The benefits of preoperative smoking cessation on abdominal wall reconstruction outcomes: An examination of abstinent versus never smokers.

INTRODUCTION: Active smoking is related to wound and respiratory complications following abdominal wall reconstruction (AWR), but no AWR studies directly compare outcomes of abstinent-smokers (AS), fulfilling four-weeks of smoking cessation, to non-smokers (NS). METHODS: Prospectively maintained institutional database was queried for all AWR between 2012 and 2019. AS and NS were included. Primary outcomes were wound and respiratory complications; secondary outcome was recurrence. Standard statistical analyses were performed. RESULTS: Evaluation included 1088 patients, 305 AS and 783 NS. AS had a lower BMI (31.3 vs 32.7 â€‹kg/m2; P â€‹= â€‹0.004) but increased ASA Class III (51.5% vs 34.5 â€‹%, P â€‹= â€‹0.009), COPD (8.9% vs 4.0 â€‹%, P â€‹= â€‹0.001), comorbidities (6.3 vs 4.7, P < 0.001), and wound class (Class III/IV: 25.3% vs 15.8 â€‹%, P â€‹= â€‹0.003). AS had increased defect size (229 vs 209.1 â€‹cm2; P â€‹= â€‹0.023), use of component separation (CST) (52.5% vs 43.8 â€‹%; P â€‹= â€‹0.010) and hospital stay (6.6 vs 6.2 days, P â€‹= â€‹0.015). Postoperative wound, mesh, and pulmonary infection, respiratory failure, and recurrence were similar. On multivariable regression, wound class and complications predicted recurrence. BMI, panniculectomy and CST predicted wound complications. BMI, CST, and wound class predicted respiratory complications. CONCLUSION: Despite greater patient and hernia complexity, smoking cessation appears to result in similar outcomes to never-smokers in this AWR population.

Cricopharyngomyotomy: Outcomes of flexible endoscopic management of small and medium sized Zenker's diverticulum.

BACKGROUND: Zenker's diverticulum (ZD) was historically treated with an open transcervical myotomy with diverticulectomy, but endoscopic approaches have gained popularity, though with little recent data. This study aimed to report flexible endoscopic cricopharyngomyotomy (FEC) outcomes, particularly in smaller diverticula. METHODS: Patients with ZD treated with FEC at a tertiary center were reviewed. Patients were grouped by diverticulum size: small (sZD)≤1.5 â€‹cm; medium (mZD) â€‹> â€‹1.5 â€‹cm. RESULTS: Of 30 patients, median age, BMI, sex, and comorbidities were similar between sZD (n â€‹= â€‹18) and mZD (n â€‹= â€‹12). Overall, 80.0 â€‹% had the procedure performed with a needle knife. Median number of clips for mucosotomy closure (5.0[5.0,6.0]vs.7.0[5.0,7.0]clips;p â€‹= â€‹0.051), operative time (59.5[51.0,75.0]vs.74.5[51.0,93.5]minutes;p â€‹= â€‹0.498), length-of-stay (1.0[1.0,1.0]vs.1.0[1.0,1.0]days;p â€‹= â€‹0.397), and follow-up (20.8[1.1,33.4]vs.15.6[5.4,50.4]months;p â€‹= â€‹0.641) were comparable. There were no postoperative leaks; incomplete myotomy occurred in one sZD, yielding a clinical success rate of 96.7 â€‹%. CONCLUSIONS: FEC has a high success rate for ZD and an advantage in small diverticula, difficult to treat with stapling or open technique.

Racial and Socioeconomic Disparities in Complex Abdominal Wall Reconstruction Referrals.

