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Lorenz WR, Holland AM, Mead BS, Scarola GT, Augenstein VA, Heniford BT. Factors Associated With Respiratory Failure After Open Ventral Hernia Repair: An Evaluation of the NSQIP Database. Am Surg 2024; 90:1916-1918. [PMID: 38523427 DOI: 10.1177/00031348241241731] [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] [Indexed: 03/26/2024]
Abstract
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.
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Affiliation(s)
- William R Lorenz
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Alexis M Holland
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Brittany S Mead
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Parker SG, Joyner J, Thomas R, Van Dellen J, Mohamed S, Jakkalasaibaba R, Blake H, Shanmuganandan A, Albadry W, Panascia J, Gray W, Vig S. A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction. Am Surg 2024; 90:1714-1726. [PMID: 38584505 DOI: 10.1177/00031348241241650] [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] [Indexed: 04/09/2024]
Abstract
INTRODUCTION Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes. METHODS We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital. RESULTS We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway. CONCLUSION In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.
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Affiliation(s)
- Samuel G Parker
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - James Joyner
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Rhys Thomas
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Jonathan Van Dellen
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Said Mohamed
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | | | - Helena Blake
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Arun Shanmuganandan
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Waleed Albadry
- Plastics Surgery Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Julia Panascia
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - William Gray
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Stella Vig
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
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Holland AM, Mead BS, Lorenz WR, Scarola GT, Augenstein VA. Racial and Socioeconomic Disparities in Complex Abdominal Wall Reconstruction Referrals. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2024; 3:12946. [PMID: 38873344 PMCID: PMC11169567 DOI: 10.3389/jaws.2024.12946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/20/2024] [Indexed: 06/15/2024]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Vedra A. Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, United States
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Holland AM, Lorenz WR, Mead BS, Scarola GT, Augenstein VA, Kercher KW, Heniford BT. The Utilization of Laparoscopic Ventral Hernia Repair (LVHR) in Incarcerated and Strangulated Cases: A National Trend in Outcomes. Am Surg 2024:31348241241692. [PMID: 38557282 DOI: 10.1177/00031348241241692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
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.
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Affiliation(s)
- Alexis M Holland
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - William R Lorenz
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Brittany S Mead
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Kent W Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
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Haskins IN, Huang LC, Phillips S, Poulose B, Perez AJ. Does a "hernia center" label provide better 30-day outcomes following elective ventral hernia repair?: An analysis of the ACHQC database. Am J Surg 2024; 228:230-236. [PMID: 37951836 DOI: 10.1016/j.amjsurg.2023.10.025] [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: 06/21/2023] [Revised: 08/10/2023] [Accepted: 10/04/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION Currently, there is no agreed upon definition of a designated hernia center (DHC) and no study has investigated the association of hernia center designation with ventral hernia repair (VHR) outcomes. We sought to investigate the current utilization of DHC and the association of hernia center designation with VHR outcomes. METHODS All patients who underwent elective, ventral hernia repair with mesh with 30-day follow-up from 2013 through 2020 were in the Americas Hernia Society Quality Collaborative (ACHQC) database. Patients were divided into two groups: those that underwent VHR at a DHC and those that underwent VHR at a non-designated hernia center site (NDHC). Using a 1:1 matched analysis, differences in the incidence of 30-day wound events, the total number of 30-day complications, one-year ventral hernia recurrence rates, and 30-day and one-year patient reported outcomes were compared between DHC and NDHC. RESULTS A total of 261 sites were included in our analysis; 78 (30%) were identified as DHC. After matching, there were 14,186 VHRs available for analysis. There was no significant difference in 30-day wound morbidity events. Patients who underwent VHR at NDHC were less likely to experience any 30-day complication or 1-year hernia recurrence while patients who underwent VHR at DHC had a statistically significant greater improvement in their HerQLes scores at one-year postoperatively. CONCLUSIONS There is currently no clear superiority to VHR at a DHC. The ACHQC may self-select for surgeons invested in hernia repair outcomes regardless of hernia center designation. More standardized criteria for a hernia center are required in order to positively influence the value of hernia care delivered in the United States.
