1
|
DeMeester SR, Bernard L, Schoppmann SF, McKay SC, Roth JS. Updated Markov Model to Determine Optimal Management Strategy for Patients with Paraesophageal Hernia and Symptoms, Cameron Ulcer, or Comorbid Conditions. J Am Coll Surg 2024; 238:1069-1082. [PMID: 38359322 DOI: 10.1097/xcs.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND The current paradigm of watchful waiting (WW) in people 65 years or older with an asymptomatic paraesophageal hernia (PEH) is based on a now 20-year-old Markov analysis. Recently, we have shown that elective laparoscopic hernia repair (ELHR) provides an increase in life-years (L-Ys) compared with WW in most healthy patients aged 40 to 90 years. However, elderly patients often have comorbid conditions and may have complications from their PEH such as Cameron lesions. The aim of this study was to determine the optimal strategy, ELHR or WW, in these patients. STUDY DESIGN A Markov model with updated variables was used to compare L-Ys gained with ELHR vs WW in hypothetical people with any type of PEH and symptoms, Cameron lesions, and/or comorbid conditions. RESULTS In men and women aged 40 to 90 years with PEH-related symptoms and/or Cameron lesions, ELHR led to an increase in L-Ys over WW. The presence of comorbid conditions impacted life expectancy overall, but ELHR remained the preferred approach in all but 90-year-old patients with symptoms but no Cameron lesions. CONCLUSIONS Using a Markov model with updated values for key variables associated with management options for patients with a PEH, we showed that life expectancy was improved with ELHR in most men and women aged 40 to 90 years, particularly in the presence of symptoms and/or Cameron lesions. Comorbid conditions increase the risk for surgery, but ELHR remained the preferred strategy in the majority of symptomatic patients. This model can be used to provide individualized management guidance for patients with a PEH.
Collapse
|
2
|
Roth JS. The Medicare Physician Fee Schedule and surgical specialties: Reform needed to preserve access. Surgery 2024; 175:927-928. [PMID: 38342729 DOI: 10.1016/j.surg.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 02/13/2024]
|
3
|
DeMeester SR, Bernard L, Schoppmann SF, Kloosterman R, Roth JS. Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients: An Updated Markov Analysis. Ann Surg 2024; 279:267-275. [PMID: 37818675 DOI: 10.1097/sla.0000000000006119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE The aim of this study was to perform an updated Markov analysis to determine the optimal management strategy for patients with an asymptomatic paraesophageal hernia (PEH): elective laparoscopic hernia repair (ELHR) versus watchful waiting (WW). BACKGROUND Currently, it is recommended that patients with an asymptomatic PEH not undergo repair based on a 20-year-old Markov analysis. The current recommendation might lead to preventable hospitalizations for acute PEH-related complications and compromised survival. METHODS A Markov model with updated variables was used to compare life-years (L-Ys) gained with ELHR versus WW in patients with a PEH. One-way sensitivity analyses evaluated the robustness of the analysis to alternative data inputs, while probabilistic sensitivity analysis quantified the level of confidence in the results in relation to the uncertainty across all model inputs. RESULTS At age 40 to 90, ELHR led to greater life expectancy than WW, particularly in women. The gain in L-Ys (2.6) was greatest in a 40-year-old woman and diminished with increasing age. Sensitivity analysis showed that alternative values resulted in modest changes in the difference in L-Ys, but ELHR remained the preferred strategy. Probabilistic analysis showed that ELHR was the preferred strategy in 100% of 10,000 simulations for age 65, 98% for age 80, 90% for age 85, and 59% of simulations in 90-year-old women. CONCLUSIONS This updated analysis showed that ELHR leads to an increase in L-Ys over WW in healthy patients aged 40 to 90 years with an asymptomatic PEH. In this new paradigm, all patients with a PEH, regardless of symptoms, should be referred for the consideration of elective repair to maximize their life expectancy.