Background: Health disparities are pervasive in surgical care. Particularly racial and socioeconomic inequalities have been demonstrated in emergency general surgery outcomes, but less so in elective abdominal wall reconstruction (AWR). The goal of this study was to evaluate the disparities in referrals to a tertiary hernia center. Methods: A prospectively maintained hernia database was queried for patients who underwent open ventral hernia (OVHR) or minimally invasive surgical (MISR) repair from 2011 to 2022 with complete insurance and address information. Patients were divided by home address into in-state (IS) and out-of-state (OOS) referrals as well as by operative technique. Demographic data and outcomes were compared. Standard and inferential statistical analyses were performed. Results: Of 554 patients, most were IS (59.0%); 334 underwent OVHR, and 220 underwent MISR. IS patients were more likely to undergo MISR (OVHR: 45.6% vs. 81.5%, laparoscopic: 38.2% vs. 14.1%, robotic: 16.2% vs. 4.4%; p < 0.001) when compared to OOS referrals. Of OVHR patients, 44.6% were IS and 55.4% were OOS. Patients' average age and BMI, sex, ASA score, and insurance payer were similar between IS and OOS groups. IS patients were more often Black (White: 77.9% vs. 93.5%, Black: 16.8% vs. 4.3%; p < 0.001). IS patients had more smokers (12.1% vs. 3.2%; p = 0.001), fewer recurrent hernias (45.0% vs. 69.7%; p < 0.001), and smaller defects (155.7 ± 142.2 vs. 256.4 ± 202.9 cm2; p < 0.001). Wound class, mesh type, and rate of fascial closure were similar, but IS patients underwent fewer panniculectomies (13.4% vs. 34.1%; p < 0.001), component separations (26.2% vs. 51.4%; p < 0.001), received smaller mesh (744.2 ± 495.6 vs. 975.7 ± 442.3 cm2; p < 0.001), and had shorter length-of-stay (4.8 ± 2.0 vs. 7.0 ± 5.5 days; p < 0.001). There was no difference in wound breakdown, seroma requiring intervention, hematoma, mesh infection, or recurrence; however, IS patients had decreased wound infections (2.0% vs. 8.6%; p = 0.009), overall wound complications (11.4% vs. 21.1%; p = 0.016), readmissions (2.7% vs. 13.0%; p = 0.001), and reoperations (3.4% vs. 11.4%; p = 0.007). Of MISR patients, 80.9% were IS and 19.1% were OOS. In contrast to OVHR, MISR IS and OOS patients had similar demographics, preoperative characteristics, intraoperative details, and postoperative outcomes. Conclusion: Although there were no differences in referred patients for MISR, this study demonstrates the racial disparities that exist among our IS and OOS complex, open AWR patients. Awareness of these disparities can help clinicians work towards equitable access to care and equal referrals to tertiary hernia centers.

Deep learning model utilizing clinical data alone outperforms image-based model for hernia recurrence following abdominal wall reconstruction with long-term follow up.

BACKGROUND: Deep learning models (DLMs) using preoperative computed tomography (CT) imaging have shown promise in predicting outcomes following abdominal wall reconstruction (AWR), including component separation, wound complications, and pulmonary failure. This study aimed to apply these methods in predicting hernia recurrence and to evaluate if incorporating additional clinical data would improve the DLM's predictive ability. METHODS: Patients were identified from a prospectively maintained single-institution database. Those who underwent AWR with available preoperative CTs were included, and those with < 18 months of follow up were excluded. Patients were separated into a training (80%) set and a testing (20%) set. A DLM was trained on the images only, and another DLM was trained on demographics only: age, sex, BMI, diabetes, and history of tobacco use. A mixed-value DLM incorporated data from both. The DLMs were evaluated by the area under the curve (AUC) in predicting recurrence. RESULTS: The models evaluated data from 190 AWR patients with a 14.7% recurrence rate after an average follow up of more than 7 years (mean ± SD: 86 ± 39 months; median [Q1, Q3]: 85.4 [56.1, 113.1]). Patients had a mean age of 57.5 ± 12.3 years and were majority (65.8%) female with a BMI of 34.2 ± 7.9 kg/m2. There were 28.9% with diabetes and 16.8% with a history of tobacco use. The AUCs for the imaging DLM, clinical DLM, and combined DLM were 0.500, 0.667, and 0.604, respectively. CONCLUSIONS: The clinical-only DLM outperformed both the image-only DLM and the mixed-value DLM in predicting recurrence. While all three models were poorly predictive of recurrence, the clinical-only DLM was the most predictive. These findings may indicate that imaging characteristics are not as useful for predicting recurrence as they have been for other AWR outcomes. Further research should focus on understanding the imaging characteristics that are identified by these DLMs and expanding the demographic information incorporated in the clinical-only DLM to further enhance the predictive ability of this model.

