Preperitoneal Ventral Hernia Repair: A Decade Long Prospective Observational Study With Analysis of 1023 Patient Outcomes.

OBJECTIVES: The aim of this study was to examine the outcomes of over a decade's experience utilizing preperitoneal ventral hernia repair (PP-VHR). BACKGROUND: PP-VHR was first described by our group in 2006, and there have been no subsequent reports of outcomes with this technique. METHODS: A prospective study of all PP-VHR from January, 2004 to April, 2016 was performed. Multivariate stepwise logistic regression and Cox proportional-hazard models were used to identify predictors of wound complications and hernia recurrence, respectively. RESULTS: There were 1023 PP-VHRs. Mean age was 57.2 ±â€Š12.6 years, BMI 33.7 ±â€Š11.4 kg/m, defect size 210.0 ±â€Š221.4 cm; 23.7% had diabetes, 13.9% were smokers, 68.7% were recurrent, and 23.6% incarcerated. Component separation was required in 43.6%, and a panniculectomy was performed in 30.0%. Wound complication was present in 27.3% of patients, with 1.7% having a mesh infection. In all, there were 53 (5.2%) hernia recurrences and 36 (3.9%) in the synthetic repairs, with a mean follow-up of 27.0 ±â€Š26.4 months. On multivariate regression (odds ratio or hazard ratio, 95% confidence interval), diabetes (1.9, 1.4-3.0), panniculectomy (2.6, 1.8-3.9), and operations requiring biologic mesh were predictors of wound complications, whereas recurrent hernia repair (2.69, 1.14-6.35), biologic mesh (3.1, 1.67-5.75), and wound complications (3.01, 1.69-5.39) were predictors of hernia recurrence. CONCLUSIONS: An open PP-VHR is a very effective means to repair large, complex, and recurrent hernias resulting in a low recurrence rate. Mesh choice in VHR is important and was associated with hernia recurrence and wound complications in this population.

Carolinas Comfort Scale as a Measure of Hernia Repair Quality of Life: A Reappraisal Utilizing 3788 International Patients.

OBJECTIVE: The goal of the present study was to reaffirm the psychometric properties of the CCS using an expansive, multinational cohort. BACKGROUND: The Carolinas Comfort Scale (CCS) is a validated, disease-specific, quality of life (QOL) questionnaire developed for patients undergoing hernia repair. METHODS: The data were obtained from the International Hernia Mesh Registry, an American, European, and Australian prospective, hernia repair database designed to capture information delineating patient demographics, surgical findings, and QOL using the CCS at 1, 6, 12, and 24 months postoperatively. RESULTS: A total of 3788 patients performed 11,060 postoperative surveys. Patient response rates exceeded 80% at 1 year postoperatively. Acceptability was demonstrated by an average of less than 2 missing items per survey. The formal test of reliability revealed a global Cronbach's alpha exceeding 0.95 for all hernia types. Test-retest validity was supported by the correlation found between 2 different administrations of the CCS using the kappa coefficient. Principal component analysis identified 2 components with a good distribution of variance, with the first component explaining approximately 60% of the variance, regardless of hernia type. Discriminant validity was assessed by comparing survey responses and use of pain medication at 1 month postoperatively and analysis revealed that symptomatic patients demonstrated significantly higher odds of requiring pain medication in all activity domains and for all hernia types. CONCLUSIONS: The present study confirms that the CCS questionnaire is a validated, sensitive, and robust instrument for assessing QOL after hernia repair, which has become a predominant outcome measure in this discipline of surgery.

Bladder Fill after Laparoscopic Inguinal Hernia Repair Reduces Time to Discharge.

Laparoscopic inguinal herniorrhaphy (LIH) has a relatively high risk of urinary retention. Bladder dysfunction may delay discharge after LIH. We hypothesized that filling the bladder before Foley catheter removal decreases time to discharge (TTD) after LIH. A secondary aim was to determine incidence of postoperative urinary retention (POUR) after bladder fill (BF). We reviewed a consecutive series of total extraperitoneal and transabdominal preperitoneal LIH procedures performed by a single surgeon at our institution from 2010 to 2013. All patients were catheterized during LIH, and selected patients received a 200-mL saline BF before Foley catheter removal. Patients were required to void >250 mL before discharge. TTD and incidence of POUR were compared between the BF and no-BF groups. A total of 161 LIH cases were reviewed. BF was performed in 89/161 (55%) of cases. TTD was significantly shorter in the BF versus the no-BF group (222 vs 286 minutes, respectively; P < 0.01). Patient and operative characteristics were similar between the BF and no-BF groups (P > 0.05). Incidence of POUR in the BF and the no-BF group was 10.1 and 16.7 per cent, respectively; however, this difference was not significant (P = 0.22). No postoperative urinary tract infection occurred in either group. In conclusions, postoperative BF significantly reduces TTD after LIH. Further studies may help to determine whether shorter postanesthesia care unit time and lower POUR rates associated with BF can lower LIH procedural costs and increase patient satisfaction.