Collapse
|
4
|
Ibele AR, Nau PN, Galvani C, Roth JS, Goldberg RF, Kurian MS, Khaitan L, Gould J, Pandya YK. Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD. Surg Endosc 2023; 37:7642-7648. [PMID: 37491660 DOI: 10.1007/s00464-023-10212-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/11/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. METHODS A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. RESULTS 187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35 kg/m2 and 30 kg/m2 respectively as cutoff for the RYGB. 89% viewed RYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations. CONCLUSION For many patients, GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.
Collapse
|
5
|
Dhanani NH, Lyons NB, Divino CM, Harris H, Holihan JL, Hope W, Itani K, Loor MM, Martindale R, Prabhu A, Reinke C, Roth JS, Towfigh S, Liang MK. Expert Consensus for Key Features of Operative Reports of Ventral Hernia. J Am Coll Surg 2023; 236:235-240. [PMID: 36102528 DOI: 10.1097/xcs.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Operative reports are important documents; however, standards for critical elements of operative reports are general and often vague. Hernia surgery is one of the most common procedures performed by general surgeons, so the aim of this project was to develop a Delphi consensus on critical elements of a ventral hernia repair operative report. STUDY DESIGN The Delphi method was used to establish consensus on key features of operative reports for ventral hernia repair. An expert panel was selected and questionnaires were distributed. The first round of voting was open-ended to allow participants to recommend what details should be included. For the second round the questionnaire was distributed with the items that did not have unanimous responses along with free text comments from the first round. RESULTS Eighteen surgeons were approached, of which 11 completed both rounds. Twenty items were on the initial questionnaire, of which 11 had 100% agreement. Of the remaining 9 items, after the second questionnaire an additional 7 reached consensus. CONCLUSION Ventral hernia repairs are a common and challenging problem and often require reoperations. Surgeons frequently refer to previous operative notes to guide future procedures, which requires detailed and comprehensive operative reports. This Delphi consensus was able to identify key components needed for an operative report describing ventral hernia repair.
Collapse
|
6
|
Hope WW, El-Ghazzawy AG, Winterstein BA, Blatnik JA, Davis SS, Greenberg JA, Sanchez NC, Pauli EM, Tseng DM, LeBlanc KA, Roberts KE, Bower CE, Parra-Davila E, Roth JS, Deeken CR, Smith EF. A prospective, multicenter trial of a long-term bioabsorbable mesh with Sepra technology in cohort of challenging laparoscopic ventral or incisional hernia repairs (ATLAS trial). Ann Med Surg (Lond) 2022; 73:103156. [PMID: 34976385 PMCID: PMC8689054 DOI: 10.1016/j.amsu.2021.103156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/04/2021] [Accepted: 12/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This prospective, multicenter, single-arm, open-label study evaluated P4HB-ST mesh in laparoscopic ventral or incisional hernia repair (LVIHR) in patients with Class I (clean) wounds at high risk for Surgical Site Occurrence (SSO). METHODS Primary endpoint was SSO requiring intervention <45 days. Secondary endpoints included: surgical procedure time, length of stay, SSO >45 days, hernia recurrence, device-related adverse events, reoperation, and Quality of Life at 1, 3, 6, 12, 18, and 24-months. RESULTS 120 patients (52.5% male), mean age of 55.0 ± 14.9 years, and BMI of 33.2 ± 4.5 kg/m2 received P4HB-ST mesh. Patient-reported comorbid conditions included: obesity (86.7%), active smoker (45.0%), COPD (5.0%), diabetes (16.7%), immunosuppression (2.5%), coronary artery disease (7.5%), chronic corticosteroid use (2.5%), hypoalbuminemia (0.8%), advanced age (10.0%), and renal insufficiency (0.8%). Hernia types were primary ventral (44.2%), primary incisional (37.5%), recurrent ventral (5.8%), and recurrent incisional (12.5%). Patients underwent LVIHR in laparoscopic (55.8%) or robotic-assisted cases (44.2%), mean defect size 15.7 ± 28.3 cm2, mean procedure time 85.9 ± 43.0 min, and mean length of stay 1.0 ± 1.4 days. There were no SSOs requiring intervention beyond 45 days, n = 38 (31.7%) recurrences, n = 22 (18.3%) reoperations, and n = 2 (1.7%) device-related adverse events (excluding recurrence). CONCLUSION P4HB-ST mesh demonstrated low rates of SSO and device-related complications, with improved quality of life scores, and reoperation rate comparable to other published studies. Recurrence rate was higher than expected at 31.7%. However, when analyzed by hernia defect size, recurrence was disproportionately high in defects ≥7.1 cm2 (43.3%) compared to defects <7.1 cm2 (18.6%). Thus, in LVIHR, P4HB-ST may be better suited for small defects. Caution is warranted when utilizing P4HB-ST in laparoscopic IPOM repair of larger defects until additional studies can further investigate outcomes.