The Utilization of Laparoscopic Ventral Hernia Repair (LVHR) in Incarcerated and Strangulated Cases: A National Trend in Outcomes.

INTRODUCTION: Early after its adoption, minimally invasive surgery had limited usefulness in emergent cases. However, with improvements in equipment, techniques, and skills, laparoscopy in complex and emergency operations expanded substantially. This study aimed to examine the trend of laparoscopy in incarcerated or strangulated ventral hernia repair (VHR) over time. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for laparoscopic repair of incarcerated and strangulated hernias (LIS-VHR) and compared over 2 time periods, 2014-2016 and 2017-2019. RESULTS: The utilization of laparoscopy in all incarcerated or strangulated VHR increased over time (2014-2016: 39.9% (n = 14 075) vs 2017-2019: 46.3% (n = 18 369), P < .001). Though likely not clinically significant, demographics and comorbidities statistically differed between groups (female: 51.7% vs 50.0%, P = .003; age 54.5 ± 13.7 vs 55.4 ± 13.8 years, P < .001; BMI 34.9 ± 8.0 vs 34.6 ± 7.8 kg/m2, P < .001). Patients from 2017 to 2019 were less comorbid (18.9% vs 16.8% smokers, P < .001; 18.2% vs 17.3% diabetic, P = .036; 4.6% vs 4.1% COPD, P = .021) but had higher ASA classification (III: 43.3% vs 45.7%; IV: 2.5% vs 2.7%, P < .001). Hernia types (primary, incisional, recurrent) were similar in each group. Operative time (89.7 ± 59.3 vs 97.4 ± 63.4 min, P < .001) became longer but length-of-stay (1.4 ± 3.3 vs 1.1 ± 2.6 days, P < .001) decreased. There was no statistical difference in surgical complications, medical complications, reoperation, or readmission rates between periods. CONCLUSION: Laparoscopic VHR has become a routine method for treating incarcerated and strangulated hernias, and its utilization continues to increase over time. Clinical outcomes have remained the same while hospital stays have decreased.

Factors Associated With Respiratory Failure After Open Ventral Hernia Repair: An Evaluation of the NSQIP Database.

An analysis of ACS-NSQIP open ventral hernia repair (OVHR) data (2017-2019) was performed. Respiratory failure (RF) occurred in 643 patients (1%) and not in 63,213 (99%) (nRF). Respiratory failure patients were older (63.7 vs 57 years, P < .001) and more comorbid: insulin-dependent diabetes (14.7% vs 5.8%, P < .001), COPD (19.4% vs 5.2%, P < .001), BMI (36.0 vs 32.8, P < .001), and current tobacco use (24.9% vs 17.6%, P < .001). Respiratory failure patients had greater ASA scores (ASA 3: 63.3% vs 47.8%, P < .001), bowel resection (8.2% vs 1.3%, P < .001), component separation (20.1% vs 9.0%, P < .001), operative times (178.4 vs 98.8 minutes, P < .001), complications (deep wound infections 3.6% vs 1.0%, organ space infections 13.2% vs 1.0%, wound dehiscence 3.1% vs 0.6%, acute renal failure 11.7% vs 0.1%), and hospital stay (13.7 vs 2.3 days), with fewer home discharges (44.3% vs 96.4%) (all P < .001). Respiratory failure patients had higher mortality compared to nRF (20.2% vs 0.1%, P < .001). Respiratory failure after OVHR is rare but correlates closely with significant wound, systemic, and social complications. Preoperative management of risk factors would be appropriate in high-risk patients.

Using impedance planimetry to define the end of a peroral endoscopic myotomy.

