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Woo KP, Ellis RC, Maskal SM, Remulla D, Shukla P, Rosen AJ, Wetzka I, Osei-Koomson W, Phillips S, Miller BT, Beffa LR, Petro CC, Krpata DM, Prabhu AS, Menzo EL, Rosen MJ. The association of permanent versus absorbable fixation on developing chronic post-herniorrhaphy groin pain in patients undergoing laparoscopic inguinal hernia repair. Surg Endosc 2024:10.1007/s00464-024-10866-z. [PMID: 38710888 DOI: 10.1007/s00464-024-10866-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/14/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Fixation of mesh during minimally invasive inguinal hernia repair is thought to contribute to chronic post-herniorrhaphy groin pain (CGP). In contrast to permanent tacks, absorbable tacks are hypothesized to minimize the likelihood of CGP. This study aimed to compare the rates of CGP after laparoscopic inguinal hernia repair between absorbable versus permanent fixation at maximum follow-up. METHODS This is a post hoc analysis of a randomized controlled trial in patients undergoing laparoscopic inguinal hernia repair (NCT03835351). All patients were contacted at maximum follow-up after surgery to administer EuraHS quality of life (QoL) surveys. The pain and restriction of activity subdomains of the survey were utilized. The primary outcome was rate of CGP, as defined by a EuraHS QoL pain domain score ≥ 4 measured at ≥ 1 year postoperatively. The secondary outcomes were pain and restriction of activity domain scores and hernia recurrence at maximum follow-up. RESULTS A total of 338 patients were contacted at a mean follow-up of 28 ± 11 months. 181 patients received permanent tacks and 157 patients received absorbable tacks during their repair. At maximum follow-up, the rates of CGP (27 [15%] vs 28 [18%], P = 0.47), average pain scores (1.78 ± 4.38 vs 2.32 ± 5.40, P = 0.22), restriction of activity scores (1.39 ± 4.32 vs 2.48 ± 7.45, P = 0.18), and the number of patients who reported an inguinal bulge (18 [9.9%] vs 15 [9.5%], P = 0.9) were similar between patients with permanent versus absorbable tacks. On multivariable analysis, there was no significant difference in the odds of CGP between the two groups (OR 1.23, 95% CI [0.60, 2.50]). CONCLUSION Mesh fixation with permanent tacks does not appear to increase the risk of CGP after laparoscopic inguinal hernia repair when compared to fixation with absorbable tacks. Prospective trials are needed to further evaluate this relationship.
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Affiliation(s)
- Kimberly P Woo
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
| | - Ryan C Ellis
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Sara M Maskal
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Daphne Remulla
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Priya Shukla
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Alexandra J Rosen
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Isabella Wetzka
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Wilhemina Osei-Koomson
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin T Miller
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Lucas R Beffa
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Clayton C Petro
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - David M Krpata
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Ajita S Prabhu
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Emanuele Lo Menzo
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston Hospital, Weston, FL, USA
| | - Michael J Rosen
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
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Vijayaraghavan A, Prabhu AS, Divya KP, Sapna ES, Cherian A, Narasimhaiah D, Krishnan S. Multiple system atrophy like presentation with hot-cross bun sign in anti-IgLON5 disease. Parkinsonism Relat Disord 2024; 122:106073. [PMID: 38461690 DOI: 10.1016/j.parkreldis.2024.106073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Asish Vijayaraghavan
- Comprehensive Care Centre for Movement Disorders, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - A S Prabhu
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - K P Divya
- Comprehensive Care Centre for Movement Disorders, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - E S Sapna
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - Ajith Cherian
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - Deepti Narasimhaiah
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - Syam Krishnan
- Comprehensive Care Centre for Movement Disorders, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
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Brooks NE, Feng X, French JC, Simon R, Lipman JM, Prabhu AS. Film Club: A group surgical video review program. Med Educ 2024; 58:629-630. [PMID: 38400771 DOI: 10.1111/medu.15357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/23/2024] [Indexed: 02/26/2024]
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Lenkov V, Beffa LRA, Miller BT, Maskal SM, Ellis RC, Tu C, Krpata DM, Rosen MJ, Prabhu AS, Petro CC. Postoperative bleeding after complex abdominal wall reconstruction: A post hoc analysis of a randomized clinical trial. Surgery 2024:S0039-6060(24)00150-8. [PMID: 38641542 DOI: 10.1016/j.surg.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/12/2024] [Accepted: 03/11/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Abdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction. METHODS All patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion. RESULTS In 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75-43.8], P < .01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34-8.53], P < .01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention. CONCLUSION Patients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk.
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Affiliation(s)
- Vyacheslav Lenkov
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH.
| | - Lucas R A Beffa
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH
| | - Benjamin T Miller
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH
| | - Sara M Maskal
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH
| | - Ryan C Ellis
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, OH
| | - David M Krpata
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH
| | - Michael J Rosen
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH
| | - Ajita S Prabhu
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH
| | - Clayton C Petro
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, OH
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Maskal SM, Ellis RC, Mali O, Lau B, Messer N, Zheng X, Miller BT, Petro CC, Prabhu AS, Rosen MJ, Beffa LRA. Long-term mesh-related complications from minimally invasive intraperitoneal onlay mesh for small to medium-sized ventral hernias. Surg Endosc 2024; 38:2019-2026. [PMID: 38424284 PMCID: PMC10978620 DOI: 10.1007/s00464-024-10716-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/28/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Intraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs. METHODS AND PROCEDURES Adult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively. RESULTS A total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8-5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up. CONCLUSION Intraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons.