Acute Colonic Pseudo-obstruction: Defining the Epidemiology, Treatment, and Adverse Outcomes of Ogilvie's Syndrome.

Acute colonic pseudo-obstruction (ACPO) is a rare but often fatal disease. Herein, we present the largest study to date on ACPO. The National Inpatient Sample was queried for ACPO diagnoses from 1998 to 2011. Patients were analyzed by treatment into four groups: medical management (MM), colonoscopy alone [(endoscopy-only group) ENDO], surgery alone (SURG), or surgery and colonoscopy (SAC). Logistic regression was used to identify predictors of adverse outcomes by treatment group. There were 106,784 cases of ACPO: 96,657 (90.5%) MM, 2,915 (2.7%) ENDO, 6,731 (6.3%) SURG, and 481 (0.5%) SAC. The medical complication (45.7%), procedural complication (15.9%), and mortality rates (7.7%) were high. Increasing procedure invasiveness was independently associated with higher odds of medical complications, procedural complications, and death (P < 0.0125). The odds of death were significantly higher in the ENDO [odds ratio (OR) = 1.2], SURG (OR 1.4), and SAC (OR = 1.8) groups (P < 0.0125). Those who fail MM and require procedures have increasing morbidity and mortality with increasing invasiveness, likely reflecting the severity of their conditions.

Mortality in hepatectomy: Model for End-Stage Liver Disease as a predictor of death using the National Surgical Quality Improvement Program database.

BACKGROUND: The predictive value of the Model for End-stage Liver Disease (MELD) for mortality after hepatectomy is unclear. This study aimed to evaluate whether MELD score predicts death after hepatectomy and to identify the most useful score type for predicting mortality. We hypothesized that an increase in this score is correlated with 30-day mortality in patients undergoing hepatic resection. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for hepatectomy. Original MELD, United Network of Organ Sharing-modified MELD (uMELD), integrated MELD (i-MELD), and sodium-corrected MELD (MELD-Na) scores were calculated. Mortality was analyzed by multivariate logistic regression. MELD types were compared using receiver operating characteristic (ROC) curves. RESULTS: From 2005 to 2011, 11,933 hepatic resections were performed, including 7,519 partial, 2,104 right, and 1,210 left resections, and 1,100 trisectionectomies. The mean duration of stay was 8.4 ± 22.0 days, and there were 275 deaths (2.4%). The 30-day mortality rates were 1.8%, 6.9%, 15.4%, and 25% according to uMELD strata of 0-9, 10-19, 20-29, and ≥ 30, respectively. Multivariate analysis revealed that increasing MELD stratum was independently associated with higher mortality (P < .001) for all MELD types. The uMELD had the largest effect size (odds ratio [OR], 1.16; 95% CI, 1.10-1.20), whereas i-MELD had the narrowest CI (OR, 1.13; 95% CI, 1.10-1.17) and largest area under the ROC curve. CONCLUSION: The postoperative 30-day mortality after hepatectomy increases with increasing MELD score across all MELD types. There is a 16% increase in the odds of mortality for each point increase in uMELD.

Impact of common crystalloid solutions on resuscitation markers following Class I hemorrhage: A randomized control trial.

