Unseen Burden of Injury: Post-Hospitalization Mortality in Geriatric Trauma Patients.

BACKGROUND/OBJECTIVES: Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. METHODS: Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. RESULTS: Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. CONCLUSION: Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.

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.

Comparison of Outcomes After Partial Versus Complete Mesh Excision.

OBJECTIVE: Evaluate outcomes of patients undergoing mesh explantation following partial mesh excision (PME) and complete mesh excision (CME). BACKGROUND: Ventral hernia repair (VHR) with mesh remains one of the most commonly performed procedures worldwide. Management of previously placed mesh during reexploration remains unclear. Studies describing PME as a feasible alternative have been limited. METHODS: The AHSQC registry was queried for VHR patients who underwent mesh excision. Variables used for propensity-matching included age, BMI, race, diabetes, COPD, OR time>2 hours, immunosuppressants, smoking, active infection, ASA class, elective case, wound classification, and history of abdominal wall infection. RESULTS: A total of 1904 VHR patients underwent excision of prior mesh. After propensity matching, complications were significantly higher (35% vs 29%, P = 0.01) after PME, including SSI/SSO, SSOPI, and reoperation. No differences were observed in patients with clean wounds, however in clean-contaminated, PME more frequently resulted in SSOPI (24% vs 9%, P = 0.02). In mesh infection/fistulas, higher rates of SSOPI (46% vs 24%, P = 0.04) and reoperation (21% vs 6%, P = 0.03) were seen after PME. Odds-ratio analysis showed increased likelihood of SSOPI (OR 1.5, 95% CI 1.05-2.14; P = 0.023) and reoperation (OR 2.2, 95% CI 1.13-4.10; P = 0.015) with PME. CONCLUSIONS: With over 350,000 VHR performed annually and increasing mesh use, guidelines for management of mesh during reexploration are needed. This analysis of a multicenter hernia database demonstrates significantly increased postoperative complications in PME patients with clean-contaminated wounds and mesh infections/fistulas, however showed similar outcomes in those with clean wounds.

Laparoscopic Weight Loss Surgery in the Elderly: An ACS NSQIP Study on the Effect of Age on Outcomes.

In an era of rising obesity and an aging population, there are conflicting data regarding outcomes of laparoscopic weight loss surgery in older Americans. The aim of this study was to characterize the short-term outcomes of laparoscopic weight loss surgery in the elderly. The ACS NSQIP database was queried for obese patients aged ≥40 years undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. Patients were subdivided into age groups: 40 to 49, 50 to 59, 60 to 64, 65 to 69, and ≥70 years, and compared with univariate and multivariate analyses. Fifty-three thousand five hundred thirty-three patients were identified. Roux-en-Y gastric bypass was performed in 57.5 per cent of cases and was more common than sleeve gastrectomy in all age groups (P < 0.05). Comorbidities increased significantly with increasing age. There was an increase in minor (4.6% vs 9.1%; P < 0.0001) and major complications (2.2% vs 6.3%; P < 0.0001), and 30-day mortality (0.1% vs 0.5%; P = 0.0001) between the 40 to 49 and ≥70 years age groups. Increased age was independently associated with major complications. Mortality also increased with age. Older patients undergoing laparoscopic weight loss surgery have increased morbidity and mortality. When controlling for comorbidities, increases in age continued to impact major and minor complications and mortality.

Short-term Outcomes of Esophagectomies in Octogenarians-An Analysis of ACS-NSQIP.