INTRODUCTION: Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic option for management of achalasia. Adequate distal myotomy is necessary for relief of symptoms, but when too long may also increase risk of reflux. The objective of this study is to evaluate clinical outcomes after POEM and final length of gastric myotomy using impedance planimetry (EndoFLIP). METHODS: A retrospective review of 34 consecutive patients undergoing POEM with EndoFLIP were included. EndoFLIP measurements, including esophagogastric junction distensibility index (DI), minimum diameter (Dmin), and cross-sectional area (CSA) were recorded at 30- and 40-mL balloon-fill pre- and post- myotomy. The myotomy was considered complete when DI ≥ 3.4 mm2/mmHg. Postoperative Eckardt score (ES) was determined at initial postoperative visit and most recent follow-up. Linear and logistic regression were used to evaluate the association between gastric myotomy length and post-myotomy EndoFLIP measurements on postoperative ES and GERD. Wilcoxon rank-sum test was used to compare gastric myotomy lengths and EndoFLIP parameters in relation to clinical success and development of GERD, and paired t-test to compare EndoFLIP measurements and ES pre- and post-myotomy. RESULTS: Final length of gastric myotomy measured 1 cm in 1 (2.9%), 1.5 cm in 11 (32.4%), 2.0 cm in 19 (55.9%), and 2.5 cm in 3 (8.8%) patients. Mean preoperative ES was 6.6 ± 2.2. All patients achieved ES < 3 postoperatively, which was maintained in 88.5% of patients at a median of 7.5 months of follow-up. Gastric myotomy length and post-myotomy EndoFLIP values were not associated with postoperative Eckardt scores or GERD. DISCUSSION: Early and late symptom relief was achieved in 100 and 88.5% of patients, respectively, at a gastric myotomy length of 1-2.5 cm. Using EndoFLIP to define a completed myotomy at DI of 3.4 mm2/mmHg yielded variable lengths of gastric myotomy.

Fragility of Randomized Clinical Trials Using Mesh in Abdominal Wall Reconstruction.

This systematic review evaluates the fragility of randomized clinical trials that used mesh in abdominal wall reconstruction.

Early warning: End-tidal carbon dioxide is associated with central venous oxygenation under continuous cardiorespiratory monitoring in a porcine model of hemorrhagic shock and resuscitation.

BACKGROUND: End-tidal carbon dioxide (ETCO2) has previously shown promise as a predictor of shock severity and mortality in trauma. ETCO2 monitoring is non-invasive, real-time, and readily available in prehospital settings, but the temporal relationship of ETCO2 to systemic oxygen transport has not been thoroughly investigated in the context of hemorrhagic shock. METHODS: A validated porcine model of hemorrhagic shock and resuscitation was used in male Yorkshire swine (N â€‹= â€‹7). Both ETCO2 and central venous oxygenation (SCVO2) were monitored and recorded continuously in addition to other traditional hemodynamic variables. RESULTS: Linear regression analysis showed that ETCO2 was associated with ScvO2 both throughout the experiment (ߠ​= â€‹1.783, 95% confidence interval (CI) [1.552-2.014], p â€‹< â€‹0.001) and during the period of most rapid hemorrhage (ߠ​= â€‹4.896, 95% CI [2.416-7.377], p â€‹< â€‹0.001) when there was a marked decrease in ETCO2. CONCLUSIONS: ETCO2 and ScvO2 were closely associated during rapid hemorrhage and continued to be temporally associated throughout shock and resuscitation.

Prospective, international analysis of quality of life outcomes in recurrent versus primary ventral hernia repairs.

BACKGROUND: Quality of life (QOL) has become a key outcome measure following ventral hernia repair (VHR), but recurrent and primary VHR have not been compared in this context previously. METHODS: The International Hernia Mesh Registry (2008-2019) was used to identify patients with QOL data scored by the Carolinas Comfort Scale preoperatively and postoperatively at 1 year. RESULTS: Repairs were performed in 227 recurrent and 1,122 primary VHs. Recurrent patients had a higher BMI, larger defects, and were more likely to have preoperative pain, but other comorbidities were equal. Recurrence rates at 1 year were equivalent. Recurrent patients had a greater improvement in pain (-6.3 ± 10.2 vs -4.3 ± 8.3,p = 0.002) and movement limitation (-5.5 ± 10.0 vs -3.2 ± 7.2,p < 0.001) compared to primary patients, but they had increased postoperative mesh sensation (4.6 ± 7.7 vs 2.7 ± 5.5,p < 0.001). CONCLUSIONS: Recurrent VHRs led to improved pain and movement limitation, but increased mesh sensation. These findings may be useful for preoperative counseling in the elective setting.