Collapse
|
7
|
Gupta M, Dugan A, Chacon E, Davenport DL, Shah MB, Marti F, Roth JS, Bernard A, Zwischenberger JB, Gedaly R. Detailed perioperative risk among patients with extreme obesity undergoing nonbariatric general surgery. Surgery 2020; 168:462-470. [DOI: 10.1016/j.surg.2020.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/28/2020] [Accepted: 03/21/2020] [Indexed: 12/23/2022]
|
8
|
Totten C, Becker P, Lourd M, Roth JS. Polyester vs polypropylene, do mesh materials matter? A meta-analysis and systematic review. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2019; 12:369-378. [PMID: 31572024 PMCID: PMC6747676 DOI: 10.2147/mder.s198988] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/05/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Controversy exists regarding the outcomes following ventral hernia repair with polypropylene (PP) or polyester (PET) mesh. Monofilament PP less frequently requires extraction in the setting of contamination compared to multifilament PET mesh. The purpose of this systematic review and meta-analysis was to analyze the clinical outcomes of ventral hernia repair with PP and PET mesh. Patients and methods A comprehensive literature search was performed using the Ovid search platform. Criteria included ventral hernia repair publications using either PP or PET mesh with a minimum follow-up duration of one year. Included studies were subject to data extraction including mesh position, weight, recurrence rates, infection, and complications. Random effect meta-analysis was run to provide pooled event rate and 95% CI. Results Ninety-seven studies including a total of 10,022 patients were included in the final analysis. Hernia recurrence rates are similar (4.8%, 95% CI [3.5–6.5] vs 4.7%, 95% CI [3.7–6.0]) as well as mesh infection rates (3.5%, 95% CI [2.5–4.9] vs 5.0%, 95% CI [3.9–6.3]) between PET and PP, respectively. Mesh infections occurred less frequently in laparoscopic repair compared to open (1.6%, 95% CI [0.9–2.6] vs 5.2%, 95% CI [4.3–6.3]). Conclusion This study suggests that mesh material does not affect recurrence or infection in ventral hernia repair and that surgery can be safely performed with both PP and PET mesh. A laparoscopic approach is associated with a decreased infection rate compared to open repair independent of mesh type.
Collapse
|
9
|
Harryman C, Plymale MA, Stearns E, Davenport DL, Chang W, Roth JS. Enhanced value with implementation of an ERAS protocol for ventral hernia repair. Surg Endosc 2019; 34:3949-3955. [PMID: 31576444 DOI: 10.1007/s00464-019-07166-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Open ventral hernia repair (VHR) is associated with postoperative complications and hospital readmissions. A comprehensive Enhanced Recovery after Surgery (ERAS) protocol for VHR contributes to improved clinical outcomes including the rapid return of bowel function and reduced infections. The purpose of this study was to compare hospital costs for patients cared for prior to ERAS implementation with patients cared for with an ERAS protocol. METHODS With IRB approval, clinical characteristics and postoperative outcomes data were obtained via retrospective review of consecutive VHR patients 2 years prior to and 14 months post ERAS implementation. Hospital cost data were obtained from the cost accounting system inclusive of index hospitalization. Clinical data and hospital costs were compared between groups. RESULTS Data for 178 patients (127 pre-ERAS, 51 post-ERAS) were analyzed. Preoperative and operative characteristics including gender, ASA class, comorbidities, and BMI were similar between groups. ERAS patients had faster return of bowel function (p = 0.001) and decreased incidence of superficial surgical site infection (p = 0.003). Hospital length of stay did not vary significantly pre and post ERAS implementation. Inpatient pharmacy costs were increased in ERAS group ($2673 vs. $1176 p < 0.001), but total hospital costs (14,692 vs. 15,151, p = 0.538) were similar between groups. CONCLUSIONS Standardization of hernia care via ERAS protocol improves clinical outcomes without impacting total costs.