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Affiliation(s)
- Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin Poulose
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, USA
| | - Arielle J Perez
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Parker SG, Blake H, Zhao S, van Dellen J, Mohamed S, Albadry W, Akhtar H, Franczak B, Jakkalasaibaba R, Rothnie A, Thomas R. An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients. Ann R Coll Surg Engl 2024; 106:29-35. [PMID: 36927113 PMCID: PMC10757872 DOI: 10.1308/rcsann.2022.0167] [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] [Accepted: 12/12/2022] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting. METHODS From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed. RESULTS Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care. DISCUSSION A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.
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Affiliation(s)
- SG Parker
- Croydon Health Services NHS Trust, UK
| | - H Blake
- Croydon Health Services NHS Trust, UK
| | - S Zhao
- Croydon Health Services NHS Trust, UK
| | | | - S Mohamed
- Croydon Health Services NHS Trust, UK
| | - W Albadry
- St George’s University Hospitals NHS Foundation Trust, UK
| | - H Akhtar
- Croydon Health Services NHS Trust, UK
| | | | | | - A Rothnie
- Croydon Health Services NHS Trust, UK
| | - R Thomas
- Croydon Health Services NHS Trust, UK
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Schlosser KA, Renshaw SM, Tamer RM, Strassels SA, Poulose BK. Ventral hernia repair: an increasing burden affecting abdominal core health. Hernia 2023; 27:415-421. [PMID: 36571666 DOI: 10.1007/s10029-022-02707-6.10.1007/s10029-022-02707-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/01/2022] [Indexed: 05/21/2023]
Abstract
PURPOSE To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States. METHODS A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021 dollars using US Bureau of Labor Statistics Consumer Price Index. RESULTS On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019. CONCLUSION Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.
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Affiliation(s)
- K A Schlosser
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - S M Renshaw
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - R M Tamer
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - S A Strassels
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - B K Poulose
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Wegdam JA, de Jong DLC, Gielen MJCAM, Nienhuijs SW, Füsers AFM, Bouvy ND, de Vries Reilingh TS. Impact of a multidisciplinary team discussion on planned ICU admissions after complex abdominal wall reconstruction. Hernia 2023; 27:623-633. [PMID: 36890358 PMCID: PMC9994771 DOI: 10.1007/s10029-023-02762-7] [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: 11/29/2022] [Accepted: 02/18/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Patients often need admission at an Intensive Care Unit (ICU), immediately after complex abdominal wall reconstruction (CAWR). Lack of ICU resources requires adequate patient selection for a planned postoperative ICU admission. Risk stratification tools like Fischer score and Hernia Patient Wound (HPW) classification may improve patient selection. This study evaluates the decision-making process in a multidisciplinary team (MDT) on justified ICU admissions for patients after CAWR. METHODS A pre-Covid-19 pandemic cohort of patients, discussed in a MDT and subsequently underwent CAWR between 2016 and 2019, was analyzed. A justified ICU admission was defined by any intervention within the first 24 h postoperatively, considered not suitable for a nursing ward. The Fischer score predicts postoperative respiratory failure by eight parameters and a high score (> 2) warrants ICU admission. The HPW classification ranks complexity of hernia (size), patient (comorbidities) and wound (infected surgical field) in four stages, with increasing risk for postoperative complications. Stages II-IV point to ICU admission. Accuracy of the MDT decision and (modifications of) risk-stratification tools on justified ICU admissions were analyzed by backward stepwise multivariate logistic regression analysis. RESULTS Pre-operatively, the MDT decided a planned ICU admission in 38% of all 232 CAWR patients. Intra-operative events changed the MDT decision in 15% of all CAWR patients. MDT overestimated ICU need in 45% of ICU planned patients and underestimated in 10% of nursing ward planned patients. Ultimately, 42% went to the ICU and 27% of all 232 CAWR patients were justified ICU patients. MDT accuracy was higher than the Fischer score, HPW classification or any modification of these risk stratification tools. CONCLUSION A MDT's decision for a planned ICU admission after complex abdominal wall reconstruction was more accurate than any of the other risk-stratifying tools. Fifteen percent of the patients experienced unexpected operative events that changed the MDT decision. This study demonstrated the added value of a MDT in the care pathway of patients with complex abdominal wall hernias.