BACKGROUND: Resuscitation after hemorrhage with crystalloid solutions can lead to marked acidosis and iatrogenically worsen the lethal triad. The effect of differing solutions on base deficit and lactate has been sparsely prospectively studied in humans. We sought to quantify the effect of normal saline (NS) and lactated Ringer's (LR) resuscitation in voluntary blood donors as a model for Class I hemorrhage. METHODS: A prospective randomized control trial was conducted in conjunction with blood drives. Donors were randomized to receive no intravenous fluid (noIVF), 2-L NS, or 2-L LR after blood donation of 500 mL. Lactate and base deficit were measured before and after fluid administration using an iSTAT. The mean laboratory values were compared between groups first using a global test followed by pairwise testing between groups using the Wilcoxon rank-sum and Kruskal-Wallis tests. The Bonferroni correction was used and a statistical significance of p < 0.0167 was set. RESULTS: A total of 157 patients completed the study. The mean (SD) age was 39.2 (12.7), and 65.0% were female. Patients in each group lost equivalent amounts of total blood volume, and a similar amount was replaced in the crystalloid group (p > 0.0167). Donors had comparable increases in lactate and base deficit after donation regardless of the group (p > 0.0167). After resuscitation with 2-L crystalloid, the lactate level increased higher in the LR group than in the noIVF or the NS group (1.36 mmol/L vs. 1.00 mmol/L vs. 1.54 mmol/L, p < 0.0001). In addition, the resuscitation base deficit increased in the NS group more than in the noIVF or LR group (-0.65 vs. -3.06 vs. -0.34, p < 0.0001). CONCLUSION: This study is one of the first human studies to prospectively demonstrate quantifiable differences in base deficit and lactate by type of crystalloid resuscitation. LR resuscitation elevated lactate levels, and NS negatively affected the base deficit. These findings are critical to the interpretation of trauma patient resuscitation with crystalloid solutions. LEVEL OF EVIDENCE: Therapeutic study, level II.

National Outcomes for Open Ventral Hernia Repair Techniques in Complex Abdominal Wall Reconstruction.

Modern adjuncts to complex, open ventral hernia repair often include component separation (CS) and/or panniculectomy (PAN). This study examines nationwide data to determine how these techniques impact postoperative complications. The National Surgical Quality Improvement Program database was queried from 2005 to 2013 for inpatient, elective open ventral hernia repairs (OVHR). Cases were grouped by the need for and type of concomitant advancement flaps: OVHR alone (OVHRA), OVHR with CS, OVHR with panniculectomy (PAN), or both CS and PAN (BOTH). Multivariate regression to control for confounding factors was conducted. There were 58,845 OVHR: 51,494 OVHRA, 5,357 CS, 1,617 PAN, and 377 BOTH. Wound complications (OVHRA 8.2%, CS 12.8%, PAN 14.4%, BOTH 17.5%), general complications (15.2%, 24.9%, 25.2%, 31.6%), and major complications (6.9%, 11.4%, 7.2%, 13.5%) were different between groups (P < 0.0001). There was no difference in mortality. Multivariate regression showed CS had higher odds of wound [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.5-2.0], general (OR 1.5, 95% CI: 1.3-1.8), and major complications (OR 2.1, 95%, CI: 1.8-2.4), and longer length of stay by 2.3 days. PAN had higher odds of wound (OR 1.5, 95%, CI: 1.3-1.8) and general complications (OR 1.7, 95%CI: 1.5-2.0). Both CS and PAN had higher odds of wound (OR 2.2, 95%, CI: 1.5-3.2), general (OR 2.5, 95%, CI: 1.8-3.4), and major complications (OR 2.2, 95%CI: 1.4-3.4), and two days longer length of stay. In conclusion, patients undergoing OVHR that require CS or PAN have a higher independent risk of complications, which increases when the procedures are combined.

Impact of implementing an electronic health record on surgical resident work flow, duty hours, and operative experience.

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means (P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation (P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation (P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events.

INTRODUCTION: Laparoscopic Heller myotomy (LHM) has supplanted an open approach due to decreased operative morbidity. Our goal was to quantify the incidence of peri-operative complications and identify risk factors for adverse outcomes in LHM. METHODS: All LHM were queried from 2005 to 2011 from the National Surgical Quality Improvement Program database. Adverse outcomes were identified, and univariate and stepwise logistic regression (MVR) was then performed to quantify association. RESULTS: There were 1,237 LHM in the study period. Patient averages were: age 51.9 ± 16.8 years, BMI 27.3 ± 6.6 kg/m(2), Charlson comorbidity index (CCI) 0.2 ± 0.6. 15.3 % had >10 % body mass loss in the preoperative 6 months. During surgery, 10.2 % underwent concomitant EGD, and mean operative time was 141.6 ± 63.4 min. There were 7(0.06 %) wound complications, 22(1.8 %) general complications, and 30(2.4 %) major complications. Average length of stay (LOS) was 2.8 ± 5.5 days. The rate of readmission and reoperation were 3.1 and 2.3 %, respectively, and there were 4(0.03 %) deaths. General and major complications were associated with alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times (p < 0.05); however, these factors did not remain significant on MVR (p > 0.05). Operative time was found to be significantly longer by 35.3 min for inpatients, 43.1 min in functionally dependent patients, 50.0 min in preoperative septic patients, and 17.2 min with concomitant EGD (p < 0.01 for all). LOS was found to be longer by 1.9 days for inpatients, 1.8 days in ASA category ≥3, and 1.2 days per one point increase in CCI (p < 0.001 for all). CONCLUSION: LHM is being performed nationally with a low incidence of operative complications and mortality. General and major complications following LHM are associated with patient alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times. Additionally, independent predictors of longer operative time and LOS were identified.