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Affiliation(s)
- Sara M Maskal
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA.
| | - Ryan C Ellis
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Ouen Mali
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Braden Lau
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Nir Messer
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | | | - Benjamin T Miller
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Clayton C Petro
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Ajita S Prabhu
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Michael J Rosen
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Lucas R A Beffa
- Center for Abdominal Core Health, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
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Maskal SM, Ellis RC, Melland-Smith M, Messer N, Phillips S, Miller BT, Beffa LRA, Petro CC, Rosen MJ, Prabhu AS. Revisiting femoral hernia diagnosis rates by patient sex in inguinal hernia repairs. Am J Surg 2024; 230:21-25. [PMID: 37914661 DOI: 10.1016/j.amjsurg.2023.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Guidelines recommend MIS repairs for females with inguinal hernias, despite limited evidence. We investigated rates of femoral hernias intraoperatively noted during MIS and Lichtenstein repairs in females. METHODS ACHQC was queried for adult females undergoing inguinal hernia repair between January 2014-November 2022. Outcomes included identified femoral hernia and size, hernia recurrence, quality of life, and sex-based recurrence. RESULTS 1357 and 316 females underwent MIS and Lichtenstein inguinal repair respectively. Femoral hernias were identified more frequently in MIS than open repairs (27%vs12%; (p < 0.001). Most femoral hernias in MIS (61%) and Lichtenstein repairs (62%) were <1.5 cm(p < 0.001). Identification rates of femoral hernias >3 cm were 1% overall(p = 0.09). Surgeon and patient-reported recurrences were similar between approaches at 1-5-years for females(p > 0.05 for all) and similar between sexes(p > 0.05). CONCLUSION Most incidental femoral hernias are small and both repair approaches demonstrated similar outcomes. The recommendation for MIS inguinal hernia repairs in females is potentially overstated.
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Affiliation(s)
- Sara M Maskal
- Cleveland Clinic, Department of Surgery, Cleveland, OH, USA.
| | - Ryan C Ellis
- Cleveland Clinic, Department of Surgery, Cleveland, OH, USA
| | | | - Nir Messer
- Cleveland Clinic, Department of Surgery, Cleveland, OH, USA
| | | | | | | | | | | | - Ajita S Prabhu
- Cleveland Clinic, Department of Surgery, Cleveland, OH, USA
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Essani V, Maskal SM, Ellis RC, Messer N, Tu C, Miller BT, Petro CC, Beffa LRA, Krpata DM, Prabhu AS, Rosen MJ. Analysis of retromuscular drain output and postoperative outcomes for heavyweight versus mediumweight polypropylene mesh following open ventral hernia repair. Hernia 2024; 28:637-642. [PMID: 38409571 PMCID: PMC10997680 DOI: 10.1007/s10029-024-02972-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/21/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE Heavyweight polypropylene (HWPP) mesh is thought to increase inflammatory response and delay tissue integration compared to mediumweight (MWPP). Reactive fluid volume (i.e., drain output) may be a reasonable surrogate for integration. We hypothesized that daily drain output is higher with HWPP compared to MWPP in open retromuscular ventral hernia repair (VHR). METHODS This is a post-hoc analysis of a multicenter, randomized clinical trial conducted March 2017-April 2019 comparing MWPP and HWPP for VHR. Retromuscular drain output in milliliters was measured at 24-h intervals up to postoperative day seven. Univariate analyses compared differences in daily drain output and time to drain removal. Multivariable analyses compared total drain output and wound morbidity within 30 days and hernia recurrence at 1 year. RESULTS 288 patients were included; 140 (48.6%) HWPP and 148 (51.4%) MWPP. Daily drain output for days 1-3 was higher for HWPP vs. MWPP (total volume: 837.8 mL vs. 656.5 mL) (p < 0.001), but similar on days 4-7 (p > 0.05). Median drain removal time was 5 days for both groups. Total drain output was not predictive of 30-day wound morbidity (p > 0.05) or hernia recurrence at 1 year (OR 1, p = 0.29). CONCLUSION While HWPP mesh initially had higher drain outputs, it rapidly returned to levels similar to MWPP by postoperative day three and there was no difference in clinical outcomes. We believe that drains placed around HWPP mesh can be managed similarly to MWPP mesh.
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Affiliation(s)
- V Essani
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - S M Maskal
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA.
| | - R C Ellis
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - N Messer
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - C Tu
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - B T Miller
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - L R A Beffa
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
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McLaughlin CM, Montelione KC, Tu C, Candela X, Pauli E, Prabhu AS, Krpata DM, Petro CC, Rosenblatt S, Rosen MJ, Horne CM. Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias. Hernia 2024; 28:507-516. [PMID: 38286880 DOI: 10.1007/s10029-023-02942-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/08/2023] [Indexed: 01/31/2024]
Abstract
PURPOSE Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias. METHODS Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS). RESULTS Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100). CONCLUSION ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.
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Affiliation(s)
- C M McLaughlin
- Department of General Surgery, Division of Plastic Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
| | - K C Montelione
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - X Candela
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Hershey, PA, USA
| | - E Pauli
- Department of General Surgery, Division of Minimally Invasive Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S Rosenblatt
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C M Horne
- Department of General Surgery, Division of Minimally Invasive Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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Messer N, Ellis RC, Maskal SM, Chang JH, Prabhu AS, Miller BT, Beffa LR, Petro CC, Mazzola Poli de Figueiredo S, Fafaj A, Essani V, Rosen MJ. Sequential surgeries following transversus abdominis release for abdominal wall reconstruction: Insights from a single-center analysis. Am J Surg 2024:S0002-9610(24)00176-4. [PMID: 38580567 DOI: 10.1016/j.amjsurg.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Abdominal surgery following transversus abdominis release (TAR) procedure commonly involves incisions through the previously implanted mesh, potentially creating vulnerabilities for hernia recurrence. Despite the popularity of the TAR procedure, current literature regarding post-AWR surgeries is limited. This study aims to reveal the incidence and outcomes of post-TAR non-hernia-related abdominal surgeries of any kind. METHODS Adult patients who underwent non-hernia-related abdominal surgery following ventral hernia repair with concurrent TAR procedure and permanent synthetic mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and January 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, and long-term hernia recurrence. RESULTS A total of 1137 patients who underwent TAR procedure were identified, with 53 patients (4.7%) undergoing subsequent non-hernia-related abdominal surgery post-TAR. Small bowel obstruction was the primary indication for reoperation (22.6%), and bowel resection was the most frequent procedure (24.5%). 49.1% of the patients required urgent or emergent surgery, with the majority (70%) having open procedures. Fascia closure was achieved by absorbable sutures in 50.9%, and of the open cases, fascia closure was achieved by running sutures technique in 35.8%. 20.8% experienced SSO, the SSOPI rate was 11.3%, and 26.4% required more than a single reoperation. A total of 88.7% were available for extended follow-up, spanning 17-30 months, resulting in a 36.1% recurrent hernia diagnosis rate. CONCLUSIONS Abdominal surgery following TAR surgery is associated with significant comorbidities and significantly impacts hernia recurrence rates. Our study findings underscore the significance of making all efforts to minimize reoperations after TAR procedure and offers suggestions on managing the abdominal wall of these complex cases.