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Affiliation(s)
- J A Wegdam
- Department of Surgery, Elkerliek Hospital, Helmond, The Netherlands.
| | - D L C de Jong
- Department of Surgery, Elkerliek Hospital, Helmond, The Netherlands
| | - M J C A M Gielen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S W Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - A F M Füsers
- Department of Intensive Care, Elkerliek Hospital, Helmond, The Netherlands
| | - N D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Predicting rare outcomes in abdominal wall reconstruction using image-based deep learning models. Surgery 2023; 173:748-755. [PMID: 36229252 DOI: 10.1016/j.surg.2022.06.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/04/2022] [Accepted: 06/27/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Deep learning models with imbalanced data sets are a challenge in the fields of artificial intelligence and surgery. The aim of this study was to develop and compare deep learning models that predict rare but devastating postoperative complications after abdominal wall reconstruction. METHODS A prospectively maintained institutional database was used to identify abdominal wall reconstruction patients with preoperative computed tomography scans. Conventional deep learning models were developed using an 8-layer convolutional neural network and a 2-class training system (ie, learns negative and positive outcomes). Conventional deep learning models were compared to deep learning models that were developed using a generative adversarial network anomaly framework, which uses image augmentation and anomaly detection. The primary outcomes were receiver operating characteristic values for predicting mesh infection and pulmonary failure. RESULTS Computed tomography scans from 510 patients were used with a total of 10,004 images. Mesh infection and pulmonary failure occurred in 3.7% and 5.6% of patients, respectively. The conventional deep learning models were less effective than generative adversarial network anomaly for predicting mesh infection (receiver operating characteristic 0.61 vs 0.73, P < .01) and pulmonary failure (receiver operating characteristic 0.59 vs 0.70, P < .01). Although the conventional deep learning models had higher accuracies/specificities for predicting mesh infection (0.93 vs 0.78, P < .01/.96 vs .78, P < .01) and pulmonary failure (0.88 vs 0.68, P < .01/.92 vs .67, P < .01), they were substantially compromised by decreased model sensitivity (0.25 vs 0.68, P < .01/.27 vs .73, P < .01). CONCLUSION Compared to conventional deep learning models, generative adversarial network anomaly deep learning models showed improved performance on imbalanced data sets, predominantly by increasing model sensitivity. Understanding patients who are at risk for rare but devastating postoperative complications can improve risk stratification, resource utilization, and the consent process.
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de Jong DLC, Wegdam JA, Berkvens EBM, Nienhuijs SW, de Vries Reilingh TS. The influence of a multidisciplinary team meeting and prehabilitation on complex abdominal wall hernia repair outcomes. Hernia 2023; 27:609-616. [PMID: 36787034 PMCID: PMC9926435 DOI: 10.1007/s10029-023-02755-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/03/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE Surgical site occurrences after transversus abdominis release in ventral hernia repair are still reported up to 15%. Evidence is rising that preoperative improvement of risk factors might contribute to optimal patient recovery. A reduction of complication rates up to 40% has been reported. The aim of this study was to determine whether prehabilitation has a favorable effect on the risk on wound and medical complications as well as on length of stay. METHODS A retrospective cohort study was performed in a tertiary referral center for abdominal wall surgery. All patients undergoing ventral hernia repair discussed at multidisciplinary team (MDT) meetings between 2015 and 2019 were included. Patients referred for a preconditioning program by the MDT were compared to patients who were deemed fit for operative repair by the MDT, without such a program. Endpoints were patients, hernia, and procedure characteristics as well as length of hospital stay, wound and general complications. RESULTS A total of 259 patients were included of which 126 received a preconditioning program. Baseline characteristics between the two groups were statistically significantly different as the prehabilitated group had higher median BMI (28 vs 30, p < 0.001), higher HbA1c (41 vs 48, p = 0.014), more smokers (4% vs 25%, p < 0.001) and higher HPW classes due to more patient factors (14% vs 48%, p < 0.001). There were no significant differences in intra-operative and postoperative outcome measures. CONCLUSIONS This study showed prehabilitation facilitates patients with relevant comorbidities achieving the same results as patients without those risk factors. The indication of a preconditioning program might be effective at the discretion of an MDT meeting. Further research could focus on the extent of such program to assess its value.