BACKGROUND: In the face of an increasingly aged population, surgical management in the elderly will rise. This study assesses the short-term outcomes of esophagectomies in octogenarians. MATERIAL AND METHODS: The National Surgical Quality Improvement Program database was queried for esophagectomy cases from 2005 to 2014. Patients aged <80 and ≥80 y were compared in univariate and multivariate analysis, controlling for confounding variables. RESULTS: Among 9354 esophagectomies, 4.3% were performed in patients aged ≥80 y. Ivor Lewis was the most common approach, comprising 43% of cases. Octogenarians more frequently had dependent functional status (P < 0.0001) and cardiovascular disease (P < 0.0001), whereas younger patients were more likely obese (P < 0.0001), smokers (P < 0.0001), and have excess preoperative weight loss (P = 0.0043). Compared to younger patients, in multivariate analysis, elderly patients were noted to have increased risk of 30-d mortality (odds ratio [OR] 1.67; confidence interval [CI] 1.03-2.67), discharge to facility (OR 3.08; CI 2.36-4.02), myocardial infarction (OR 2.49; CI 1.29-4.82), and pneumonia (OR 1.47; CI 1.12-1.910). However, regardless of age, dependent functional status demonstrated the strongest association with mortality (OR 3.41; CI 2.14-6.61). Within the elderly, each additional year above 80 y old increased the risk of discharge to a facility by 17% (OR 1.17; CI 1.04-1.30). Cases requiring nongastric intestinal conduit were also more likely to suffer from early mortality (OR 2.87; CI 1.87-4.40). CONCLUSIONS: Age is independently associated with multiple adverse outcomes, including mortality, discharge to facility, and postoperative cardiopulmonary complications. Functional dependence is even more so associated with poor outcomes. Careful selection of very elderly patients is required to minimize additional risk.

Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open.

BACKGROUND: The decision to perform laparoscopic or open ventral hernia repair (VHR) is multifactorial. This study evaluates the impact of operative approach, BMI, and hernia size on outcomes after VHR. STUDY DESIGN: The International Hernia Mesh Registry was queried for VHR (2007-2017). A predictive algorithm was constructed, factoring the impact of BMI, hernia size, age, sex, diabetes, and operative approach on outcomes. RESULTS: Of the 1,906 VHRs, 58.8% were performed open, patient mean age was 54.9 ± 13.5 years, BMI was 31.2 ± 6.8 kg/m2, and defect area was 44.8 ± 88.1 cm2. Patients undergoing open VHRs were more likely to have an infection develop (3.1% vs 0.3%; p < 0.0001), but less likely to have a seroma develop (6.8% vs 15.3%; p < 0.0001) at mean follow-up 23.2 ± 12.0 months. With multivariate regression controlling for confounding variables, patients undergoing laparoscopic VHR had increased risk of seroma (odds ratio [OR] 1.78; 95% CI 1.05 to 3.03), a decreased risk of infection (OR 0.05; 95% CI 0.01 to 0.42), and had worse quality of life at 1, 6, 12, and 24 months postoperatively compared with patients undergoing open repair. Recurrent hernias were associated with subsequent recurrence (OR 2.69; 95% CI 1.24 to 5.81) and need for reoperation (OR 4.93; 95% CI 2.24 to 10.87). Multivariate predictive models demonstrated independent predictors of infection, including open approach, recurrent hernias, and low ratio of BMI to defect size. CONCLUSIONS: Ideal outcomes are dependent on both patient and operative factors. Open repair in thin patients with large defects should be considered due to reduced complications and improved quality of life. Laparoscopic repair in obese patients and recurrent hernias can decrease the associated risk of infection.

Management of Surgical Incisions Using Incisional Negative-Pressure Therapy.

Use of negative-pressure therapy (NPT) is a well-established therapy for chronic, open, contaminated wounds, promoting formation of granulation tissue and healing. The application of NPT after primary closure (ie, incisional NPT) has also been shown to reduce surgical site infection and surgical site occurrence in high-risk procedures across multiple disciplines. Incisional NPT is believed to decrease edema and shear stress, promote angiogenesis and lymphatic drainage, and increase vascular flow and scar formation. Incisional NPT may be considered when there is a high risk of surgical site occurrence or surgical site infection, particularly in procedures with nonautologous implants, such as hernia mesh or other permanent prosthetics. Here we discuss the proposed physiologic mechanism as demonstrated in animal models and review clinical outcomes across multiple specialties.