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Affiliation(s)
- Nir Messer
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA; Department of Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel -Aviv University, Tel Aviv, Israel.
| | - Ryan C Ellis
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sara M Maskal
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jenny H Chang
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin T Miller
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lucas Ra Beffa
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Aldo Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Varisha Essani
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Maskal SM, Thomas JD, Miller BT, Fafaj A, Zolin SJ, Montelione K, Ellis RC, Prabhu AS, Krpata DM, Beffa LRA, Costanzo A, Zheng X, Rosenblatt S, Rosen MJ, Petro CC. Corrigendum to: Open retromuscular keyhole compared with Sugarbaker mesh for parastomal hernia repair: Early results of a randomized clinical trial '175(3):813-821.'. Surgery 2024:S0039-6060(24)00124-7. [PMID: 38503603 DOI: 10.1016/j.surg.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Affiliation(s)
- Sara M Maskal
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Aldo Fafaj
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Ryan C Ellis
- Cleveland Clinic, Department of Surgery, Cleveland, OH
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11
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Maskal SM, Thomas JD, Miller BT, Fafaj A, Zolin SJ, Montelione K, Ellis RC, Prabhu AS, Krpata DM, Beffa LRA, Costanzo A, Zheng X, Rosenblatt S, Rosen MJ, Petro CC. Open retromuscular keyhole compared with Sugarbaker mesh for parastomal hernia repair: Early results of a randomized clinical trial. Surgery 2024; 175:813-821. [PMID: 37770344 DOI: 10.1016/j.surg.2023.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/14/2023] [Accepted: 06/18/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days. METHODS This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications. RESULTS A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days. CONCLUSION Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio.
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Affiliation(s)
- Sara M Maskal
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Aldo Fafaj
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Ryan C Ellis
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | - Ajita S Prabhu
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/aprabhumd1
| | - David M Krpata
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/DKrpataMD
| | - Lucas R A Beffa
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/BeffaLukeMD
| | | | | | | | - Michael J Rosen
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/MikeRosen
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12
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Maskal SM, Melland-Smith M, Ellis RC, Huang LC, Ma J, Beffa LRA, Petro CC, Prabhu AS, Krpata DM, Rosen MJ, Miller BT. Tipping the scale in abdominal wall reconstruction: An analysis of short- and long-term outcomes by body mass index. Surgery 2024; 175:806-812. [PMID: 37741776 DOI: 10.1016/j.surg.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/27/2023] [Accepted: 07/08/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Morbid obesity, with a body mass index 35 kg/m2, is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short-term wound morbidity, its effect on long-term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long-term outcomes. METHODS Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90-day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, inflammatory bowel disease, mesh weight, and mesh-to-hernia size ratio. RESULTS A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14-1.77; P < .01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13-1.74; P < .01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P < .01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P = .01). Hernia recurrence rate at 1 year was lower for the body mass index ≥35 kg/m2 group (7% vs 12%; P = .02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02-1.74; P = .04) was associated with recurrence; body mass index was not (P = .11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year. CONCLUSION Morbid obesity is associated with 90-day wound morbidity; however, short-term complications did not translate to higher reoperation or long-term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m2 should not be used to deny symptomatic patients abdominal wall reconstruction.
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Affiliation(s)
- Sara M Maskal
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH.
| | | | - Ryan C Ellis
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH
| | | | - Jianing Ma
- Ohio State University College of Medicine, Columbus, OH
| | - Lucas R A Beffa
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH. https://twitter.com/beffalukemd
| | - Clayton C Petro
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH. https://twitter.com/ClaytonCharles
| | - Ajita S Prabhu
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH. https://twitter.com/aprabhumd1
| | - David M Krpata
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH. https://twitter.com/DKrpata
| | - Michael J Rosen
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH. https://twitter.com/MikeRosenMD
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Messer N, Melland MS, Miller BT, Krpata DM, Beffa LRA, Zheng X, Petro CC, Maskal SM, Ellis RC, Prabhu AS, Rosen MJ. Evaluating the impact of lifting mandatory smoking cessation prior to elective abdominal wall reconstruction. A single-center experience. Am J Surg 2024; 229:52-56. [PMID: 37833195 DOI: 10.1016/j.amjsurg.2023.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/05/2023] [Accepted: 09/11/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Many studies identify active smoking as a significant risk factor for postoperative wound and mesh complications in patients undergoing abdominal wall reconstruction surgery. However, our group conducted an analysis using data from the ACHQC database, which revealed similar rates of surgical site infection (SSI) and surgical site occurrence requiring procedural intervention (SSOPI) between active smokers and non-smokers As a result, the Cl eveland Clinic Center for Abdominal Core Health instituted a policy change where active smokers were no longer subject to surgical delay. Our study aims to evaluate the impact of active smoking on the outcomes of these patients. METHODS We identified active smoking patients who had undergone open, elective, clean ventral hernia repair (VHR) with transversus abdominis release (TAR) and permanent synthetic mesh at Cleveland Clinic Foundation. Propensity matching was performed to create a 1:3 ratio of "current-smokers" and "never-smokers" and compared wound complications and all 30-day morbidity between the two groups. RESULTS 106 current-smokers and 304 never-smokers were matched. Demographics were similar between the two groups after matching, with the exception of chronic obstructive pulmonary disease (COPD) (22.1% vs. 13.4%, p < .001) and body mass index (BMI) (31.1 vs. 32.6, p = .02). Rates of SSI (12.2% vs. 6.9%, p = .13), SSO (21.7% vs. 13.2%, p = .052), SSOPI (11.3% vs. 6.3%, p = .13), and reoperation (1.9% vs. 3.9%, p = .53) were not significantly different between active smokers and never-smokers correspondingly. One case (0.3%) of partial mesh excision was observed in the never-smokers group (p = 1). The current-smokers group exhibited a significantly higher incidence of pneumonia compared to the never-smokers group (5.7% vs. 0.7%, p = .005). CONCLUSION Our study revealed that operating on active smokers did result in a slight increase in wound morbidity, although it did not reach statistical significance. Additionally, pulmonary complications were higher in the smoking group. Notably, we did not see any mesh infections in the smoking group during early follow up. We believe that this data is important for shared decision making on patients that are actively smoking contemplating elective hernia repair.
