Gastric Outlet Obstruction from Stomach-Containing Groin Hernias: Case Report and a Systematic Review.

Most abdominopelvic structures can find their way to a groin hernia. However, location, and relative fixation are important for migration. Gastric outlet obstruction (GOO) from a stomach-containing groin hernia (SCOGH) is exceedingly rare. In the current report, we present a 77-year-old man who presented with GOO from SCOGH to our facility. We performed a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) of patients presenting with SCOGH since it was first reported in 1802. Ninety-one cases of SCOGH were identified (85 inguinal and six femoral) over the last two centuries (1802-2023). GOO from SCOGH occurred in 48% of patients in one review and 18% in our systematic analysis. Initial presentation ranged from a completely asymptomatic patient to peritonitis. Management varied from entirely conservative treatment to elective hernia repair to emergent laparotomy. Only one case of laparoscopic management was documented. Twenty-one deaths from SCOGH were reported, with most occurring in early manuscripts (1802-1896 [n = 9] and 1910-1997 [n = 10]). In the recent medical era, outcomes for patients with this rare clinical presentation are satisfactory and treatment ranging from conservative, non-operative management to surgical repair should be tailored towards patients' clinical presentation.

Examination of abdominal wall perfusion using varying suture techniques for midline abdominal laparotomy closure.

BACKGROUND: With a growing interest in the primary prevention of incisional hernias, it has been hypothesized that different suturing techniques may cause various levels of tissue ischemia. Using ICG laser-induced fluorescence angiography (ICG-FA), we studied the effect of different suture materials and closure techniques on abdominal wall perfusion. METHODS: Fifteen porcine subjects underwent midline laparotomy, bilateral skin flap creation, and three separate 7 cm midline fascial incisions. Animals underwent fascial closure with 5 different techniques: (1) Running 0-PDS® II (polydioxanone) Suture with large bites; (2) Running 0-PDS II Suture with small bites; (3) Interrupted figure-of-eight (8) PDS II Suture, (4) Running 0-barbed STRATAFIX™ Symmetric PDS™ Plus Knotless Tissue Control Device large bite; (5) Running 0-STRATAFIX Symmetric PDS Plus Device small bites. ICG-FA signal intensity was recorded prior to fascial incision (baseline), immediately following fascial closure (closure), and at one-week (1-week.). Post-mortem, the abdominal walls were analyzed for inflammation, neovascularity, and necrosis. RESULTS: PDS II Suture with small bites, fascial closure at the caudal 1/3 of the abdominal wall, and the 1-week time period were all independently associated with increased tissue perfusion. There was also a significant increase in tissue perfusion from closure to 1-week when using small bites PDS II Suture compared to PDS II Suture figure-of-8 (p < 0.001) and a trend towards significance when compared with large bites PDS II Suture (p = 0.056). Additionally, the change in perfusion from baseline to 1 week with small bites was higher than with figure of 8 (p = 0.002). Across all locations, small bite PDS II Suture has greater total inflammation than figure of 8 (p < 0.001). CONCLUSIONS: The results suggest that the small bite technique increases abdominal wall perfusion and ICG-FA technology can reliably map abdominal wall perfusion. This finding may help explain the reduced incisional hernia rates seen in clinical studies with the small bite closure technique.

Representation of women in speaking roles at surgical conferences.

BACKGROUND: There are a number of factors that may hinder women's surgical careers. Here, we focus on one possible factor: the representation of women at surgical conferences. METHODS: Using a purposive sample of 16 national surgical societies, we assessed the proportion of women speakers at each society's annual meeting in plenary speaker and session speaker (panelist and moderator) roles in 2011 and 2016. RESULTS: Overall, 23.8% (28,591/120,351) of all society members were women. Of the 129 plenary speakers, 19.4% (n = 25) were women. Twelve conferences (42.9%) had zero women as plenary speakers. Of the 5,161 session speakers, 1,120 (21.7%) were women. Three-hundred fifty-three (39.5%) of the 893 panels included only male speakers. The proportion of women on conference organizing committees was positively correlated with having women session speakers (r = 0.71, p=<0.001) CONCLUSIONS: There is underrepresentation of women as conference speakers, particularly in plenary roles. There was wide variability in the representation of women across conferences.

