, and follow up. Many practice patterns such as the omission of routine preoperative sleep apnea testing and biliary ultrasounds remained constant and were validated by the outcomes measured. Several changes, however, were implemented based on outcomes analyses, including antecolic placement of the roux limb, a pars flaccida approach to the creation of the gastric pouch, longer alimentary limbs in superobese patients, and a selective approach to postoperative upper gastrointestinal imaging. Postoperative weight regain and inability to maintain long-term follow up in a significant per cent of patients were two identified and ongoing problems. Maintenance of a bariatric patient database is essential with its routine review resulting in changes to practice patterns and operative techniques. An effective method for long-term patient follow up remains elusive and may contribute to postoperative weight regain in some patients.

Postoperative CPAP and BiPAP use can be safely omitted after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Obstructive sleep apnea (OSA) is prevalent in the morbidly obese population. The need for routine preoperative testing for OSA has been debated in bariatric surgery publications. Most investigators have advocated the use of continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) in the postoperative setting; however, others have reported pouch perforations or other gastrointestinal complications as a result of their use. From a review of our experience, we present an algorithm for the safe postoperative treatment of patients with OSA without the use of CPAP or BiPAP. METHODS: From January 2003 to December 2007, 1095 laparoscopic Roux-en-Y gastric bypasses were performed at our institution. Preoperative testing for OSA was not routinely performed. A prospective database was maintained. The data included patient demographics, co-morbidities (including OSA and CPAP/BiPAP use), perioperative events, complications, and follow-up information. Patients with known OSA were not given CPAP/BiPAP after surgery. They were observed in a monitored setting during their inpatient stay, ensuring continuous oxygen saturation of >92%. All patients used patient-controlled analgesia, were trained in the use of incentive spirometry, and ambulated within a few hours of surgery. The outcomes were compared between the OSA patients using preoperative CPAP/BiPAP versus those with OSA without preoperative CPAP/BiPAP versus patients with no history of OSA. RESULTS: A total of 811 patients were included in the study group with no known history of OSA. Of the 284 patients with a confirmed diagnosis of OSA, 144 were CPAP/BiPAP dependent. Statistically significant differences were present in age distribution and gender, with men having greater CPAP/BiPAP dependency. No significant differences were found in body mass index, length of stay, pulmonary complications, or deaths. One pulmonary complication occurred in the OSA, CPAP/BiPAP-dependent group, three in the OSA, non-CPAP group, and six in the no-known OSA group. No anastomotic leaks or deaths occurred in the series. CONCLUSION: Postoperative CPAP/BiPAP can be safely omitted in laparoscopic Roux-en-Y gastric bypass patients with known OSA, provided they are observed in a monitored setting and their pulmonary status is optimized by aggressive incentive spirometry and early ambulation.

Current management of adolescent pilonidal disease.

BACKGROUND: Controversy persists regarding the optimal management for adolescent pilonidal disease. We reviewed the outcome of wide local excision (WLE) vs unroofing and marsupialization (UM) for pilonidal disease. METHODS: A retrospective review 2002 to 2007 of adolescents undergoing surgical treatment of pilonidal disease was performed. Data were analyzed using Student's t test. RESULTS: Twenty-six patients were treated for pilonidal disease during this period. Average age was 16.7 years (range, 14-19 years) with 50% males. Nine patients underwent WLE and 17 had UM. Before initial evaluation, 44% of patients in the WLE group had drainage of acute abscess compared to 59% in the UM group (P > .05). Postoperative complications in the WLE group (78%) were significantly higher compared to the UM group (0%). Median time for final healing was significantly higher in the WLE group (32 weeks) compared to the UM group (6 weeks). The reoperative rate was also significantly higher in the WLE group (56%) compared to the UM group (0%). No patient had recurrent disease after complete healing in either group. CONCLUSION: Unroofing and marsupialization for primary pilonidal disease has a shorter time to heal and carries a lower complication and reoperative rate compared to WLE.

Laparoscopic stoma formation.

BACKGROUND: Laparoscopic stoma formation has gained wide acceptance as an alternative to open abdominal surgery. Although laparoscopic stoma formation has a low morbidity, complications have been reported. Contributing factors to these complications are twisting of the bowel, maturing the wrong limb, or both of these. In this report, we describe a simple technique that can reduce these complications. METHODS: The bowel segment to be exteriorized is grasped with a locking nontraumatic, nonrotating grasper. After the orientation of the bowel is verified, the surgeon ties the handle of the instrument to the trocar by using a cotton umbilical tape. The trocar and the instrument become one working unit, and if the umbilical tape is wrapped around the shaft of the instrument, then the bowel is twisted. It is easy to untwist it by aligning the umbilical tape with the shaft of the instrument. To mature the stoma, the umbilical tape is removed and the grasper is unlocked. CONCLUSION: Laparoscopic stoma is an effective treatment for several benign and malignant disorders, and in general has a low morbidity. Our report describes a simple technique that can reduce the rare but significant postoperative stoma or small bowel obstruction.

Bariatric surgery and type 2 diabetes mellitus: surgically induced remission.

The relationship between obesity and type 2 diabetes mellitus (T2DM) is well known. Morbidly obese patients with T2DM who undergo bariatric surgery have improvement or remission of their diabetes. Different types of bariatric operations offer varying degrees of T2DM remission. These operations are classified as restrictive, malabsorptive, or a combination of both. The gold-standard operation, known as the Roux-en-Y gastric bypass, is a combination operation.Most often, improvement of the diabetes is seen within days of the operation. Various theories to explain this rapid change include calorie restriction and hormonal changes from exclusion of the upper gastrointestinal tract. Weight loss accounts for the sustained improvements in glucose control. The patients who benefit the most are those who are early in their disease course.Having a single treatment for both obesity and T2DM is ideal. As bariatric surgery has become a safe operation when performed by experienced surgeons, it should be considered a treatment for these diseases. The impact it can have on the lives of individual patients and society as a whole is tremendous.