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Affiliation(s)
- Nir Messer
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA; Department of Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel -Aviv University, Tel Aviv, Israel.
| | - Megan S Melland
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin T Miller
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lucas R A Beffa
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Xinyan Zheng
- The Abdominal Core Health Quality Collaborative, USA
| | - Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sara M Maskal
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ryan C Ellis
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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14
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Messer N, Prabhu AS, Miller BT, Krpata DM, Beffa LRA, Phillips SE, Petro CC, Maskal SM, Ellis RC, Figueiredo S, Fafaj A, Rosen MJ. Outcomes of complex abdominal wall reconstruction in patients with connective tissue disorders: a single center experience. Hernia 2024:10.1007/s10029-023-02957-y. [PMID: 38427113 DOI: 10.1007/s10029-023-02957-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/25/2023] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Individuals diagnosed with connective tissue disorders (CTD) are known to be predisposed to incisional hernia formation. However, there is a scarcity of data on outcomes for these patients undergoing hernia repair. We sought to describe our outcomes in performing abdominal wall reconstructions in these complex patients. METHODS Adult patients with CTD undergoing open, elective, posterior component separation with permanent synthetic mesh at our institution from January 2018 to October 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term hernia recurrence, and patient-reported quality of life. RESULTS Twelve patients were identified. Connective tissue disorders included Marfan's n = 7 (58.3%), Loeys-Dietz syndrome n = 2 (16.7%), Systemic Lupus Erythematosus n = 2 (16.7%), and Scleroderma n = 1 (8.3%). Prior incisions included three midline laparotomies and nine thoracoabdominal, mean hernia width measured 14 cm, and 9 were recurrent hernias. Surgical site occurrences (SSOs) were observed in 25% of cases, and 16.7% necessitated procedural intervention. All twelve patients were available for long-term follow-up, with a mean of 34 (12-62) months. There were no instances of reoperation or mesh excision related to the TAR procedure. One patient developed a recurrence after having his mesh violated for repair of a new visceral aneurysm. Mean HerQLes scores at 1 year were 70 and 89 at ≥ 2 years; Mean scaled PROMIS scores were 30.7 at 1 year and 36.3 at ≥ 2 years. CONCLUSION Ventral hernia repair with TAR is feasible in patients with connective tissue disorder and can be a suitable alternative in patients with large complex hernias.
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Affiliation(s)
- N Messer
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Department of Surgery, Sackler Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel-Aviv University, Tel Aviv, Israel.
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - B T Miller
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - L R A Beffa
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S E Phillips
- The Abdominal Core Health Quality Collaborative, Centennial, CO, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S M Maskal
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - R C Ellis
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S Figueiredo
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Fafaj
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
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Wehrle CJ, Prabhu AS, Thompson R, Petro CC, Miller BT, Krpata DM, Rosen MJ, Huang LC, Beffa LR. Mesh versus suture repair of incisional hernias 2 cm or less: Is mesh necessary? A propensity score-matched analysis of the abdominal core health quality collaborative. Surgery 2024; 175:799-805. [PMID: 37716868 DOI: 10.1016/j.surg.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/13/2023] [Accepted: 08/08/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Mesh has been the acceptable standard for incisional hernia repair regardless of hernia size. It is not clear whether there is a size of incisional hernias in whom repair would be best performed without mesh. This study aims to compare outcomes of mesh versus suture repairs for incisional hernias <2 cm in size. METHODS Incisional hernia repairs from 2012 to 2021 for hernias ≤2 cm in width were queried from the Abdominal Core Health Quality Collaborative. Those with 1-year follow up were considered. Hernia recurrence was defined using composite hernia recurrence, which combines both clinical and patient reported outcomes. Propensity score matching was performed between mesh and non-mesh using body mass index, smoking, diabetes, and drains as covariates. RESULTS A total of 352 patients met inclusion criteria. After propensity score matching, there were 132 repairs with mesh and 71 without. There was no difference in recurrence rates at 1 year between mesh and non-mesh repairs (15% vs 24%, P = .12). Mesh was associated with a higher rate of 30-day postoperative complications (11% vs 1%, P = .017). There were no differences in 1-year quality of life scores. CONCLUSION The repair of incisional hernias ≤2 cm without mesh results in similar recurrence rates, similar quality of life scores, and lower postoperative early complications compared with repairs with mesh. Our findings suggest that there may be select patients with small incisional hernias that could reasonably undergo incisional hernia repair without mesh. Longer-term follow-up is needed to confirm ideal candidates and durability of these repairs.
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Affiliation(s)
- Chase J Wehrle
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH.
| | - Ajita S Prabhu
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Reid Thompson
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Clayton C Petro
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Benjamin T Miller
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - David M Krpata
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Michael J Rosen
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Li-Ching Huang
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Lucas R Beffa
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH. https://twitter.com/BeffaLukeMD
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Maskal S, Foreman JM, Ellis RC, Phillips S, Messer N, Melland-Smith M, Beffa LRA, Petro CC, Prabhu AS, Rosen MJ, Miller BT. Cannabis smoking and abdominal wall reconstruction outcomes: a propensity score-matched analysis. Hernia 2024:10.1007/s10029-024-02976-3. [PMID: 38386125 DOI: 10.1007/s10029-024-02976-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/25/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE Despite increasing use of cannabis, literature on perioperative effects is lagging. We compared active cannabis-smokers versus non-smokers and postoperative wound morbidity and reoperations following open abdominal wall reconstruction (AWR). METHODS Patients who underwent open, clean, AWR with transversus abdominis release and retromuscular synthetic mesh placement at our institution between January 2014 and May 2022 were identified using the Abdominal Core Health Quality Collaborative database. Active cannabis-smokers were 1:3 propensity matched to non-smokers based on demographics and comorbidities. Wound complications, 30 day morbidity, pain (PROMIS 3a-Pain Intensity), and hernia-specific quality of life (HerQles) were compared. RESULTS Seventy-two cannabis-smokers were matched to 216 non-smokers. SSO (18% vs 17% p = 0.86), SSI (11.1% vs 9.3%, p = 0.65), SSOPI (12% vs 12%, p = 0.92), and all postoperative complications (46% vs 43%, p = 0.63) were similar between cannabis-smokers and non-smokers. Reoperations were more common in the cannabis-smoker group (8.3% vs 2.8%, p = 0.041), driven by major wound complications (6.9% vs 3.2%, p = 0.004). No mesh excisions occurred. HerQles scores were similar at baseline (22 [11, 41] vs 35 [14, 55], p = 0.06), and were worse for cannabis-smokers compared to non-smokers at 30 days (30 [12, 50] vs 38 [20, 67], p = 0.032), but not significantly different at 1 year postoperatively (72 [53, 90] vs 78 [57, 92], p = 0.39). Pain scores were worse for cannabis-smokers compared to non-smokers at 30 days postoperatively (52 [46, 58] vs 49 [44, 54], p = 0.01), but there were no differences at 6 months or 1 year postoperatively (p > 0.05 for all). CONCLUSION Cannabis smokers will likely experience similar complication rates after clean, open AWR, but should be counseled that despite similar wound complication rates, the severity of their wound complications may be greater than non-smokers.