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Schlosser KA, Renshaw SM, Tamer RM, Strassels SA, Poulose BK. Ventral hernia repair: an increasing burden affecting abdominal core health. Hernia 2022; 27:415-421. [PMID: 36571666 DOI: 10.1007/s10029-022-02707-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/01/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States. METHODS A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021 dollars using US Bureau of Labor Statistics Consumer Price Index. RESULTS On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019. CONCLUSION Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.
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Affiliation(s)
- K A Schlosser
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - S M Renshaw
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - R M Tamer
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - S A Strassels
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - B K Poulose
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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12
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Gamboa Bernal MP, Contreras SD, Gonzalez A, Cabrera Rivera PA, Perez CJ. Multidisciplinary approach as a treatment option for abdominal wall reconstruction in patients with heart failure: A case report. Int J Surg Case Rep 2022; 100:107770. [DOI: 10.1016/j.ijscr.2022.107770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/21/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
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13
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Chaves CER, Girón F, Conde D, Rodriguez L, Venegas D, Vanegas M, Pardo M, Núñez-Rocha RE, Vargas F, Navarro J, Ricaurte A. Transversus abdominis release (TAR) procedure: a retrospective analysis of an abdominal wall reconstruction group. Sci Rep 2022; 12:18325. [PMID: 36316384 PMCID: PMC9622848 DOI: 10.1038/s41598-022-22062-x] [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: 02/11/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022] Open
Abstract
Complex abdominal wall defects are important conditions with high morbidity, leading to impairment of patients' physical condition and quality of life. In the last decade, the abdominal wall reconstruction paradigm has changed due to the formation of experienced and excellence groups, improving clinical outcomes after surgery. Therefore, our study shows the perspective and outcomes of an abdominal wall reconstruction group (AWRG) in Colombia, focused on the transverse abdominis release (TAR) procedure. A retrospective review of a prospectively collected database was conducted. All the patients older than 18 years old that underwent TAR procedures between January 2014-December 2020 were included. Analysis and description of postoperative outcomes (recurrence, surgical site infection (SSI), seroma, hematoma, and re-intervention) were performed. 47 patients underwent TAR procedure. 62% of patients were male. Mean age was 55 ± 13.4 years. Mean BMI was 27.8 ± 4.5 kg/m2. Abdominal wall defects were classified with EHS ventral Hernia classification having a W3 hernia in 72% of all defects (Mean gap size of 11.49 cm ± 4.03 cm). Mean CeDAR preoperative risk score was 20.5% ± 14.5%. Preoperative use of BOTOX Therapy (OR 1.0 P 0.00 95% CI 0.3-1.1) or pneumoperitoneum (OR 0.7 P 0.04 95% CI 0.3-0.89) are slightly associated with postoperative hematoma. In terms of hernia relapse, we have 12% of cases; all of them over a year after the surgery. TAR procedure for complex abdominal wall defects under specific clinical conditions including emergency scenarios is viable. Specialized and experienced groups show better postoperative outcomes; further studies are needed to confirm our results.