Collapse
|
10
|
Rosen MJ, Borao FJ, Binenbaum SJ, Roth JS, Gillian GK, Gould J, Heniford BT. A multi-center, prospective clinical trial of a hepatic derived porcine surgical mesh for the laparoscopic repair of symptomatic paraesophageal hernias. Am J Surg 2019; 218:315-322. [DOI: 10.1016/j.amjsurg.2019.03.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 03/22/2019] [Accepted: 03/28/2019] [Indexed: 01/22/2023]
|
11
|
Davenport DL, Hughes TG, Mirembo RI, Plymale MA, Roth JS. Professional fee payments by specialty for inpatient open ventral hernia repair: who gets paid for treating comorbidities and complications? Surg Endosc 2018; 33:494-498. [PMID: 29987571 DOI: 10.1007/s00464-018-6323-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/29/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this study was to determine perioperative professional fee payments to providers from different specialties for the care of patients undergoing inpatient open ventral hernia repair (VHR). METHODS Perioperative data of patients undergoing VHR at a single center over 3 years were selected from our NSQIP database. 180-day follow-up data were obtained via retrospective review of records and phone calls to patients. Professional fee payments (PFPs) to all providers were obtained from our physician billing system for the VHR hospitalization, the 180 days prior to operation (180Prior) and the 180 days post-discharge (180Post). RESULTS PFPs for 283 cases were analyzed. Average total 360-day PFPs per patient were $3409 ± SD 3294, with 14.5% ($493 ± 1546) for services in the 180Preop period, 72.5% ($2473 ± 1881) for the VHR hospitalization, and 13.0% ($443 ± 1097) in the 180Postop period. The surgical service received 62% of PFPs followed by anesthesia (18%), medical specialties (9%), radiology (6%), and all other provider services (5%). Medical specialties received increased PFPs for care of patients with COPD and HCT < 38% ($90 and $521, respectively) and for the pulmonary complications ($2471) and sepsis ($2714) that correlated with those patient comorbidities; surgeons did not. Operative duration, mesh size, and separation of components were associated with increased surgeon PFPs (p < .05). At 6 months, wound complications were associated with increased surgeon and radiology payments (p < .01). CONCLUSIONS Management of acute comorbid conditions and the associated higher postoperative morbidity is not reimbursed to the surgeon under the 90-day global fee. These represent opportunity costs of care that pressure busy surgeons to select against these patients or to delegate more management to their medical specialty colleagues, thereby increasing total system costs. A comorbid risk adjustment of procedural reimbursement is warranted. In negotiating bundled payments, surgeon groups should keep in mind that surgeon reimbursement, unlike medical specialty and hospital reimbursement, have been bundled since the 1990s.