Emergent Laparoscopic Ventral Hernia Repairs.

BACKGROUND: Emergent repairs of incarcerated and strangulated ventral hernia repairs (VHR) are associated with higher perioperative morbidity and mortality than those repaired electively. Despite increasing utilization of minimally invasive techniques in elective repairs, the role for laparoscopy in emergent VHR is not well defined, and its feasibility has been demonstrated only in single center studies. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2009-2016) was queried for emergent VHR. Laparoscopic and open techniques were compared using univariate and multivariate analyses. RESULTS: A total of 11,075 patients who underwent emergent ventral and incisional hernia repairs were identified: 85.5% open ventral hernia repair (OVHR), 14.5% laparoscopic ventral hernia repair (LVHR). Patients who underwent emergent OVHRs were older, more comorbid, and more likely to be septic at the time of surgery than those undergoing emergent LVHRs. Emergent OVHR patients were more likely to have minor complications (22.1% versus 11.0%; OR 1.7; 95% CI 1.069-2.834). After controlling for confounding variables, LVHR and OVHR had similar outcomes, with the exception of higher rates of superficial surgical site infection in OVHR (5.0% versus 1.8%; odd's ratio (OR) 2.7; 95% confidence interval (CI) 1.176-6.138). Following multivariate analysis, laparoscopic approach demonstrated similar outcomes in major complications, reoperation, and 30-d mortality compared to open repairs. However, when controlling for other confounding factors, LVHR had reduced length of stay compared to OVHR (6.7 versus 4.0 d; 1.6 d longer, standard error 0.77, P < 0.03). CONCLUSIONS: Emergent LVHR is associated with fewer superficial surgical site infection and shorter length of stay than OVHR but no difference in major complications, reoperation or 30-d mortality is associated with LVHR in the emergency setting.

Roux-En-Y gastric bypass following failed fundoplication.

INTRODUCTION: Roux-En-Y gastric bypass (RYGB) is an alternative to reoperative fundoplication. The aim of this study was to expand long-term outcomes of patients undergoing RYGB after failed fundoplication and assess symptom resolution. METHODS: A single institution prospective study was performed of patients undergoing fundoplication takedown and RYGB between March 2007 and September 2016. Demographics, body mass index (BMI), preoperative symptoms, operative duration and findings, and postoperative outcomes were recorded. Data were assessed using standard statistical methods. RESULTS: 87 patients with failed antireflux surgery underwent RYGB. Median age 58 years (range 25-79 years). Median preoperative BMI 32.4 kg/m2 (range 21.6-50.6 kg/m2). Comorbidities included hypertension (48.3%) and diabetes (11.5%). Sixty-six patients had undergone 1 prior fundoplication, 18 had 2 prior fundoplications, and 3 had 3 prior fundoplications. At least one previous open antireflux procedure had been performed in 16.1% of patients. The most common recurrent symptoms were reflux (85.1%), dysphagia (36.7%), pain (35.6%), and regurgitation (29.9%). Median symptom-free interval from last antireflux surgery was 3 years (range 0-25 years). RYGB was performed laparoscopically in 47.1% of cases, robotically in 44.8% of cases, and open in 5.9%. Operative duration was longer in the robotic group (p = 0.04). During RYGB, 85.1% patients were found to have an associated hiatal hernia, 34.5% had intrathoracic migration of the fundoplication, 32.2% a slipped fundoplication onto proximal stomach, and 13.8% had wrap disruption. Median length of stay (LOS) was 4 days (range 1-33 days). Median follow-up was 35.8 months, 11 patients (12.6%) had recurrent reflux symptoms. Excess body weight loss (%EWL) was 80.4%. There was no mortality but 8 patients required reoperation during follow-up. CONCLUSIONS: Fundoplication takedown with RYGB was successful for long-term reflux resolution. Most can be performed via a minimally invasive approach with acceptable perioperative morbidity, symptom resolution, and the additional benefit of %EWL.