Defining surgical risk in octogenarians undergoing paraesophageal hernia repair.

BACKGROUND: With an aging population, the utility of surgery in elderly patients, particularly octogenarians, is of increasing interest. The goal of this study was to analyze outcomes of octogenarians versus non-octogenarians undergoing paraesophageal hernia repair (PEHR). METHODS: The Nationwide Readmission Database was queried for patients > 18 years old who underwent PEHR from 2016 to 2018. Exclusion criteria included a diagnosis of gastrointestinal malignancy or a concurrent bariatric procedure. Patients ≥ 80 were compared to those 18-79 years old using standard statistical methods, and subgroup analyses of elective and non-elective PEHRs were performed. RESULTS: From 2016 to 2018, 46,450 patients were identified with 5425 (11.7%) octogenarians and 41,025 (88.3%) non-octogenarians. Octogenarians were more likely to have a non-elective operation (46.3% vs 18.2%, p < 0.001), and those undergoing non-elective PEHR had a higher mortality (5.5% vs 1.2%, p < 0.001). Outcomes were improved with elective PEHR, but octogenarians still had higher mortality (1.3% vs 0.2%, p < 0.001), longer LOS (3[2, 5] vs 2[1, 3] days, p < 0.001), and higher readmission rates within 30 days (11.1% vs 6.5%, p < 0.001) compared to non-octogenarian elective patients. Multivariable logistic regression showed that being an octogenarian was not independently predictive of mortality (odds ratio (OR) 1.373[95% confidence interval 0.962-1.959], p = 0.081), but a non-elective operation was (OR 3.180[2.492-4.057], p < 0.001). Being an octogenarian was a risk factor for readmission within 30 days (OR 1.512[1.348-1.697], p < 0.001). CONCLUSIONS: Octogenarians represented a substantial proportion of patients undergoing PEHR and were more likely to undergo a non-elective operation. Being an octogenarian was not an independent predictor of perioperative mortality, but a non-elective operation was. Octogenarians' morbidity and mortality was reduced in elective procedures but was still higher than non-octogenarians. Elective PEHR in octogenarians is reasonable but should involve a thorough risk-benefit analysis.

The incidence and impact of enterotomy during laparoscopic and robotic ventral hernia repair: a nationwide readmissions analysis.

INTRODUCTION: Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes. METHODS: The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients. RESULTS: In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m2 (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036). CONCLUSION: Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates.

Digital Nerve Management and Neuroma Prevention in Hand Amputations.

BACKGROUND: Hand and digit amputations represent a relatively common injury affecting an active patient population. Neuroma formation following amputation at the level of the digital nerve can cause significant disability and lead to revision surgery. One method for managing digital nerves in primary and revision partial hand amputations is to perform interdigital end-to-end nerve coaptations to prevent neuroma formation. METHODS: All patients with an amputation at the level of the common or proper digital nerves that had appropriate follow-up at our institution from 2010 to 2020 were included. Common or proper digital nerves were managed with either traction neurectomy or digital end-to-end neurorrhaphy. The primary outcome was the development of a neuroma. Secondary outcomes included revision surgery, complications, and visual analog pain scores. RESULTS: A total of 289 nerves in 54 patients underwent hand or digital amputation in the study period. Thirteen hands with 78 nerves (27%) underwent direct end-to-end coaptation with a postoperative neuroma incidence of 12.8% compared with 22.7% in the 211 nerves that did not have a coaptation performed. Significantly fewer patients reported persistent pain if an end-to-end coaptation was performed (0% vs. 11.8%, P < .01). The prevalence of depression and workers compensation status was significantly higher in in patients with symptomatic neuromas than in patients without symptomatic neuromas (P < .01). CONCLUSIONS: Digital nerve end-to-end neurorrhaphy is a method for neuroma prevention in partial hand amputations that results in decreased residual hand pain without increase complications. Depression and worker's compensations status were significantly associated with symptomatic neuroma formation.