Collapse
|
12
|
Davenport DL, Ueland WR, Kumar S, Plymale M, Bernard AC, Roth JS. A comparison of short-term outcomes between laparoscopic and open emergent repair of perforated peptic ulcers. Surg Endosc 2018; 33:764-772. [DOI: 10.1007/s00464-018-6341-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/06/2018] [Indexed: 12/12/2022]
|
13
|
Neff C, Totten C, Plymale M, Oyler DR, Davenport D, Roth JS. Associations between anxiolytic medications and ventral hernia repair. Hernia 2018; 22:753-757. [PMID: 29594842 DOI: 10.1007/s10029-018-1766-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/23/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE This study examines the relationship between anxiolytic medications (AXM) on outcomes following ventral hernia repair. METHODS A single-center review of prospectively obtained perioperative and 30-day outcome data, including AXM use at admission, as part of the National Surgery Quality Improvement Program. RESULTS Sixty-three of the 393 patients who presented for ventral hernia repair were taking an AXM (15.6%). AXM users were more likely to have a higher ASA class, dyspnea, and treated hypertension (p < 0.05). AXM use was associated with increased operative duration, hernia size, increased estimated blood loss, and need for component separation. After adjusting for medical comorbidities, AXM users were not found to have greater 30-day morbidity or mortality. Patients taking AXM were found to have greater length of stay and increased hospital readmissions. CONCLUSIONS Patients taking anxiolytic medications undergoing ventral hernia repairs have higher ASA scores, more complex hernia characteristics, and require more concurrent procedures. They were found to have longer operative times, increased blood loss, greater duration of hospital stay, and increased readmissions that were associated with the increased perioperative risk factors. Further studies are required to determine causal links.
Collapse
|
14
|
Muse TO, Zwischenberger BA, Miller MT, Borman DA, Davenport DL, Roth JS. Outcomes after Ventral Hernia Repair Using the Rives-Stoppa, Endoscopic, and Open Component Separation Techniques. Am Surg 2018. [DOI: 10.1177/000313481808400330] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Complex ventral hernias remain a challenge for general surgeons despite advances in minimally invasive surgical techniques. This study compares outcomes following Rives-Stoppa (RS) repair, components separation technique with mesh (CST-M) or without mesh (CST), and endoscopic components separation technique (ECST). A retrospective review of patients undergoing open ventral hernia repair between 2006 and 2011 was performed. Analysis included patient demographics, surgical site occurrences, hernia recurrence, hospital readmission, and mortality. The search was limited to open repairs, specifically the RS, CST-M, CST, and ECST with mesh techniques. A total of 362 patients underwent repair with RS (66), CST-M (126), CST (117), or ECST (53). The groups were demographically similar. ECST was more frequently used for patients with a history of two or more recurrences ( P < 0.001). The RS method had the lowest rate of recurrence (9.1%) compared with CST and CST-M with 28 and 25 per cent recurrences, respectively ( P = 0.011). The RS recurrence rate was not significantly different than ECST (15%). There were no significant differences between groups for surgical site occurrences ( P = 0.305), hospital read-mission ( P = 0.288), or death ( P = 0.197). When components separation is necessary for complex ventral hernia repair, ECST is a viable option without added morbidity or mortality.
Collapse
|
15
|
Muse TO, Zwischenberger BA, Miller MT, Borman DA, Davenport DL, Roth JS. Outcomes after Ventral Hernia Repair Using the Rives-Stoppa, Endoscopic, and Open Component Separation Techniques. Am Surg 2018; 84:433-437. [PMID: 29559061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Complex ventral hernias remain a challenge for general surgeons despite advances in minimally invasive surgical techniques. This study compares outcomes following Rives-Stoppa (RS) repair, components separation technique with mesh (CST-M) or without mesh (CST), and endoscopic components separation technique (ECST). A retrospective review of patients undergoing open ventral hernia repair between 2006 and 2011 was performed. Analysis included patient demographics, surgical site occurrences, hernia recurrence, hospital readmission, and mortality. The search was limited to open repairs, specifically the RS, CST-M, CST, and ECST with mesh techniques. A total of 362 patients underwent repair with RS (66), CST-M (126), CST (117), or ECST (53). The groups were demographically similar. ECST was more frequently used for patients with a history of two or more recurrences (P < 0.001). The RS method had the lowest rate of recurrence (9.1%) compared with CST and CST-M with 28 and 25 per cent recurrences, respectively (P = 0.011). The RS recurrence rate was not significantly different than ECST (15%). There were no significant differences between groups for surgical site occurrences (P = 0.305), hospital readmission (P = 0.288), or death (P = 0.197). When components separation is necessary for complex ventral hernia repair, ECST is a viable option without added morbidity or mortality.