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Affiliation(s)
- S Maskal
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA.
| | - J M Foreman
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - R C Ellis
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - S Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - N Messer
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - M Melland-Smith
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - L R A Beffa
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - C C Petro
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - A S Prabhu
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - M J Rosen
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - B T Miller
- General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
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Miller BT, Ellis R, Maskal SM, Petro CC, Krpata DM, Prabhu AS, Beffa LR, Tu C, Rosen MJ. Abdominal Wall Tension and Early Outcomes after Posterior Component Separation with Transversus Abdominis Release: Does a "Tension-Free" Closure Really Matter? J Am Coll Surg 2024:00019464-990000000-00918. [PMID: 38372372 DOI: 10.1097/xcs.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Ventral hernias result in fibrosis of the lateral abdominal wall muscles, increasing tension on fascial closure. Little is known about the effect of abdominal wall tension on outcomes after abdominal wall reconstruction. We aimed to identify an association between abdominal wall tension and early postoperative outcomes in patients who underwent posterior components separation (PCS) with transversus abdominis release (TAR). STUDY DESIGN Using a proprietary, sterilizable tensiometer, the tension needed to bring the anterior fascial elements to the midline of the abdominal wall during PCS with TAR were recorded. Tensiometer measurements, in pounds (lb), were calibrated by accounting for the acceleration of Earth's gravity. Baseline fascial tension, change in fascial tension, and fascial tension at closure were evaluated with respect to 30-day outcomes, including wound morbidity, hospital readmission, reoperation, ileus, bleeding, and pulmonary complications. RESULTS A total of 100 patients underwent bilateral abdominal wall tensiometry, for a total of 200 measurements (left and right side for each patient). Mean baseline anterior fascial tension was 6.78 lb (SD 4.55) on each side. At abdominal closure, the mean anterior fascial tension was 3.12 (SD 3.21) lb on each side. Baseline fascial tension and fascial tension after PCS with TAR at abdominal closure were not associated with surgical site infection, surgical site occurrence, readmission, ileus, and bleeding requiring transfusion. The event rates for all other complications were too infrequent for statistical analysis. CONCLUSION Baseline and residual fascial tension of the anterior abdominal wall do not correlate with early postoperative morbidity in patients undergoing PCS with TAR. Further work is needed to determine if abdominal wall tension in this context is associated with long-term outcomes, such as hernia recurrence.
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Affiliation(s)
- Benjamin T Miller
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ryan Ellis
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sara M Maskal
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C Petro
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M Krpata
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajita S Prabhu
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lucas Ra Beffa
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J Rosen
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
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Warren JA, Lucas C, Beffa LR, Petro CC, Prabhu AS, Krpata DM, Rosen MJ, Orenstein SB, Nikolian VC, Pauli EM, Horne CM, LaBelle M, Phillips S, Poulose BK, Carbonell AM. Reducing the incidence of surgical site infection after ventral hernia repair: Outcomes from the RINSE randomized control trial. Am J Surg 2024:S0002-9610(24)00006-0. [PMID: 38199871 DOI: 10.1016/j.amjsurg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND The clinical and financial impact of surgical site infection after ventral hernia repair is significant. Here we investigate the impact of dual antibiotic irrigation on SSI after VHR. METHODS This was a multicenter, prospective randomized control trial of open retromuscular VHR with mesh. Patients were randomized to gentamicin + clindamycin (G + C) (n = 125) vs saline (n = 125) irrigation at time of mesh placement. Primary outcome was 30-day SSI. RESULTS No significant difference was seen in SSI between control and antibiotic irrigation (9.91 vs 9.09 %; p = 0.836). No differences were seen in secondary outcomes: SSO (11.71 vs 13.64 %; p = 0.667); 90-day SSO (11.1 vs 13.9 %; p = 0.603); 90-day SSI (6.9 vs 3.8 %; p = 0.389); SSIPI (7.21 vs 7.27 %, p = 0.985); SSOPI (3.6 vs 3.64 %; p = 0.990); 30-day readmission (9.91 vs 6.36 %; p = 0.335); reoperation (5.41 vs 0.91 %; p = 0.056). CONCLUSION Dual antibiotic irrigation with G + C did not reduce the risk of surgical site infection during open retromuscular ventral hernia repair.
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Affiliation(s)
- Jeremy A Warren
- University of South Carolina School of Medicine Greenville and Prisma Health Upstate Department of Surgery, Greenville, SC, USA.