Tacks, staples, or suture: method of peritoneal closure in laparoscopic transabdominal preperitoneal inguinal hernia repair effects early quality of life.

INTRODUCTION: TAPP inguinal hernia repair (IHR) entails the development of a peritoneal flap (PF) in order to reduce the hernia sac and create a preperitoneal space in which to place mesh. Many methods for closure of the PF exist including sutures, tacks, and staples. We hypothesized that patients who had PF closure with suture would have better short-term QOL outcomes. METHODS AND PROCEDURES: A prospective institutional hernia-specific database was queried for all adult, TAPP IHRs from July 2012 to August 2013. Unilateral and bilateral patients were included and each hernia was analyzed separately. The main outcome of interest was quality of life (QOL) at two- and four-week follow-up, as measured by the Carolinas Comfort Scale. RESULTS: There were 227 patients who underwent TAPP, with 99 bilateral and 128 unilateral IHR, for a total of 326 IHR. PF closure was performed using tacks in 45.1%, suture in 19.0%, and staples in 35.9%. Patient characteristics were statistically similar between the tack, suture, and staple group. There were 32.9% direct, 46.5% indirect, and 20.6% pantaloon hernias, which were not significantly different when compared by PF closure method. Post-operative complications and length of stay were same for the three groups. There were no hernia recurrences. Post-operative activity limitation at two weeks was significantly better in the suture group when compared to the stapled group (p = 0.005). Additionally, sutured PF closure had less early post-operative pain when compared to the tack group (p = 0.038). CONCLUSIONS: Following TAPP IHR, suture closure of the PF significantly improves 2-week post-operative movement limitation compared to stapled and tacked PF closure. Continued randomized studies are needed to determine the best surgical hernia repair methods for ideal post-op QOL.

A little slower, but just as good: postgraduate year resident versus attending outcomes in laparoscopic ventral hernia repair.

INTRODUCTION: The purpose of this study was to analyze the effect of residents on patient outcomes in laparoscopic ventral hernia repair (LVHR).We hypothesized that increasing postgraduate year (PGY) level would correlate with better outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2011 for elective LVHR. Attending only cases were used as the control, and resident cases were stratified into junior (PGY 1-3), chief (4-5), and fellow (6+) cases. Standard statistical tests and multivariate regression controlling for age, body mass index, Charlson comorbidity index, smoking, functional status, and inpatient cases were performed for trainee involvement and PGY level. RESULTS: There were 6,841 ventral hernia repairs that met inclusion criteria: 2,773 attending and 4,068 resident cases. There were 1,644 junior, 1,983 chief, and 441 fellow cases. Patients were similar between the attending and resident groups. The resident group had a higher rate of inpatient cases, general complications, longer operative time, and hospital length of stay. After controlling for confounders in multivariate analysis, only operative time was significantly different; resident cases were 17.7 min longer (CI 15.0-20.6; p < 0.001). There was no significant difference in the rate of wound or major complications, readmission, reoperation, or mortality between attending and resident cases. Demographics were not significantly different between the PGY level strata. On multivariate regression by PGY level with attending alone as the reference, only operative time was significantly different. Juniors (15.7 min, CI 12.2-19.2), chiefs (18.0 min, CI 14.7-21.3), and fellows (24.9 min, CI 19.1-30.7) had significantly longer cases than attending alone; all p < 0.001. CONCLUSION: Trainee involvement during LVHR does not change the clinical outcomes for patients as compared to those performed by an attending only. Operative time is significantly longer with increasing PGY level, perhaps indicating the complexity of the operation or increasing trainee involvement as primary surgeon. However, patient care does not suffer, affirming the current surgical training curriculum is appropriate.