Collapse
|
16
|
Holihan JL, Li LT, Askenasy EP, Greenberg JA, Keith JN, Martindale RG, Roth JS, Liang MK. Analysis of model development strategies: predicting ventral hernia recurrence. J Surg Res 2016; 206:159-167. [DOI: 10.1016/j.jss.2016.07.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/18/2016] [Accepted: 07/25/2016] [Indexed: 12/30/2022]
|
17
|
Earle D, Roth JS, Saber A, Haggerty S, Bradley JF, Fanelli R, Price R, Richardson WS, Stefanidis D. SAGES guidelines for laparoscopic ventral hernia repair. Surg Endosc 2016; 30:3163-83. [PMID: 27405477 DOI: 10.1007/s00464-016-5072-x] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/21/2016] [Indexed: 01/21/2023]
|
18
|
Holihan JL, Alawadi ZM, Harris JW, Harvin J, Shah SK, Goodenough CJ, Kao LS, Liang MK, Roth JS, Walker PA, Ko TC. In Brief. Curr Probl Surg 2016. [DOI: 10.1067/j.cpsurg.2016.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
19
|
Holihan JL, Alawadi ZM, Harris JW, Harvin J, Shah SK, Goodenough CJ, Kao LS, Liang MK, Roth JS, Walker PA, Ko TC. Ventral hernia: Patient selection, treatment, and management. Curr Probl Surg 2016; 53:307-54. [DOI: 10.1067/j.cpsurg.2016.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/14/2016] [Indexed: 12/14/2022]
|
20
|
Plymale MA, Ragulojan R, Davenport DL, Roth JS. Ventral and incisional hernia: the cost of comorbidities and complications. Surg Endosc 2016; 31:341-351. [PMID: 27287900 DOI: 10.1007/s00464-016-4977-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/09/2016] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Ventral and incisional hernia repair (VIHR) is among the most frequently performed abdominal operations with significant incidence of postoperative complications and readmissions. Payers are targeting increased "value" of care through improved outcomes and reduced costs. Cost data in clinically relevant terms is still rare. This study aims to identify hospital costs associated with clinically relevant factors in order to facilitate strategies by surgeons to enhance the value of VIHR. METHODS An IRB-approved retrospective review of VIHRs performed at the University of Kentucky from April 2009 through September 2013 was conducted. NSQIP clinical data and hospital cost data were matched. Operating room (ORC), total encounter (TEC), and 90-day postdischarge (90PDC) hospital costs were analyzed relative to clinical variables using non-parametric tests. RESULTS In total 385 patients that underwent VIHR during the time period were included in the analyses. Considering all VIHRs, median [interquartile range (IQR)] ORC was $6900 ($5600-$10,000); TEC was $10,700 ($7500-$18,600); and 90PDC was $0 ($0-$800). Compared to all VIHRs, ASA Class ≥ 3 was associated with increased ORC and TEC (p < .001), and 90PDC (p < .01). Preoperative open wound was associated with increased ORC and TEC (p < .001). Numerous operative variables were associated with both increased ORC and TEC. Wound Class > 1 was associated with increased ORC and TEC (p < .001) and 90PDC (p < .01). Inpatient occurrence of any complication was associated with increased TEC and 90PDC (p < .001). CONCLUSIONS ASA Class ≥ 3, Wound Class > 1, open abdominal wound, and postoperative complications significantly increase costs. Although the hospital encounter represents the majority of the cost associated with VIHR, additional costs are incurred during the 90-day postoperative period. An appreciation of global costs is essential in developing alternative payment models for hernia in order to provide the greatest value in hernia care.