| | - Claiborne Lucas
- Prisma Health Upstate Department of Surgery, Greenville, SC, USA
| | | | | | | | | | | | | | | | - Eric M Pauli
- Penn State Health Milton S Hershey Medical Center Department of Surgery, Hershey, PA, USA
| | - Charlotte M Horne
- Penn State Health Milton S Hershey Medical Center Department of Surgery, Hershey, PA, USA
| | - Molly LaBelle
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | | | - Benjamin K Poulose
- The Ohio State University Wexner Department of Surgery and Center for Abdominal Core Health, Columbus, OH, USA
| | - Alfredo M Carbonell
- University of South Carolina School of Medicine Greenville and Prisma Health Upstate Department of Surgery, Greenville, SC, USA
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Miller BT, Ellis RC, Petro CC, Krpata DM, Prabhu AS, Beffa LRA, Huang LC, Tu C, Rosen MJ. Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release. JAMA Surg 2023; 158:1321-1326. [PMID: 37792324 PMCID: PMC10551814 DOI: 10.1001/jamasurg.2023.4847] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/16/2023] [Indexed: 10/05/2023]
Abstract
Importance Posterior components separation (PCS) is a commonly used myofascial release technique in ventral hernia repairs. The contribution of each release with anterior and posterior fascial advancement has not yet been characterized in patients with ventral hernias. Objective To quantitatively assess the changes in tension on the anterior and posterior fascial elements of the abdominal wall during PCS to inform surgeons regarding the technical contribution of each step with those changes, which may help to guide intraoperative decision-making. Design, Setting, and Participants This case series enrolled patients from December 2, 2021, to August 2, 2022, and was conducted at the Cleveland Clinic Center for Abdominal Core Health. The participants included adult patients with European Hernia Society classification M1 to M5 ventral hernias undergoing abdominal wall reconstruction with PCS. Intervention A proprietary, sterilizable tensiometer measured the force needed to bring the fascial edge of the abdominal wall to the midline after each step of a PCS (retrorectus dissection, division of the posterior lamella of the internal oblique aponeurosis, and transversus abdominis muscle release [TAR]). Main Outcome The primary study outcome was the percentage change in tension on the anterior and posterior fascia associated with each step of PCS with TAR. Results The study included 100 patients (median [IQR] age, 60 [54-68] years; 52 [52%] male). The median (IQR) hernia width was 13.0 (10.0-15.2) cm. After complete PCS, the mean (SD) percentage changes in tension on the anterior and posterior fascia were -53.27% (0.53%) and -98.47% (0.08%), respectively. Of the total change in anterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of -82.56% (0.68%), incision of the posterior lamella of the internal oblique with a change of -17.67% (0.41%), and TAR with no change. Of the total change in posterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of -3.04% (2.42%), incision of the posterior lamella of the internal oblique with a change of -58.78% (0.39%), and TAR with a change of -38.17% (0.39%). Conclusions and Relevance In this case series, retrorectus dissection but not TAR was associated with reduced tension on the anterior fascia, suggesting that it should be performed if anterior fascial advancement is needed. Dividing the posterior lamella of the internal oblique aponeurosis and TAR was associated with reduced tension on the posterior fascia, suggesting that it should be performed for posterior fascial advancement.
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Affiliation(s)
- Benjamin T. Miller
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ryan C. Ellis
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C. Petro
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajita S. Prabhu
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lucas R. A. Beffa
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J. Rosen
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
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20
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Maskal SM, Chang JH, Ellis RC, Phillips S, Melland-Smith M, Messer N, Beffa LRA, Petro CC, Prabhu AS, Rosen MJ, Miller BT. Distressed community index as a predictor of presentation and postoperative outcomes in ventral hernia repair. Am J Surg 2023; 226:580-585. [PMID: 37331908 DOI: 10.1016/j.amjsurg.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/26/2023] [Accepted: 06/10/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND We evaluated the impact of socioeconomic status on presentation, management, and outcomes of ventral hernias. METHODS The Abdominal Core Health Quality Collaborative was queried for adult patients undergoing ventral hernia repair. Socioeconomic quintiles were assigned using the Distressed Community Index (DCI): prosperous (0-20), comfortable (21-40), mid-tier (41-60), at-risk (61-80), and distressed (81-100). Outcomes included presenting symptoms, urgency, operative details, 30-day outcomes, and one-year hernia recurrence rates. Multivariable regression evaluated 30-day wound complications. RESULTS 39,494 subjects were identified; 32,471 had zip codes (82.2%).Urgent presentation (3.6% vs. 2.3%) and contaminated cases (0.83% vs. 2.06%) were more common in the distressed group compared to the prosperous group (p < 0.001). Higher DCI correlated with readmission (distressed: 4.7% vs prosperous: 2.9%,p < 0.001) and reoperation (distressed 1.8% vs prosperous: 0.92%,p < 0.001). Wound complications were independently associated with increasing DCI (p < 0.05). Clinical recurrence rates were similar at one-year (distressed: 10.4% vs prosperous: 8.6%, p = 0.54). CONCLUSIONS Inequity exists in presentation and perioperative outcomes for ventral hernia repair and efforts should be focused on increasing access to elective surgery and improving postoperative wound care.
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Affiliation(s)
| | | | - Ryan C Ellis
- Cleveland Clinic, General Surgery, Cleveland, USA
| | | | | | - Nir Messer
- Cleveland Clinic, General Surgery, Cleveland, USA
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21
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Chang JH, Maskal SM, Ellis RC, Prabhu AS, Rosen MJ, Walsh RM, Miller BT. Zooming to Net Zero: Using Virtual Visits to Decrease Carbon Emissions and Costs from Surgery. J Gastrointest Surg 2023; 27:2199-2201. [PMID: 37259016 PMCID: PMC10231850 DOI: 10.1007/s11605-023-05713-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/12/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Jenny H Chang
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave A100, Cleveland, OH, 44195, USA.
| | - Sara M Maskal
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave A100, Cleveland, OH, 44195, USA
| | - Ryan C Ellis
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave A100, Cleveland, OH, 44195, USA
| | - Ajita S Prabhu
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave A100, Cleveland, OH, 44195, USA
| | - Michael J Rosen
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave A100, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave A100, Cleveland, OH, 44195, USA
| | - Benjamin T Miller
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave A100, Cleveland, OH, 44195, USA
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Abstract
Despite the heavy reliance of surgeons on mesh with which to repair hernias, less attention is paid to the technical specifications of mesh and/or regulatory processes for bringing medical devices to market during surgical training. This article summarizes some of the key controversies and points regarding mesh materials and regulatory processes related to mesh devices.
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Affiliation(s)
- Ajita S Prabhu
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Crile A-100, Cleveland, OH 44195, USA.