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.

A nationwide evaluation of robotic ventral hernia surgery.

BACKGROUND: The purpose of this study was to examine outcomes of robotic ventral hernia repair(RVHR) versus laparoscopic ventral hernia repair(LVHR). METHODS: The Nationwide Inpatient Sample was queried from October 2008 to December 2013 for ventral hernia repairs. Demographics, morbidity, mortality, and charges were compared between RVHR and LVHR. RESULTS: From 2008-2013, 149,622 ventral hernia surgeries were identified; 117,028 open, 32,243 laparoscopic, and 351 robotic. Open repairs were excluded. RVHR rose annually with 2013 containing 47.9% of all RVHRs. RVHR patients were more likely to be older and have more chronic conditions. There was no difference between length of stay. Pneumonia rates were higher with RVHR; however, after controlling for confounding variables, there was no difference in pneumonia rates. Mortality and other major complications were similar. Total charges were increased for RVHR in univariate and multivariate analysis. RVHR was more common in teaching hospitals and wealthier zip codes. CONCLUSION: RVHR demonstrates comparable safety to the laparoscopic technique, with increased charges and increased volume in urban teaching hospitals and patients from areas of higher median income.

AbsorbaSeal™ Vascular Closure Device: A Novel Device for Hemostasis Following Interventional Peripheral Vascular Procedures.

INTRODUCTION: Vascular closure devices (VCDs) are designed to achieve rapid hemostasis during percutaneous coronary and peripheral vascular procedures. Studies demonstrate that VCDs improve time to hemostasis (TTH) and time to ambulation (TTA) in comparison to standard manual compression. The available products, however, typically have 13-17 steps in their application, often require hemostatic collagen or other agents as part of the process, and can result in significant scarring at the puncture site that can impact future access. The aim of this study was to investigate the performance of a three-step, novel VCD for access site TTH, short-term and long-term histology, and a first-in-man clinical study. MATERIALS AND METHODS: This study evaluated AbsorbaSeal™ (CyndRx, LLC, Brentwood, Tennessee), a simple, three-step, VCD with bio-absorbable components. Following an institutional review board (IRB) approval, a 6-F sheath was placed directly into the porcine aorta, AbsorbaSeal™ was used to seal the puncture site, and a measure of total time of deployment (TTD) and TTH was performed, as well as histologic evaluation at 30, 60, and 180 days. A complement activation test was performed to determine the potential for activation of the complement system as a mediator of inflammation. The test was performed by directly incubating the VCDs AbsorbaSeal™ and Angio-Seal™ (Terumo Interventional Systems, Tokyo, Japan) in human serum. Serum samples were removed after 30, 60, and 90 minutes and tested for the presence and amount of complement protein SC5b-9. In the first in-man trial, the device was deployed in anticoagulated patients undergoing interventional vascular procedures. The TTH, estimated blood loss, patient pain scores, and procedural and follow-up complications were recorded. RESULTS: In the acute and chronic porcine studies, TTD averaged 25 seconds (17-29 seconds). Vascular control was immediate, yielding a TTH of effectively zero seconds. Histologic evaluation demonstrated complete endothelial coverage of the device by 30 days without evidence of bleeding, clotting, or inflammation. At 60 days, the significant mass of the device had dissolved and normal appearing collagen surrounded the devices with essentially no inflammatory response. By six months, all but one microscopic segment of one of the devices had been absorbed with normal appearing vascular endothelium, and no, or minimal, scarring appreciated. The complement test demonstrated that the AbsorbaSeal™ had similar, or lower, complement concentrations than the negative controls and significantly less than Angio-Seal™. This supported the histologic findings of minimal to no inflammation. The VCD was deployed in 20 patients undergoing interventional vascular procedures. The mean TTH was 2.3 ± 1.5 minutes. Estimated blood loss was 11.7 mL ± 3.5 mL, and no significant hematoma was noted. Post-procedure pain scores were low, with a mean of 1.4 ± 0.8 on a 0-10 pain rating scale. There were no perioperative complications and no adverse events at follow-up. CONCLUSIONS: The AbsorbaSeal™ is safe and simple to use for vascular closure after interventional vascular procedures with favorable outcomes including a short TTH, minimal procedural blood loss, low postoperative pain scores, and no perioperative complications or adverse effects. Histologic evaluation reveals rapid device absorption and little scar formation both short- and long-term. A direct study of complement activation supports that AbsorbaSeal™ evokes a minimal inflammatory response that is significantly less than Angioseal.