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Affiliation(s)
- Carlos Eduardo Rey Chaves
- grid.41312.350000 0001 1033 6040School of Medicine, Pontificia Universidad Javeriana, Calle 6A #51a - 48, 111711 Bogotá D.C., Colombia
| | - Felipe Girón
- grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia ,grid.7247.60000000419370714School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Danny Conde
- Department of Surgery, Hospital Universitario Méderi, Bogotá, Colombia ,grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Lina Rodriguez
- grid.7247.60000000419370714School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - David Venegas
- grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Marco Vanegas
- grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Manuel Pardo
- grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Ricardo E. Núñez-Rocha
- grid.7247.60000000419370714School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Felipe Vargas
- Department of Surgery, Hospital Universitario Méderi, Bogotá, Colombia ,grid.412191.e0000 0001 2205 5940School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Jorge Navarro
- grid.41312.350000 0001 1033 6040School of Medicine, Pontificia Universidad Javeriana, Calle 6A #51a - 48, 111711 Bogotá D.C., Colombia ,Department of Surgery, Hospital Universitario Méderi, Bogotá, Colombia
| | - Alberto Ricaurte
- Department of Surgery, Hospital Universitario Méderi, Bogotá, Colombia
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Wegdam JA, de Jong DLC, de Vries Reilingh TS, Schipper EE, Bouvy ND, Nienhuijs SW. Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2022; 1:10517. [PMID: 38314160 PMCID: PMC10831686 DOI: 10.3389/jaws.2022.10517] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/07/2022] [Indexed: 02/06/2024]
Abstract
Background: The posterior component separation technique with transversus abdominis release (TAR) was introduced in 2012 as an alternative to the classic anterior component separation technique (Ramirez). This study describes outcome and learning curve of TAR, five years after implementation of this new technique in a regional hospital in the Netherlands. Methods: A standardized work up protocol, based on the Plan-Do-Check-Act cycle, was used to implement the TAR. The TAR technique as described by Novitsky was performed. After each 20 procedures, outcome parameters were evaluated and new quality measurements implemented. Primary outcome measure was Textbook Outcome, the rate of patients with an uneventful clinical postoperative course after TAR. Textbook Outcome is defined by a maximum of 7 days hospitalization without any complication (wound or systemic), reoperation or readmittance, within the first 90 postoperative days, and without a recurrence during follow up. The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve. Secondary outcome measures were the details and incidences of the surgical site and systemic complications within 90 days, as well as long-term recurrences. Results: From 2016, sixty-nine consecutive patients underwent a TAR. Textbook Outcome was 35% and the institutional learning curve did not flatten after 69 procedures. Systemic complications occurred in 48%, wound complications in 41%, and recurrences in 4%. Separate analyses of three successive cohorts of each 20 TARs demonstrated that both Textbook Outcome (10%, 30% and 55%, respectively) and the rate of surgical site events (45%, 15%, and 10%) significantly (p < 0.05) improved with more experience. Conclusion: Implementation of the open transversus abdominis release demonstrated that outcome was positively correlated to an increasing number of TARs performed. TAR has a long learning curve, only partially determined by the technical aspects of the operation. Implementation of the TAR requires a solid plan. Building, and maintaining, an adequate setting for patients with complex ventral hernias is the real challenge and driving force to improve outcome.
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Affiliation(s)
| | | | | | | | - Nicole D. Bouvy
- Maastricht University Medical Centre, Maastricht, Netherlands
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15
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Kollias V, Reid J, Udayasiri D, Granger J, Karatassas A, Hensman I, Maddern G. Towards a complete cycle of care: a multidisciplinary pathway to improve outcomes in complex abdominal wall hernia repair. ANZ J Surg 2022; 92:2025-2036. [PMID: 35635058 DOI: 10.1111/ans.17765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/01/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The burden of complex abdominal wall hernia (CAWH) is increasing, with associated high morbidity and healthcare costs. This study evaluates current evidenoptce regarding multidisciplinary care for CAWH patients to improve patient outcomes. METHODS A systematic review of Scopus, MEDLINE, Embase, PubMed, Web of Knowledge and Cochrane Library was conducted to identify proposed or established multidisciplinary team (MDT) pathways, necessary MDT constituents, and to evaluate patient outcomes. The pre-optimization pathways were then compared with a recent Delphi consensus statement. RESULTS Seven articles matched the relevant search criteria. Three were concept articles, without prospective data analysis. Four were case series that applied multidisciplinary care and included limited data analyses with outcomes reported up to 50 months. The consensus was that CAWH MDT requires multiple clinical specialties, including hernia, upper gastrointestinal, colorectal and/or plastic and reconstructive surgeons, along with allied health specialists, radiologists, anaesthetists/pain specialists and infectious diseases consultants. A successful MDT should aim to achieve pre-optimization and plan the definitive repair. These pre-optimization pathways were similar to the recent Delphi consensus by international hernia experts. Using these data, we propose a CAWH multidisciplinary pathway model in an Australian tertiary hospital involving a stepwise approach with well-defined referral criteria, perioperative high-risk management with pre-optimization, surgical planning, postoperative care and follow-up protocols. This pathway incorporates prospective data collection in a Clinical Quality Registry (CQR) to validate its appropriateness. CONCLUSIONS CAWH MDT can provide comprehensive, patient-centred care with improved postoperative outcomes. CQR are important to better evaluate long-term outcomes and ensure rigorous quality control.