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23
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Petro CC, Maskal SM, Renton DB, Yunis JP, Meara MP, Diaz K, Wilber M, McKenzie K, Tu C, Phillips SE, Miller BT, Beffa LR, Rosen MJ, Prabhu AS. Robotic Enhanced-View Totally Extraperitoneal vs Intraperitoneal Onlay Mesh Evaluation: 1-Year Exploratory Outcomes of the REVEAL Randomized Clinical Trial. J Am Coll Surg 2023; 237:614-620. [PMID: 37310015 DOI: 10.1097/xcs.0000000000000784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Patients with small- to medium-sized ventral hernias randomized to robotic enhanced-view totally extraperitoneal (eTEP) or robotic intraperitoneal onlay mesh (rIPOM) previously demonstrated comparable 30-day patient-reported outcomes. Here we report 1-year exploratory outcomes for this multi-center, patient-blinded randomized clinical trial. STUDY DESIGN Patients with midline ventral hernias 7 cm wide or less undergoing mesh repair were randomized to robotic eTEP or rIPOM. Planned exploratory outcomes at 1 year include pain intensity (using the Patient-Reported Outcomes Measurement Information System [PROMIS 3a]), Hernia-Related Quality of Life Survey (HerQLes) scores, pragmatic hernia recurrence, and reoperation. RESULTS One hundred randomized patients (51 eTEP, 49 rIPOM) reached a median 12-month follow-up (interquartile range 11 to 13) with 7% lost. After regression analysis adjusting for baseline scores, there was no difference in postoperative pain intensity at 1-year for eTEP compared with rIPOM (odds ratio [OR] 2.1 [95% CI 0.85 to 5.1]; p = 0.11). HerQLes scores were 15 points lower on average (ie less improved) at 1 year after eTEP repairs compared with rIPOM, a difference maintained after regression analysis (OR 0.31 [95% CI 0.15 to 0.67]; p = 0.003). Pragmatic hernia recurrence was 12.2% (6 of 49) for eTEP and 15.9% (7 of 44) for rIPOM (p = 0.834). In the first year, 2 eTEP and 1 rIPOM patients required reoperations related to their index repair (p = 0.82). CONCLUSIONS Exploratory analyses showed similar outcomes at 1 year in regard to pain, hernia recurrence, and reoperation. Abdominal wall quality of life at 1 year appears to favor rIPOM, and the possibility that an eTEP dissection is less advantageous in that regard should be the subject of future investigation.
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Affiliation(s)
- Clayton C Petro
- From the Department of Surgery, Center for Abdominal Core Health (Petro, Maskal, Miller, Beffa, Rosen, Prabhu), Cleveland Clinic Foundation, Cleveland, OH
| | - Sara M Maskal
- From the Department of Surgery, Center for Abdominal Core Health (Petro, Maskal, Miller, Beffa, Rosen, Prabhu), Cleveland Clinic Foundation, Cleveland, OH
| | - David B Renton
- Department of Surgery, Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH (Renton, Meara, Diaz)
| | - Jonathan P Yunis
- Center for Hernia Repair, Sarasota Memorial Hospital, Sarasota, FL (Yunis, Wilber, McKenzie)
| | - Michael P Meara
- Department of Surgery, Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH (Renton, Meara, Diaz)
| | - Kayla Diaz
- Department of Surgery, Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, OH (Renton, Meara, Diaz)
| | - Melanie Wilber
- Center for Hernia Repair, Sarasota Memorial Hospital, Sarasota, FL (Yunis, Wilber, McKenzie)
| | - Kristen McKenzie
- Center for Hernia Repair, Sarasota Memorial Hospital, Sarasota, FL (Yunis, Wilber, McKenzie)
| | - Chao Tu
- Department of Statistics (Tu), Cleveland Clinic Foundation, Cleveland, OH
| | - Sharon E Phillips
- the Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN (Phillips)
| | - Benjamin T Miller
- From the Department of Surgery, Center for Abdominal Core Health (Petro, Maskal, Miller, Beffa, Rosen, Prabhu), Cleveland Clinic Foundation, Cleveland, OH
| | - Lucas R Beffa
- From the Department of Surgery, Center for Abdominal Core Health (Petro, Maskal, Miller, Beffa, Rosen, Prabhu), Cleveland Clinic Foundation, Cleveland, OH
| | - Michael J Rosen
- From the Department of Surgery, Center for Abdominal Core Health (Petro, Maskal, Miller, Beffa, Rosen, Prabhu), Cleveland Clinic Foundation, Cleveland, OH
| | - Ajita S Prabhu
- From the Department of Surgery, Center for Abdominal Core Health (Petro, Maskal, Miller, Beffa, Rosen, Prabhu), Cleveland Clinic Foundation, Cleveland, OH
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Shukla P, Huang LC, Zhao A, Sharew B, Miller B, Beffa L, Petro CC, Krpata DM, Prabhu AS, Rosen MJ. Determining the Minimum Clinically Important Difference for the European Hernia Society Quality of Life Instrument in Inguinal Hernia Repair Patients. J Am Coll Surg 2023; 237:525-532. [PMID: 37171090 DOI: 10.1097/xcs.0000000000000754] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Patient-reported outcomes in clinical research allow for a more comprehensive and meaningful assessment of interventions but are subjective and difficult to interpret. European Registry for Abdominal Wall Hernias-Quality of Life (EuraHS-QoL) is a tool designed to assess perioperative quality of life for patients undergoing inguinal hernia repair, one of the most performed operations worldwide. Defining the minimum clinically important difference (MCID) for EuraHS-QoL tool can help standardize its interpretation for research purposes and facilitate improved shared decision making in clinical settings. STUDY DESIGN A combination of 3 approaches for estimating MCIDs was used in this study. First, 2 distribution-based approaches were used that based estimates on statistical parameters of the data. The SEM provided a minimum value for the MCID, and one-half of the SD provided a point estimate of the MCID. Second, anchor-based approaches integrated patient perceptions of their overall well-being before and after surgery to provide benchmarks for the MCID. Last, iterative surveys of expert hernia surgeons were used to yield the final MCIDs for each domain and the composite EuraHS-QoL score. RESULTS The overall range of EuraHS-QoL is 0 to 90, with subdomain ranges of 0 to 30 for the pain domain, 0 to 40 for the restriction of activities domain, and 0 to 20 for the cosmesis domain, with higher scores representing worse outcomes. The overall MCID for EuraHS-QoL is 10. Domain-specific MCIDs are 3 for the pain domain, 5 for the restriction of activities domain, and 2 for the cosmesis domain. CONCLUSIONS In this study, we define overall and domain-specific MCIDs for the EuraHS-QoL instrument using statistical methods, patient-based methods, and clinical expertise, providing estimates that are both statistically and clinically significant.