Assessing gender bias in qualitative evaluations of surgical residents.

BACKGROUND: There are notable disparities in the training, recruitment, promotion, and evaluation of men and women in surgery. The qualitative assessment of surgical residents may be implicitly gender biased. METHODS: We used inductive analysis to identify themes in written evaluations of residents. We also performed a content analysis of words fitting previously defined communal, grindstone, ability, and standout categories. RESULTS: Differences in themes that emerged from evaluations of male and female residents were notable regarding overall performance, references to the future, professional competency, job domains, disposition and humanism, and overall tone of evaluations. Comments about men were more positive than those about women, and evaluations of men included more standout words. CONCLUSIONS: The more positive evaluations of men may handicap women if they are seen as less likely to perform well based on these evaluations. These differences suggest that implicit bias may play a role in the qualitative evaluation of surgical residents.

Postoperative opioid prescribing practices and the impact of the hydrocodone schedule change.

BACKGROUND: In 2014, hydrocodone was moved from Schedule III to II, thus it could no longer be "called in" to a pharmacy. We analyzed current postoperative opioid prescribing patterns and the impact of the schedule change on the type and amount prescribed. METHODS: Opioid prescriptions for common surgeries at 1 medical center from 2013 to 2016 were analyzed retrospectively. Milligram morphine equivalents prescribed before and after the schedule change were compared by t tests, and interrupted time series models and drug frequencies were compared by χ2 and Fisher exact tests. RESULTS: Data from 7,046 patients (7,361 prescriptions) after 29 different operations were analyzed. Milligram morphine equivalents prescribed for minor open procedures ranged from 211 to 342 milligram morphine equivalents, from 323 to 1297 for major open procedures, from 238 to 359 for basic laparoscopic procedures, and from 221 to 868 for complex laparoscopic procedures. Mean milligram morphine equivalents prescribed were not affected for most procedures, but over the entire population, milligram morphine equivalents prescribed began decreasing after the rule change. The percentage of hydrocodone prescriptions decreased after the rule change (from 33.8% down to 27.0%) and oxycodone and tramadol prescriptions increased. CONCLUSION: Before versus after the rule change, hydrocodone prescriptions decreased and oxycodone and tramadol prescriptions increased. Milligram morphine equivalents prescribed varied considerably across and within classes of procedures, but the schedule change did not affect mean milligram morphine equivalents prescribed for most procedures.

Opioid Medication Use in the Surgical Patient: An Assessment of Prescribing Patterns and Use.

BACKGROUND: With the epidemic of prescription opioid abuse in the US, rates of opioid-related unintentional deaths have risen dramatically. However, few data exist comparing postoperative opioid prescriptions with patient use. We sought to better elucidate this relationship in surgical patients. STUDY DESIGN: A prospective cohort study was conducted of narcotic-naïve patients undergoing open and laparoscopic abdominal procedures on a minimally invasive surgery service. During the first 14 post-discharge days and at their first postoperative clinic visit, patients recorded pain scores and number of opioid pills taken. Clinical data were extracted from the medical record. Descriptive statistics were used in data analysis. RESULTS: From 2014 through 2017, one hundred and seventy-six patients completed postoperative pain surveys. Mean age was 60.4 ± 14.9 years and sex was distributed equally. Most patients (69.9%) underwent laparoscopic procedures. Hydrocodone-acetaminophen was the most commonly prescribed postoperative pain medication (118 patients [67.0%]), followed by oxycodone-acetaminophen (26 patients [14.8%]). Patients were prescribed a median of 150 morphine milligram equivalents (MME) (interquartile range [IQR] 150 to 225 MME), equivalent to twenty 5-mg oral oxycodone pills (IQR 20 to 30 pills). However, by their first postoperative visit, they had only taken a median 30 MME (IQR 10 to 90 MME), or 4 pills (IQR 1.3 to 12 pills). Eight (4.5%) patients received a refill or an additional prescription for pain medications. At the first postoperative visit, 76.7% of respondents were satisfied or very satisfied with their overall postoperative pain management. CONCLUSIONS: Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion.