Collapse
|
21
|
Plymale MA, Harris JW, Davenport DL, Smith N, Levy S, Scott Roth J. Abdominal Wall Reconstruction: The Uncertainty of the Impact of Drain Duration upon Outcomes. Am Surg 2016; 82:207-211. [PMID: 27099055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Drains are commonly used after abdominal wall reconstruction (AWR) to prevent seroma formation. Drain management is subjective, and the merits and drawbacks of drains are not well understood. After receiving Institutional Review Board approval, we queried our prospectively maintained surgical database for AWR cases from 2009 to 2012 to ascertain if the number of days postoperatively that drains are left in place impacts the incidence of surgical site complications. Number of drains, drain duration, wound complications, and interval to development of complications were recorded. Wound complications were defined as superficial cellulitis, seroma, hematoma, superficial infection, and deep infection. Among 117 AWRs, we investigated the 64 cases with Centers for Disease Control grade one wound classification. Longest drain duration varied widely (2-171 days postoperatively; mean = 22 days). Cases were divided into four groups based on duration prior to removal of all drains: ≤7 days (n = 18), 8 to 14 days (n = 16), 15 to 28 days (n = 18), or ≥29 days (n = 12). No significant relationship was found between incidence of seroma/hematoma and days postoperatively of last drain removal. Wound complications increased linearly with drain time. Using logistic regression to adjust for obesity (body mass index >35kg/m(2)), drain duration >2 weeks and operative time >220 minutes, only body mass index >35 remained an independent predictor of wound occurrence, P < 0.05. Wound complications occur frequently after AWR. Wound infections occur more commonly among patients with drains in place for more than 2 weeks. Strategies to reduce drain duration require furthermore investigation.
Collapse
|
22
|
Plymale MA, Harris JW, Davenport DL, Smith N, Levy S, Roth JS. Abdominal Wall Reconstruction: The Uncertainty of the Impact of Drain Duration upon Outcomes. Am Surg 2016. [DOI: 10.1177/000313481608200312] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Drains are commonly used after abdominal wall reconstruction (AWR) to prevent seroma formation. Drain management is subjective, and the merits and drawbacks of drains are not well understood. After receiving Institutional Review Board approval, we queried our prospectively maintained surgical database for AWR cases from 2009 to 2012 to ascertain if the number of days postoperatively that drains are left in place impacts the incidence of surgical site complications. Number of drains, drain duration, wound complications, and interval to development of complications were recorded. Wound complications were defined as superficial cellulitis, seroma, hematoma, superficial infection, and deep infection. Among 117 AWRs, we investigated the 64 cases with Centers for Disease Control grade one wound classification. Longest drain duration varied widely (2–171 days postoperatively; mean = 22 days). Cases were divided into four groups based on duration prior to removal of all drains: ≤ 7 days (n = 18), 8 to 14 days (n = 16), 15 to 28 days (n = 18), or ≥29 days (n = 12). No significant relationship was found between incidence of seroma/hematoma and days postoperatively of last drain removal. Wound complications increased linearly with drain time. Using logistic regression to adjust for obesity (body mass index >35kg/m2), drain duration >2 weeks and operative time >220 minutes, only body mass index >35 remained an independent predictor of wound occurrence, P < 0.05. Wound complications occur frequently after AWR. Wound infections occur more commonly among patients with drains in place for more than 2 weeks. Strategies to reduce drain duration require furthermore investigation.