Open preperitoneal ventral hernia repair: Prospective observational study of quality improvement outcomes over 18 years and 1,842 patients.

BACKGROUND: This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications. METHODS: Prospective, tertiary hernia center data (2004-2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. "Early" (2004-2012) and "Recent" (2013-2021) groups were based on surgery date. RESULTS: Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m2; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm2; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9-4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1-3.7], P = .02 vs 1.8 [1.1-3.1], P = .02), anterior component separation technique (1.8 [1.1-2.9], P = .02 vs 3.2[1.9-5.3], P < .01), and operative time (per minute: 1.01 [1.008-1.015], P < .01 vs 1.004 [1.001-1.007], P < .01). Diabetes (2.6 [1.7-4.0], P < .01) and tobacco (1.8 [1.1-2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1-20.1], P < .01 vs 3.4 [1.3-8.2]. P < .01) and recurrent hernias (4.9 [2.3-11.5], P < .01 vs 2.1 [1.1-4.2], P = .036). CONCLUSION: Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center's outcomes has significantly improved patient care results.

Observational study of complex abdominal wall reconstruction using porcine dermal matrix: How have outcomes changed over 14 years?

BACKGROUND: Our center has adopted many evidence-based practices to improve outcomes for complex abdominal wall reconstruction with porcine dermal matrix. This study analyzed outcomes over time using porcine dermal matrix in complex abdominal wall reconstruction. METHODS: Prospective, tertiary hernia center data was examined for patients undergoing complex abdominal wall reconstruction with porcine dermal matrix. Early (2008-2014) and Recent (2015-2021) cohorts were defined by dividing the study interval in half. Multivariable analyses of wound complications and recurrence were performed. RESULTS: Comparing 117 Early vs 245 Recent patients, both groups had high rates of previously repaired hernias (76.1% vs 67.4%; P = .110), Centers for Disease Control and Prevention class 3 or 4 wounds (76.0% vs 66.6%; P = .002), and very large hernia defects (320 ± 317 vs 282 ± 164 cm2; P = .640). Recent patients had higher rates of preoperative botulinum injection (0% vs 21.2%; P < .001), posterior component separation (15.4% vs 35.5%; P < .001), and delayed primary closure (23.1% vs 38.8%; P < .001), but lower rates of concurrent panniculectomy (32.3% vs 27.8%; P = .027) and similar anterior component separation (29.1% vs 18.2%; P = .060). Most mesh was placed preperitoneal (74.4% vs 93.3%; P < .001). Recent patients had less inlay (9.4% vs 2.1%; P < .01) and other mesh locations as fascial closure rate increased (88.0% vs 95.5%; P < .001). Over time, there was a decrease in wound complications (42.1% vs 14.3%; P < .001), length of stay (median [interquartile range]:8 [6-13] vs 7 [6-9]; P = .003), and 30-day readmissions (32.7% vs 10.3%; P < .001). Hernia recurrence decreased (10.3% vs 3.7%; P = .016) with mean follow-up of 2.8 ± 3.2 and 1.7 ± 1.7 years, respectively. Respective multivariable models(odds ratio, 95% confidence interval) demonstrated an increased risk of wound complications with diabetes (2.65, 1.16-5.98; P = .020), panniculectomy (2.63, 1.21-5.73; P = .014), and anterior component separation (5.1, 1.98-12.9; P < .001), with recurrence risk increased by wound complication (3.8, 1.4-2-7.62; P = .032). CONCLUSION: Porcine dermal matrix in complex abdominal wall reconstruction performs well with low recurrence rates. Internal assessment and implementation of evidence-based practices improved outcomes such as length of stay, wound complications, and recurrence rate.

Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study.

BACKGROUND: Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study. METHODS: A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated. RESULTS: Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm2 vs botulinum toxin A 289.7 ± 162.4 cm2; P = .73) (mean volume: 1,498.3 + 2,043.4 cm3 vs 2,914.7 + 6,539.4 cm3; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13). CONCLUSION: In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.

Clinical and Radiologic Outcomes after Meniscal Root Repair: A Case Series.