The effect of component separation technique on quality of life (QOL) and surgical outcomes in complex open ventral hernia repair (OVHR).

INTRODUCTION: Outcomes following OVHR may be affected by type of component separation. In this study, outcomes including QOL of patients undergoing OVHR were evaluated based on the utilization of transversus abdominis release (TAR), posterior rectus sheath release (PRSR) alone or in combination with external oblique release (EOR + PRSR). METHODS: A prospective, single-institution study following open ventral hernia repair involving component separation was performed from May 2005 to April 2015. Self-reported QOL outcomes were obtained preoperatively and at 1, 6 and 12 months postoperatively using the Carolinas Comfort Scale (CCS). A CCS of 2 (mild but bothersome discomfort) or greater was considered symptomatic. Comorbidities, complications, outcomes and CCS scores were reviewed. Univariate group comparisons were performed using Chi-square and Wilcoxon two-sample tests with statistical significance set at p < 0.05. RESULTS: During the study period, 292 OVHRs with CST met inclusion criteria. Single-sided, different releases on opposite sides, etc., were eliminated. Demographics included: average age-57.9 ± 11.9 years, BMI-34.0 ± 7.9 kgm2, 53.2% female, 69% at least one prior hernia repair and average defect size-291.2 ± 236.2 cm2. Preoperative discomfort (82 vs. 75 vs. 79%, p = 0.77) and movement limitation (94 vs. 70 vs. 78%, p = 0.1) in TAR, PRSR and EOR + PRSR were similar. Average follow-up was 16.4 months. At 1, 6 and 12 months postoperatively, there was no difference in reported CCS pain scores, movement limitation or mesh sensation among the groups (p > 0.05). Comparing OVHR patients outcomes by CST type, TAR was associated with decreased wound infections compared to others (3.2 vs. 16.1 vs. 20%, p = 0.07) while recurrence rates were increased in EOR + PRSR compared to TAR and PRSR alone(8.4 vs. 3 vs. 1.8%, p = 0.03). Eighty percent of recurrences had a biologic mesh secondary to contaminated field during hernia repair. The other two recurrences were one which occurred superior to the mesh at a suture site and one who developed a wound infection postoperatively. Mesh infection rates were low (0 vs. 1.5 vs. 2.6%, p > 0.05) even including contaminated cases (0 vs. 2 vs. 3.6%, p > 0.05) and were statistically equivalent among all three techniques. CONCLUSION: While QOL is not impacted by type of component separation on short- or long-term follow-up, the TAR may provide benefits such as decreased wound infection rates. Overall QOL had a significant improvement from preoperative regardless of type of component separation. When controlling for field contamination, there were no differences in recurrence or infection.

Does peritoneal flap closure technique following transabdominal preperitoneal (TAPP) inguinal hernia repair make a difference in postoperative pain? A long-term quality of life comparison.