Outcomes of pancreatic debridement in acute pancreatitis: analysis of the nationwide inpatient sample from 1998 to 2010.

BACKGROUND: The objective of this study was to perform a national review of patients with acute pancreatitis (AP) who undergo pancreatic debridement (PD) to evaluate for risk factors of in-hospital mortality. METHODS: The Nationwide Inpatient Sample was used to identify patients with AP who underwent PD between 1998 and 2010. Risk factors for in-hospital mortality were assessed with multivariate logistic regression. RESULTS: From 1998 to 2010, there were 585,978 nonelective admissions with AP, of which 1,783 (.3%) underwent PD. From 1998 to 2010, the incidence of PD decreased from .44% to .25% (P < .01) and PD in-hospital mortality decreased from 29.0% to 15% (P < .05). Of patients undergoing PD, independent factors associated with increased odds of mortality were increased age (odds ratio [OR] 1.04, confidence interval [CI] 1.03 to 1.05; P < .01), sepsis with organ failure (OR 1.76, CI 1.24 to 2.51; P < .01), peptic ulcer disease (OR 1.83, CI 1.02 to 3.30; P < .05), liver disease (OR 2.27, CI 1.36 to 3.78; P < .01), and renal insufficiency (OR 1.78, CI 1.14 to 2.78; P < .05). CONCLUSIONS: The incidence and operative mortality of PD have decreased significantly over the last decade in the United States with higher odds of dying in patients who are older, with chronic liver, renal, or ulcer disease, and higher rates of sepsis with organ failure.

The impact of regionalization of pancreaticoduodenectomy for pancreatic Cancer in North Carolina since 2004.

Pancreaticoduodenectomy (PD) carries a significant risk. High-volume centers (HVCs) provide improved outcomes and regionalization is advocated. Rapid regionalization could, however, have detrimental effects. North Carolina has multiple HVCs, including an additional HVC added in late 2006. We investigated regionalization of PD and its effects before, and after, the establishment of this fourth HVC. The North Carolina Hospital Discharge Database was queried for all PDs performed during 2004 to 2006 and 2007 to 2009. Hospitals were categorized by PD volume as: low (one to nine/year), medium (10 to 19/year), and high (20/year or more). Mortality and major morbidity was assessed by comparing volume groups across time periods. Number of PDs for cancer increased 91 per cent (129 to 246 cases) at HVCs, whereas decreasing at low-volume (62 to 58 cases) and medium-volume (80 to 46 cases) centers. Percentage of PD for cancer performed at HVCs increased significantly (47.6 to 70.3%) while decreasing for low- and medium-volume centers (P < 0.001). Mortality was significantly less at HVCs (2.8%) compared with low-volume centers (10.3%) for 2007 to 2009. Odds ratio for mortality was significantly lower at HVCs during 2004 to 2006 (0.31) and 2007 to 2009 (0.34). Mortality for PD performed for cancer decreased from 6.6 to 4.6 per cent (P = 0.31). Major morbidity was not significantly different between groups within either time period; however, there was a significant increase in major morbidity at low-volume centers (P = 0.018). Regionalization of PD for cancer is occurring in North Carolina. Mortality was significantly lower at HVCs, and rapid regionalization has not detracted from the superior outcomes at HVCs.

Umbilical hernia repair with mesh: identifying effectors of ideal outcomes.

BACKGROUND: Quality of life has become an important focus for improvement in hernia repair. METHODS: The International Hernia Mesh Registry was queried. The Carolinas Comfort Scale quantitated quality of life at 1-month, 6-month, and annual follow-up. Scores of 0 (completely asymptomatic) in all categories without recurrence defined an ideal outcome. RESULTS: The analysis consisted of 363 umbilical hernia repairs; 18.7% were laparoscopic. Demographics included age of 51.5 ± 13.8 years, 24.5% were female, and the average body mass index was 30.63 ± 5.9 kg/m(2). Mean defect size was 4.3 ± 3.1 cm(2). Mean follow-up was 18.2 months. Absent/minimal preoperative symptoms were predictive of ideal outcome at all time points and increasing age was predictive at 6 months and 1 year. At 6 months, the use of fixation sutures alone versus tacks (odds ratio 14.1) predicted ideal outcome. CONCLUSIONS: Ideal outcomes are dependent on both patient-specific and operative factors. The durable, ideal outcome in umbilical hernia repair is most likely in an older, asymptomatic patient who undergoes mesh fixation with permanent suture.