Combined in vivo and ex vivo analysis of mesh mechanics in a porcine hernia model.

BACKGROUND: Hernia meshes exhibit variability in mechanical properties, and their mechanical match to tissue has not been comprehensively studied. We used an innovative imaging model of in vivo strain tracking and ex vivo mechanical analysis to assess effects of mesh properties on repaired abdominal walls in a porcine model. We hypothesized that meshes with dissimilar mechanical properties compared to native tissue would alter abdominal wall mechanics more than better-matched meshes. METHODS: Seven mini-pigs underwent ventral hernia creation and subsequent open repair with one of two heavyweight polypropylene meshes. Following mesh implantation with attached radio-opaque beads, fluoroscopic images were taken at insufflation pressures from 5 to 30 mmHg on postoperative days 0, 7, and 28. At 28 days, animals were euthanized and ex vivo mechanical testing performed on full-thickness samples across repaired abdominal walls. Testing was conducted on 13 mini-pig controls, and on meshes separately. Stiffness and anisotropy (the ratio of stiffness in the transverse versus craniocaudal directions) were assessed. RESULTS: 3D reconstructions of repaired abdominal walls showed stretch patterns. As pressure increased, both meshes expanded, with no differences between groups. Over time, meshes contracted 17.65% (Mesh A) and 0.12% (Mesh B; p = 0.06). Mesh mechanics showed that Mesh A deviated from anisotropic native tissue more than Mesh B. Compared to native tissue, Mesh A was stiffer both transversely and craniocaudally. Explanted repaired abdominal walls of both treatment groups were stiffer than native tissue. Repaired tissue became less anisotropic over time, as mesh properties prevailed over native abdominal wall properties. CONCLUSIONS: This technique assessed 3D stretch at the mesh level in vivo in a porcine model. While the abdominal wall expanded, mesh-ingrown areas contracted, potentially indicating stresses at mesh edges. Ex vivo mechanics demonstrate that repaired tissue adopts mesh properties, suggesting that a better-matched mesh could reduce changes to abdominal wall mechanics.

Determining the minimal clinically important difference for the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog scale (VAS) measuring pain after shoulder arthroplasty.

BACKGROUND: Minimal clinically important differences (MCIDs) for the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) measuring pain have not been previously described using an anchor-based method after shoulder arthroplasty. The purpose of this study was to determine the MCIDs for these measures after shoulder arthroplasty for glenohumeral arthritis or advanced rotator cuff disease. METHODS: Primary anatomic total shoulder arthroplasty (TSA), primary reverse TSA, or hemiarthroplasty was performed in 326 patients by 1 of 5 shoulder and elbow surgeons. The SST score, ASES score, and VAS pain score were collected preoperatively and at a minimum of 2 years postoperatively (mean, 3.5 years). The MCIDs were calculated for the ASES score, SST score, and VAS pain score using an anchor-based method. RESULTS: The MCIDs for the ASES score, SST score, and VAS pain score were 20.9 (P < .001), 2.4 (P < .0001), and 1.4 (P = .0158), respectively. Duration of follow-up and type of arthroplasty (anatomic TSA vs reverse TSA) did not have a significant effect on the MCIDs (P > .1) except shorter follow-up correlated with a larger MCID for the ASES score (P = .0081). Younger age correlated with larger MCIDs for all scores (P < .024). Female sex correlated with larger MCIDs for the VAS pain score (P = .123) and ASES score (P = .05). CONCLUSIONS: Patients treated with a shoulder arthroplasty require a 1.4-point improvement in the VAS pain score, a 2.4-point improvement in the SST score, and a 21-point improvement in the ASES score to achieve a minimal clinical importance difference from the procedure.