Collapse
|
23
|
Holihan JL, Bondre I, Askenasy EP, Greenberg JA, Keith JN, Martindale RG, Roth JS, Liang MK. Sublay versus underlay in open ventral hernia repair. J Surg Res 2015; 202:26-32. [PMID: 27083944 DOI: 10.1016/j.jss.2015.12.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/03/2015] [Accepted: 12/11/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ideal location for mesh placement in open ventral hernia repair (OVHR) remains under debate. Current trends lean toward underlay or sublay repair. We hypothesize that in patients undergoing OVHR, sublay versus underlay placement of mesh results in fewer surgical site infections (SSIs) and recurrences. MATERIALS AND METHODS A multi-institution database of all OVHRs performed from 2010 to 2011 was accessed. Patients with mesh placed in the sublay or underlay position and at least 1 mo of follow-up were included. Primary outcome was SSI. Secondary outcome was hernia recurrence. Multivariate analysis was performed using logistic regression for SSI and Cox regression for recurrence. Subgroup analysis of elective, midline ventral incisional hernias was also performed. RESULTS Of 447 patients, 139 (31.1%) had a sublay repair. The unadjusted analysis showed no difference in SSI and lower recurrence using sublay compared with underlay. On multivariate analysis, there was no difference in SSI using sublay compared with underlay (odds ratio 1.5, 95% confidence interval [CI] 0.8-2.8). Recurrence was less common with sublay (hazard ratio 0.4, 95% CI 0.2-0.8). On subgroup analysis of elective, midline incisional hernias only (n = 247), there were more SSIs with sublay compared with underlay repair (28.0% versus 15.1%, P = 0.018); however, there was no difference in major SSI (sublay 9.3% versus underlay 5.8%, P = 0.315). There were fewer recurrences using sublay repair compared with underlay repair (10.7% versus 25.0%, P = 0.010). CONCLUSIONS In this multi-center, risk-adjusted study, sublay repair was associated with fewer recurrences than underlay repair and no difference in SSI. Randomized controlled trials are warranted to validate these findings.
Collapse
|
24
|
Wennergren J, Levy S, Bower C, Miller M, Borman D, Davenport D, Plymale M, Scott Roth J. Revisional paraesophageal hernia repair outcomes compare favorably to initial operations. Surg Endosc 2015; 30:3854-60. [DOI: 10.1007/s00464-015-4688-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 11/16/2015] [Indexed: 01/04/2023]
|
25
|
Johnson KC, Miller MT, Plymale MA, Levy S, Davenport DL, Roth JS. Abdominal Wall Reconstruction: A Comparison of Totally Extraperitoneal and Transabdominal Preperitoneal Approaches. J Am Coll Surg 2015; 222:159-65. [PMID: 26705900 DOI: 10.1016/j.jamcollsurg.2015.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 10/30/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Abdominal wall reconstruction for complex ventral and incisional hernias is associated with significant complications. Commonly, the peritoneal cavity is opened and adhesiolysis is performed with the potential for enterotomy. A totally extraperitoneal (TE) approach to abdominal wall reconstruction is feasible in many ventral hernia repairs and can reduce visceral injuries without impacting other outcomes. This study compares outcomes after retro-rectus ventral hernia repairs with TE and transabdominal (TA) preperitoneal approaches. STUDY DESIGN An IRB-approved review of a prospective hernia database was performed for all ventral hernia repairs between 2009 and 2013. Preoperative patient characteristics, including demographics and comorbidities; operative variables, including surgical technique, operative duration, type/size/location of mesh, concomitant procedures, and incidence of inadvertent injury; and patient outcomes in terms of length of stay, wound and nonwound complications, and readmissions or returns to the operating room were obtained. Groups were compared using t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests as appropriate. Significance was set at p < .05. RESULTS One hundred and seventy-five complex abdominal wall reconstructions were performed between 2009 and 2013. Of those, 85 patients underwent hernia repair for CDC grade 1 hernias with retro-rectus mesh placement performed (n = 45 TA, n = 40 TE). Groups did not differ in age, BMI, sex, smoking status, hernia defect size, history of COPD, asthma, hypertension, cancer, or renal failure. More TA patients had diabetes (36% vs. 13%; p = 0.02) and previous hernia repair (73% vs. 45%; p = 0.01) than TE patients. Mesh size was larger in the TE group (625 ± 234 cm(2) vs. 424 ± 214 cm(2); p < .001). There was no difference in enterotomy between TA and TE groups (0% vs. 2%; p = 1.0). However, there was a reduced operative time with TE (170 ± 49 minutes vs. 212 ± 49 minutes; p < .001). CONCLUSIONS Abdominal wall reconstruction can be performed safely in a TE fashion. The extraperitoneal approach results in shorter operative duration, but had similar complications when compared with TA preperitoneal approach.
Collapse
|