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Affiliation(s)
- Victoria Kollias
- Department of General Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Jessica Reid
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Dilshan Udayasiri
- Department of General Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Jeremy Granger
- Department of General Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Alex Karatassas
- Department of Surgery, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Indran Hensman
- Department of Surgery, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Guy Maddern
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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16
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Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach. J Gastrointest Surg 2022; 26:693-701. [PMID: 35013880 DOI: 10.1007/s11605-021-05241-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/31/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population. METHODS Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors' experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center. RESULTS An abundance of publications have been combined with multiple members of our abdominal core health centers members experience's culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center. CONCLUSIONS Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.
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17
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Elhage SA, Deerenberg EB, Ayuso SA, Murphy KJ, Shao JM, Kercher KW, Smart NJ, Fischer JP, Augenstein VA, Colavita PD, Heniford BT. Development and Validation of Image-Based Deep Learning Models to Predict Surgical Complexity and Complications in Abdominal Wall Reconstruction. JAMA Surg 2021; 156:933-940. [PMID: 34232255 DOI: 10.1001/jamasurg.2021.3012] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Image-based deep learning models (DLMs) have been used in other disciplines, but this method has yet to be used to predict surgical outcomes. Objective To apply image-based deep learning to predict complexity, defined as need for component separation, and pulmonary and wound complications after abdominal wall reconstruction (AWR). Design, Setting, and Participants This quality improvement study was performed at an 874-bed hospital and tertiary hernia referral center from September 2019 to January 2020. A prospective database was queried for patients with ventral hernias who underwent open AWR by experienced surgeons and had preoperative computed tomography images containing the entire hernia defect. An 8-layer convolutional neural network was generated to analyze image characteristics. Images were batched into training (approximately 80%) or test sets (approximately 20%) to analyze model output. Test sets were blinded from the convolutional neural network until training was completed. For the surgical complexity model, a separate validation set of computed tomography images was evaluated by a blinded panel of 6 expert AWR surgeons and the surgical complexity DLM. Analysis started February 2020. Exposures Image-based DLM. Main Outcomes and Measures The primary outcome was model performance as measured by area under the curve in the receiver operating curve (ROC) calculated for each model; accuracy with accompanying sensitivity and specificity were also calculated. Measures were DLM prediction of surgical complexity using need for component separation techniques as a surrogate and prediction of postoperative surgical site infection and pulmonary failure. The DLM for predicting surgical complexity was compared against the prediction of 6 expert AWR surgeons. Results A total of 369 patients and 9303 computed tomography images were used. The mean (SD) age of patients was 57.9 (12.6) years, 232 (62.9%) were female, and 323 (87.5%) were White. The surgical complexity DLM performed well (ROC = 0.744; P < .001) and, when compared with surgeon prediction on the validation set, performed better with an accuracy of 81.3% compared with 65.0% (P < .001). Surgical site infection was predicted successfully with an ROC of 0.898 (P < .001). However, the DLM for predicting pulmonary failure was less effective with an ROC of 0.545 (P = .03). Conclusions and Relevance Image-based DLM using routine, preoperative computed tomography images was successful in predicting surgical complexity and more accurate than expert surgeon judgment. An additional DLM accurately predicted the development of surgical site infection.