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.

The first nationwide evaluation of robotic general surgery: a regionalized, small but safe start.

BACKGROUND: The purpose of this study was to evaluate the outcomes of the most commonly performed robotic-assisted general surgery (RAGS) procedures in a nationwide database and compare them with their laparoscopic counterparts. METHODS: The Nationwide Inpatient Sample was queried from October 2008 to December 2010 for patients undergoing elective, abdominal RAGS procedures. The two most common, robotic-assisted fundoplication (RF) and gastroenterostomy without gastrectomy (RG), were individually compared with the laparoscopic counterparts (LF and LG, respectively). RESULTS: During the study, 297,335 patients underwent abdominal general surgery procedures, in which 1,809 (0.6 %) utilized robotic-assistance. From 2009 to 2010, the incidence of RAGS nearly doubled from 573 to 1128 cases. The top five RAGS procedures by frequency were LG, LF, laparoscopic lysis of adhesions, other anterior resection of rectum, and laparoscopic sigmoidectomy. Eight of the top ten RAGS were colorectal or foregut operations. RG was performed in 282 patients (0.9 %) and LG in 29,677 patients (99.1 %). When comparing RG with LG there was no difference in age, gender, race, Charlson comorbidity index (CCI), postoperative complications, or mortality; however, length of stay (LOS) was longer in RG (2.5 ± 2.4 vs. 2.2 ± 1.5 days; p < 0.0001). Total cost for RG was substantially higher ($60,837 ± 28,887 vs. $42,743 ± 23,366; p < 0.0001), and more often performed at teaching hospitals (87.2 vs. 50.9 %; p < 0.0001) in urban areas (100 vs. 93.0 %; p < 0.0001). RF was performed in 272 patients (3.5 %) and LF in 7,484 patients (96.5 %). RF patients were more often male compared with LF (38.2 vs. 32.3 %; p < 0.05); however, there was no difference in age, race, CCI, LOS, or postoperative complications. RF was more expensive than LF ($37,638 ± 21,134 vs. $32,947 ± 24,052; p < 0.0001), and more often performed at teaching hospitals (72.4 vs. 54.9 %; p < 0.0001) in urban areas (98.5 vs. 88.7 %; p < 0.0001). CONCLUSIONS: This nationwide study of RAGS exemplifies its low but increasing incidence across the country. RAGS is regionalized to urban teaching centers compared with conventional laparoscopic techniques. Despite similar postoperative outcomes, there is significantly increased cost associated with RAGS.

Does a calculated "NAFLD fibrosis score" reliably negate the need for liver biopsy in patients undergoing bariatric surgery?

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) represents the most common cause of chronic liver disease in the USA. Biopsy has been the standard for determining fibrosis but is invasive, costly, and associated with risk. Previous studies report a calculated "NAFLD fibrosis scores" (cNFS) as a means to overcome the need for biopsy. We compared cNFS versus biopsy-pathological scoring for patients undergoing bariatric surgery. METHODS: We retrospectively reviewed patients with available preoperative labs and patient information undergoing Roux-en-Y gastric bypass (RYGBP) surgery at a single institution over a 5.5-year period. Biopsy samples were blind scored by a single hepatopathologist and compared with scores calculated using a previously reported cNFS. RESULTS: Of the 225 patients that met the inclusion criteria, the mean body mass index was 44.6 ± 5.4 kg/m(2) and 85 % were female. Using the cNFS, 39.6 % of patients were categorized into low fibrosis, 52 % indeterminate, and 8.4 % high fibrosis groups. Analysis of fibrosis by pathology scoring demonstrated 2 of 89 (2.2 %) and 7 of 110 (3.4 %) had significant fibrosis in the low and intermediate groups, respectively. Conversely, in the high fibrosis group calculated by cNFS, only 6 of 19 (31.6 %) exhibited significant fibrosis by pathology scoring. CONCLUSIONS: No definitive model for accurately predicting presence of NAFLD and fibrosis currently exits. Furthermore, under no circumstances should a clinical "NAFLD fibrosis score" replace liver biopsy at this time for RYGBP patients.

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.