BACKGROUND: Transabdominal, preperitoneal (TAPP), laparoscopic inguinal hernia repair (IHR) requires the creation of a peritoneal flap (PF) that must be closed after mesh placement. Our previous study indicated that sutured PF closure resulted in less short-term postoperative pain at 2 and 4 weeks compared to tacks and staples. Therefore, the aim of this follow-up study was to compare short-term QOL with a greater sample size and long-term QOL at 2 years by method of PF closure. MATERIALS AND METHODS: A prospective institutional hernia-specific database was assessed for all adult TAPP IHRs from July 2012 to May 2015. QOL outcomes were compared by PF closure method at 2 and 4 weeks and 6, 12, and 24 months as measured by the Carolinas Comfort Scale. Standard statistical tests were used for the whole population and then the Bonferroni Correction was used to compare groups (p < 0.0167). Multivariate analysis controlling for age, gender, recurrent hernias, and preoperative symptomatic pain was used to compare QOL by PF closure method. RESULTS: A total of 679 TAPP IHRs in 466 patients were analyzed; 253 were unilateral, and 213 were bilateral. PF closure was performed using tacks in 36.7 %, suture in 24.3 %, and staples in 39.0 %. There was no difference in hernia recurrence (only 1 patient at 36 months). There were no statistical differences in QOL between 2 and 4 weeks and 6- to 24-month follow-up. When resolution of symptoms from preoperative levels was examined, there was no difference in the three groups at any time point (p > 0.05). After controlling for confounding variables on multivariate analysis, there was no difference in QOL by PF closure method at any time point (p > 0.05). CONCLUSION: Tacked, sutured, and stapled techniques for peritoneal flap closure following TAPP have no significant differences in operative outcomes, postoperative quality of life, or resolution of symptoms.

The cost of preventable comorbidities on wound complications in open ventral hernia repair.

BACKGROUND: Patients with complex ventral hernias may benefit from preoperative optimization. This study evaluates the financial impact of preventable comorbidities (PCM) in elective open ventral hernia repair. METHODS: In this single institution prospectively collected data from 2007-2011, hospital charges (included all hernia-related visits, interventions, or readmissions) and wound-related complications in patients with PCM-diabetes, tobacco use, and obesity-were compared to patients without such risks using standard statistical methods. RESULTS: Within the study period, there were 118 patients with no PCM; of those, 33 had complications, and 85 did not. In the 131 patients with two or more PCM, 81 had complications; 89 of 251 patients had complications in the group with only 1 PCM; groups with PCM were significantly more likely to have complications compared to the no PCM group (62% versus 35.4% versus 28%, P < 0.05). The majority of the patient population was female (57.2%) with a mean age of 57.8 y (range, 22-84 ys), and median defect size was 150 cm2 (interquartile range, 50-283 cm2). Body mass index was higher in PCM group with complications than in PCM without complications (40 versus 36 kg/m2, P < 0.05). For patients with complications, the average hospital charges were $80,660 in the PCM group compared to $55,444 in the no PCM group (P = 0.038). Hospital charges in those with PCM without complications compared to no PCM with complications were equivalent ($65,453 versus $55,444, P = 0.55). Even when no complications occurred, patients with PCM incurred higher charges than No PCM for inpatient ($61,269 versus $31,236, P < 0.02), outpatient ($4,185 versus $552, P < 0.04), and total hospital charges ($65,453 versus $31,788, P ≤ 0.001). Those patients without complications but with a single PCM incurred larger charges than those with no PCM during follow-up ($3578 versus $552, P = 0.04), but there was no difference in hospital or overall total charges (P > 0.05). Interestingly, patients without complications, both hospital ($38,333 versus $61,269, P = 0.02) and total charges ($41,911 versus $65,453, P = 0.01) were increased for patients with 2+ PCM compared to those with only a single PCM. If complications occurred, no difference between the single PCM group compared to the two or more PCM groups existed for hospital, follow-up, or overall charges (P > 0.05). CONCLUSIONS: Patients with PCM undergoing open ventral hernia repair are more likely to have complications than patients without comorbidities. Patients with PCM generate higher hospital charges than those without PCM even when no complications occur; furthermore, the more PCM, the patient has the more significant the impact. Interestingly, patients with multiple PCM and no complications had equivalent hospital costs compared to patients with no PCM and with complications. Aggressive risk reduction may translate into significant savings. Preoperative preparation of patients before elective surgery is indicated.