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Affiliation(s)
- Sharbel Adib Elhage
- Department of Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands
| | | | - Sullivan Armando Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | | | - Jenny Meng Shao
- Department of Surgery, University of Pennsylvania, Philadelphia
| | - Kent Williams Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Neil James Smart
- Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - John Patrick Fischer
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Vedra Abdomerovic Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Paul Dominick Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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National health disparities in incisional hernia repair outcomes: An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2012-2014. Surgery 2021; 169:1393-1399. [PMID: 33422347 DOI: 10.1016/j.surg.2020.11.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Incisional hernias represent an acquired defect from failed healing of an abdominal facial incision and are therefore distinct from primary hernias. While literature regarding incisional hernia incidence, risk factors, and treatment are abundant, no study has examined national health disparities specific to incisional hernia repair. The objective of this study was to analyze national health disparities unique to surgical incisional hernia repair procedures. METHODS Patient data queried from the Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014 using International Classification of Diseases 9th revision procedure codes for incisional hernia repair were used to generate univariate and multivariate models including demographics, socioeconomic factors, admission status, and hospital characteristics. Primary outcomes were nonelective admission status, in-hospital mortality, surgical complications, and extended duration of stay. RESULTS We estimated that 89,258 incisional hernia repair procedures occurred annually from 2012 to 2014, incurring $6.3 billion in hospital charges. By multivariate analysis, multiple risk factors contribute to significantly increased odds of nonelective repair. These include age over 65, female sex, non-White race, nonprivate insurance, obesity, and increased Charlson comorbidity index. Nonelective incisional hernia repair was strongly correlated with worse outcomes including in-hospital mortality (odds ratio [95% confidence interval] 3.01 [2.51, 3.61]), postoperative complications (odds ratio 1.2 [1.14, 1.25]), and extended duration of stay (odds ratio 2.96 [2.81, 3.12]). After controlling for admission status, other disparities persisted including extended duration of stay for Black individuals (odds ratio 1.21 (1.12, 1.31]). CONCLUSION Providers should be aware of these significant health disparities in incisional hernia repair status and outcomes especially for elderly, non-White, nonprivate insurance, and obese/comorbid patients. Management strategies that increase access to elective repair and that prevent incisional hernia should be expanded to address these disparities.
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Schlosser KA, Maloney SR, Thielan ON, Prasad T, Kercher KW, Augenstein VA, Heniford BT, Colavita PD. Sarcopenia in Patients Undergoing Open Ventral Hernia Repair. Am Surg 2020. [DOI: 10.1177/000313481908500940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Radiologic indicators of sarcopenia have been associated with adverse operative outcomes in some surgical populations. This study assesses the association of radiologic indicators of frailty with outcomes after open ventral hernia repair (OVHR). A prospective, institutional, herniaspecific database was queried for patients undergoing OVHR from 2007 to 2018 with preoperative CT. Psoas muscle cross-sectional area at L3 was measured and adjusted for height (skeletal muscle index (SMI)). L3 vertebral body density (L3 VBD) was measured. Demographics and outcomes were evaluated as related to SMI and L3 VBD. Of 1178 patients, 9.7 per cent of females and 15.8 per cent of males had sarcopenia and 11.6 per cent of females and 9.2 per cent of males had osteopenia. Neither sarcopenia nor osteopenia were associated with outcomes of wound infection, read-mission, reoperation, hernia recurrence, or major complications. When examined as continuous variables or by quartile, SMI and L3 VBD were not associated with adverse outcomes, including in subsets of male or female patients, the elderly, contaminated cases, and the obese. Radiologic markers of sarcopenia and osteopenia are not associated with adverse outcomes after OVHR. Further study should examine age or other potential predictors of outcomes in this patient population, such as independent status.
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Affiliation(s)
| | - Sean R. Maloney
- From the Carolinas Medical Center, Charlotte, North Carolina
| | - Otto N. Thielan
- From the Carolinas Medical Center, Charlotte, North Carolina
| | | | - Kent W. Kercher
- From the Carolinas Medical Center, Charlotte, North Carolina
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Zolin SJ, Fafaj A, Krpata DM. Transversus abdominis release (TAR): what are the real indications and where is the limit? Hernia 2020; 24:333-340. [PMID: 32152808 DOI: 10.1007/s10029-020-02150-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/19/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE To review literature surrounding transversus abdominis release (TAR) for incisional hernia repair, with the aim of describing key preoperative and technical considerations for this procedure. METHODS Existing literature on TAR was reviewed and synthesized with the clinical experience and approach to TAR from a high-volume hernia center. RESULTS Recommendations regarding patient selection, optimization and technique for TAR are presented. CONCLUSIONS While published outcomes of TAR from expert centers are favorable, potentially devastating complications may result when TAR is performed incorrectly or in suboptimal clinical situations. Appropriate patient selection, optimization, and surgeon expertise are necessary if TAR is to be performed.