This study aimed to describe the demographics, clinical outcomes, and radiologic outcomes of patients who underwent meniscal root repair at a single, large academic institution. Patients who underwent meniscal root repair between January 2011 and April 2015 were identified. Patient demographics, injury characteristics, and intraoperative findings of medial femoral condyle chondromalacia and other concomitant pathology were retrospectively recorded. Enrolled patients returned to clinic for prospectively collected International Knee Documentation Committee (IKDC) subjective and objective forms, knee radiographs, and magnetic resonance imaging (MRI). A total of 25 root injuries (23 patients) were included in the final analysis. Majority of root injuries were medial menisci (68%) and repaired using transosseous pull-out technique (80%). Most patients (65%) were male, relatively young (median age = 37 years), overweight (median body mass index [BMI] = 26 kg/m2), and reported a traumatic event associated with their injury (60%). Also, 36% (9/25) of root repairs were performed concomitantly with an anterior cruciate ligament (ACL) reconstruction; 100% (8/8) lateral meniscal root injuries were associated with a concomitant ACL injury compared with 6% (1/17) of medial root injuries. Overall, 53% (9/17) of medial meniscal root repairs were performed in the setting of high-grade (Outerbridge's grade III/IV) chondral pathology of the ipsilateral femoral condyle. Median follow-up was 16 months. The Kellgren-Lawrence radiographic scale progressed in two knees that underwent meniscal root repair based on comparison of preoperative to follow-up radiographs. MRI showed 88% (22/25) of meniscal roots had completely healed, 6% (1/17) of the medial root repairs showed evidence of extrusion, and 44% (11/25) of repairs were associated with progressive chondromalacia. All patients had normal or near normal IKDC objective scores at time of follow-up. Surgeons should have a high suspicion for concomitant ACL injuries in the setting of lateral meniscal root tears, and be wary of concomitant high-grade chondral damage in the setting of medial meniscal root tears. Most meniscal root repairs appeared completely healed with low rates of medial meniscal extrusion on MRI at short-term follow-up, despite a high rate of chondromalacia progression. Present study is a large case series with prospective follow-up and reflects level of evidence IV.

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction.

INTRODUCTION: Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds. METHODS: A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both. RESULTS: In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm2 vs. 208 ± 155cm2; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection. CONCLUSIONS: Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

Hernia recurrence after primary repair of small umbilical hernia defects.

BACKGROUND: An evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined. METHODS: A prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications. RESULTS: Of 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant. CONCLUSIONS: With long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary.

Impact of a Clinical Genomics Program on Trial Accrual for Targeted Treatments: Practical Approach Overcoming Barriers to Accrual for Underserved Patients.

PURPOSE: Clinical trials of novel and targeted agents increasingly require biomarkers for eligibility. Precision oncology continues to evolve, but challenges hamper broad use of molecular profiling (MP) that could increase the number of patients benefiting from targeted therapy. We implemented an integrated clinical genomics program (CGP), including a virtual Molecular Tumor Board (MTB), and examined its impact on MP use and impact on clinical trial accrual in a multisite regional-based cancer system with an emphasis on effects for isolated clinicians. METHODS: We assessed MP and MTB use from 2010 to 2020 by practice location, physician experience, and patient characteristics. Use of MTB-recommended treatments was assessed. Clinical trial enrollment was evaluated for patients with MP versus MP and MTB review. RESULTS: After CGP implementation, the number of physicians using MP and the number of MP tests increased ≥ 10-fold. The proportion of Hispanic patients with MP was the same as that in the system (both 2%) with marginal differences observed in the proportion of African Americans tested compared with the system population (16% v 19%). Physicians followed MTB treatment recommendations in 74% of cases. Rapid clinical decline was the most common reason why physicians did not follow MTB recommendations. Clinical trial accrual was 15% (669 of 4,459) for patients with MP alone and 28% (94 of 334) with both MP and MTB review. Clinical trial availability and patient out-of-pocket costs affected MP use. CONCLUSION: Integrating CGP into clinical workflow with decision support tools, trial matching, and management of patient costs led to increased use of MP by physicians with all levels of experience, enhanced clinical trial accrual, and has the potential to reduce disparities in MP.