Prospective, multi-institutional surgical and quality-of-life outcomes comparison of heavyweight, midweight, and lightweight mesh in open ventral hernia repair.

BACKGROUND: Mesh choice in open ventral hernia repair (OVHR) remains controversial. Our aim was to analyze prospective outcomes among heavyweight, midweight, and lightweight (LW) mesh. METHODS: A study of the International Hernia Mesh Registry was performed for OVHR. Operative details, complications, recurrence, and quality of life (QOL) at 1, 6, 12, 24, and 36 months were evaluated. RESULTS: There were 549 OVHRs, 99 using heavyweight, 262 midweight, and 188 LW mesh. Heavyweight group had larger defects (P ≤ .008). Midweight patients had fewer superficial surgical site infections (P = .04) and shorter LOS (P < .0001). Recurrence rates were equal (6.1% vs 6.1% vs 8.0%; P = .71). After controlling for surgical location, component separation, and preoperative pain with multivariate analysis, LW mesh was associated with an overall worse QOL at 6 months and pain at 1 year. CONCLUSIONS: MW mesh had fewer superficial surgical site infections and shorter LOS. After controlling for potential confounding variables, LW mesh had a worse QOL at 6 and 12 months.

Quantification of the Effect of Diabetes Mellitus on Ventral Hernia Repair: Results from Two National Registries.

Two national databases were analyzed to determine the effect of varying severity of diabetes mellitus (DM) on ventral hernia repair (VHR) outcomes. The National Surgical Quality Improvement Program (NSQIP) and the National Inpatient Sample (NIS) were queried for patients with and without DM who underwent elective VHR between 2005 to 2012 and 1998 to 2011, respectively. In addition, patients with insulin dependent versus noninsulin-dependent DM were compared in NSQIP; complicated and uncomplicated diabetics were compared in NIS. Univariate and multivariate analyses were used. In NSQIP, 25,819 of 219,625 patients undergoing VHR were diabetic. In open VHR (OVHR), DM patients had an increased complication rate (P < 0.0001); DM patients requiring insulin had increased odds of wound, minor, and major complications (P < 0.0001). For laparoscopic VHR (LVHR), insulin dependence did not affect complication rates (P > 0.05). In NIS, 45,248 of 238,627 patients undergoing VHR were diabetic. In OVHR, patients with complicated diabetes had higher rates of minor complications (17.3% vs 12.7%, P < 0.0001) and had 58 per cent greater odds of major complications than patients with uncomplicated diabetes. LVHR had no difference in complications for complicated versus uncomplicated DM (P > 0.05). After multivariate analysis, insulin-dependent or complicated DM undergoing OVHR had significantly worse outcomes compared with noninsulin-dependent and uncomplicated diabetics. Preoperative optimization and LVHR should be considered in diabetic patients.

Biologic mesh in ventral hernia repair: Outcomes, recurrence, and charge analysis.