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Affiliation(s)
- S J Zolin
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA.
| | - A Fafaj
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA
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21
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Schlosser KA, Maloney SR, Gbozah K, Prasad T, Colavita PD, Augenstein VA, Heniford BT. The impact of weight change on intra-abdominal and hernia volumes. Surgery 2020; 167:876-882. [PMID: 32151368 DOI: 10.1016/j.surg.2020.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/05/2020] [Accepted: 01/14/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Weight loss is often encouraged or required before open ventral hernia repair. This study evaluates the impact of weight change on total, intra-abdominal, subcutaneous, and hernia volume. METHODS Patients who underwent open ventral hernia repair from 2007 to 2018 with two preoperative computed tomography scans were identified. Scans were reviewed using 3D volumetric software. Demographics, operative characteristics, and outcomes were evaluated. The impact of weight change on intra-abdominal, subcutaneous, and hernia volume was assessed using Spearman's correlation coefficients and linear regression models. RESULTS A total of 250 patients met the criteria with a mean defect area of 155.6 ± 155.4 cm2, subcutaneous volume of 6,800.0 ± 3,868.8 cm3, hernia volume of 915.7 ± 1,234.5 cm3, intra-abdominal volume equaling 4,250.2 ± 2,118.1 cm3, and time between computed tomography scans 13.9 ± 11.0 months. Weight change was associated with change in hernia, intra-abdominal, total, and subcutaneous volume (Spearman's correlation coefficients 0.17, 0.48, 0.51, 0.45, respectively, P ≤ 0.03 all values) and not associated in hernia length, width, or area (P ≥ 0.18 all values). A Δ5 kg was significantly associated with Δintra-abdominal volume (164.1 ± 30.0 cm3/Δ5 kg,P < .0001), Δtotal volume (209.9 ± 33.0 cm3/Δ5 kg, P < .0001), and Δsubcutaneous volume (234.4 ± 50.8 cm3/Δ5 kg, P < .0001). Per Δ5 kg, male patients had more than double the Δintra-abdominal, Δtotal, and Δsubcutaneous volume than did female patients. A weight change of 5 kg to10 kg was associated with approximately double the change in computed tomography parameters/Δ5 kg than any weight change after 10 kg. Regardless of weight change, all measured hernia parameters increased over time, with mean hernia volume of +40.6 ± 94.9 cm3/mo and area of +7.8 ± 13.3 cm2/mo (Spearman's correlation coefficient -0.03 to 0.07, P value 0.37-0.96). CONCLUSION Weight change is linearly correlated with intra-abdominal and subcutaneous fat gain or loss. Males show greater abdominal-related response to weight gain or loss. Hernia dimensions increase over time regardless of weight change.
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Affiliation(s)
- Kathryn A Schlosser
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Sean R Maloney
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Korene Gbozah
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Tanushree Prasad
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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22
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The impact of preoperative anxiety, depression, and chronic pain on outcomes in abdominal wall reconstruction. Hernia 2019; 23:1045-1051. [DOI: 10.1007/s10029-019-02059-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 09/27/2019] [Indexed: 11/26/2022]
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23
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Schlosser KA, Maloney SR, Prasad T, Colavita PD, Augenstein VA, Heniford BT. Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair. Surg Endosc 2019; 34:4131-4139. [PMID: 31637601 DOI: 10.1007/s00464-019-07181-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR. METHODS OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables. RESULTS There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7 kg/m2, age of 58.5 ± 12.4 years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24 h respiratory support with ezPAP, CPAP, or biPAP (RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1 kg/m2, p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4 years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9 cm2, p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7 cm3, p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI. CONCLUSION The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.
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Affiliation(s)
- Kathryn A Schlosser
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Sean R Maloney
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Tanushree Prasad
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA. .,Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
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Maloney SR, Schlosser KA, Prasad T, Kasten KR, Gersin KS, Colavita PD, Kercher KW, Augenstein VA, Heniford BT. Twelve years of component separation technique in abdominal wall reconstruction. Surgery 2019; 166:435-444. [DOI: 10.1016/j.surg.2019.05.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/29/2019] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
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