BACKGROUND: Biologic mesh choice in ventral hernia repair is challenging due to lack of prospective data. This study examines long-term, single-center biologic mesh outcomes. METHODS: Prospective operative outcomes data was queried for open ventral hernia repair with biologic mesh. Univariate and multivariate analysis were used to compare mesh outcomes. RESULTS: In the study, 223 patients underwent open ventral hernia repair with biologic mesh, including 40 with Alloderm, 23 AlloMax, 70 FlexHD, 68 Strattice, and 22 Xenmatrix. Overall, 9.8% had an American Society of Anesthesiology classification of 4, 54.6% with a classification of 3, and 35.6% with a classification of 1 or 2. Operative time averaged 241 minutes with estimated blood loss of 202 mL. Hernia defects averaged 257 ± 245 cm2 with mesh size 384 cm2. Biologic mesh was used as a fascial bridge in 19.6%, component separation was performed in 47.5%, and 82% had concomitant procedure. Inpatient mortality was 1.4%. Hernia recurrence varied significantly by mesh type: 35% Alloderm, 34.5% AlloMax, 37.1% FlexHD, 14.7% Strattice, and 59.1% Xenmatrix (P = .001). The mean follow-up was 18.2 months. After multivariate analysis comparing to Strattice, AlloMax had a 3.4 higher odds ratio for recurrence, FlexHD a 2.9 odds ratio, and Xenmatrix a 7.8 odds ratio. The rate of mesh infections requiring explantation was <1%. Total hospital charges averaged $131,004 ± $143,320. Mean charges varied significantly between meshes; Xenmatrix was the most expensive and AlloMax was the least expensive (P < .05). CONCLUSION: In 223 ventral hernia repair performed with biologic mesh at a tertiary care institution, Strattice, a porcine acellular dermal mesh, had significantly lower odds of hernia recurrence compared with AlloMax, FlexHD, and Xenmatrix. Choice of biologic mesh affects long-term postoperative outcomes in ventral hernia repair.

Predictive modeling for chronic pain after ventral hernia repair.

BACKGROUND: Few studies predict which patients have dissolution of their postoperative discomfort or develop chronic pain after ventral hernia repair (VHR). This study develops a predictive model to determine which patients are at the greatest risk of chronic pain after VHR. METHODS: A prospective study of VHR patients was performed via the International Hernia Mesh Registry. Anonymous, self-reported, quality of life data using the Carolinas Comfort Scale (CCS) was recorded preoperatively, and 1,6, and 12 months postoperatively. Pain was identified as a score of 2 or more (mild but bothersome to severe) for any Carolinas Comfort Scale pain-specific questions. Logistic regression analyses were performed to determine statistically significant predictors of chronic pain. Univariate analysis selected potential predictors with a P value less than .15, and a subsequent multivariable model was built using backward elimination setting retention criterion at P < .15. Goodness-of-fit of the model was tested using Hosmer-Lemeshow test. A value of greater than 70% for the area under the curve (AUC) was considered most accurate diagnostically. The final model was then internally validated with bootstrap analysis. RESULTS: A total of 887 patients underwent VHR between 2007 and 2014. The patients had an average age of 57.2 ± 12.8 years, 52.4% were female, 17.0% were active smokers, and 13.2% used narcotics preoperatively. With 74% follow-up at 1 year, 26.0% of the patients reported chronic discomfort. After logistic regression model, independent predictors of pain at 6 months were preoperative pain score 2 or more (P < .0001), preoperative narcotic use (P = .06), and 1-month postoperative pain score 2 or more (P < .0001), AUC = .74. Baseline, 1-month, and 6-month predictors determined the final multivariate regression model for prediction of chronic pain at 1 year, AUC = .73. Older age was protective against chronic pain (odds ratio [OR] .98, 95%confidence interval [CI] = .96 to .998, P = .03), female sex increased risk with an OR of 1.7(CI = 1.1 to 2.7, P = .02); preoperative pain, and recurrent hernia repair nearly doubled the risk of developing chronic pain postoperatively (OR = 3.0, CI = 1.8 to 4.8, P < .0001 and 1.6, CI = .98 to 2.6, P = .06, respectively). Importantly, presence of pain at 1 month was a strong predictor of chronic pain at 1-year follow-up (OR = 2.6, CI = 1.7 to 4.2, P < .0001). CONCLUSIONS: Patients who have preoperative pain and at 1 month postoperatively are significantly more likely to have chronic pain. Both short- and long-term pain can be predicted from female sex, younger age, and repair of recurrent hernias. This predictive model may aid in preoperative counseling and when considering postoperative intervention for pain management in VHR patients.