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Affiliation(s)
- Priya Shukla
- From the Cleveland Clinic Lerner College of Medicine, Cleveland, OH (Shukla, Zhao, Sharew)
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN (Huang)
| | - Alison Zhao
- From the Cleveland Clinic Lerner College of Medicine, Cleveland, OH (Shukla, Zhao, Sharew)
| | - Betemariam Sharew
- From the Cleveland Clinic Lerner College of Medicine, Cleveland, OH (Shukla, Zhao, Sharew)
| | - Ben Miller
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH (Miller, Beffa, Petro, Krpata, Prabhu, Rosen)
| | - Lucas Beffa
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH (Miller, Beffa, Petro, Krpata, Prabhu, Rosen)
| | - Clayton C Petro
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH (Miller, Beffa, Petro, Krpata, Prabhu, Rosen)
| | - David M Krpata
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH (Miller, Beffa, Petro, Krpata, Prabhu, Rosen)
| | - Ajita S Prabhu
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH (Miller, Beffa, Petro, Krpata, Prabhu, Rosen)
| | - Michael J Rosen
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH (Miller, Beffa, Petro, Krpata, Prabhu, Rosen)
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25
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Ellis RC, Petro CC, Krpata DM, Beffa LRA, Miller BT, Montelione KC, Maskal SM, Tu C, Huang LC, Lau B, Fafaj A, Rosenblatt S, Rosen MJ, Prabhu AS. Transfascial Fixation vs No Fixation for Open Retromuscular Ventral Hernia Repairs: A Randomized Clinical Trial. JAMA Surg 2023; 158:789-795. [PMID: 37342018 PMCID: PMC10285673 DOI: 10.1001/jamasurg.2023.1786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/21/2023] [Indexed: 06/22/2023]
Abstract
IMPORTANCE Transfascial (TF) mesh fixation in open retromuscular ventral hernia repair (RVHR) has been advocated to reduce hernia recurrence. However, TF sutures may cause increased pain, and, to date, the purported advantages have never been objectively measured. OBJECTIVE To determine whether abandonment of TF mesh fixation would result in a noninferior hernia recurrence rate at 1 year compared with TF mesh fixation in open RVHR. DESIGN, SETTING, AND PARTICIPANTS In this prospective, registry-based, double-blinded, noninferiority, parallel-group, randomized clinical trial, a total of 325 patients with a ventral hernia defect width of 20 cm or less with fascial closure were enrolled at a single center from November 29, 2019, to September 24, 2021. Follow-up was completed December 18, 2022. INTERVENTIONS Eligible patients were randomized to mesh fixation with percutaneous TF sutures or no mesh fixation with sham incisions. MAIN OUTCOME AND MEASURES The primary outcome was to determine whether no TF suture fixation was noninferior to TF suture fixation for open RVHR with regard to recurrence at 1 year. A 10% noninferior margin was set. The secondary outcomes were postoperative pain and quality of life. RESULTS A total of 325 adults (185 women [56.9%]; median age, 59 [IQR, 50-67] years) with similar baseline characteristics were randomized; 269 patients (82.8%) were followed up at 1 year. Median hernia width was similar in the TF fixation and no fixation groups (15.0 [IQR, 12.0-17.0] cm for both). Hernia recurrence rates at 1 year were similar between the groups (TF fixation, 12 of 162 [7.4%]; no fixation, 15 of 163 [9.2%]; P = .70). Recurrence-adjusted risk difference was found to be -0.02 (95% CI, -0.07 to 0.04). There were no differences in immediate postoperative pain or quality of life. CONCLUSIONS AND RELEVANCE The absence of TF suture fixation was noninferior to TF suture fixation for open RVHR with synthetic mesh. Transfascial fixation for open RVRH can be safely abandoned in this population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03938688.
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Affiliation(s)
- Ryan C. Ellis
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C. Petro
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lucas R. A. Beffa
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Benjamin T. Miller
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Katie C. Montelione
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sara M. Maskal
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Braden Lau
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Aldo Fafaj
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven Rosenblatt
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J. Rosen
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajita S. Prabhu
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
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26
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Blake KE, Perlmutter B, Saieed G, Said SA, Maskal SM, Petro CC, Krpata DM, Rosen MJ, Prabhu AS. The impact of comorbidities on postoperative outcomes of ventral hernia repair: the patients' perspective. Hernia 2023:10.1007/s10029-023-02826-8. [PMID: 37410195 DOI: 10.1007/s10029-023-02826-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/15/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among surgeons, the extent to which patients understand the significance of their co-morbidities is unknown, and a few studies have sought to determine patient perspectives regarding the impact of their modifiable co-morbidities on their post-operative outcomes. We attempted to determine how accurately patients predict their surgical outcomes after VHR compared to a surgical risk calculator while considering their modifiable co-morbidities. METHODS This is a prospective, single-center, survey-based study evaluating patients' perceptions of how their modifiable risk factors affect outcomes after elective ventral hernia repair. Pre-operatively, after surgeon counseling, patients predicted the percentage of impact that they believed their modifiable co-morbidities (diabetes, obesity, and smoking) had on 30-day surgical site infections (SSI) and hospital readmissions. Their predictions were compared to the Outcomes Reporting App for CLinicians and Patient Engagement (ORACLE) surgical risk calculator. Results were analyzed using demographic information. RESULTS 222 surveys were administered and 157 were included in the analysis after excluding for incomplete data. 21% had diabetes, 85% were either overweight with body mass index (BMI) 25-29.9 or obese (BMI ≥ 30), and 22% were smokers. The overall mean SSI rate was 10.8%, SSOPI rate was 12.7%, and 30-day readmission rate was 10.2%. ORACLE predictions correlated with observed SSI rates (OR 1.31, 95% CI 1.12-1.54, p < 0.001), but patient predictions did not (OR 1.00, 95% CI 0.98-1.03, p = 0.868). The correlation between patient predictions and ORACLE calculations was weak ([Formula: see text] = 0.17). Patient predictions were on average 10.1 ± 18.0% different than ORACLE, and 65% overestimated their SSI probability. Similarly, ORACLE predictions correlated with observed 30-day readmission rates (OR 1.10, 95% CI 1.00-1.21, p = 0.0459), but patient predictions did not (OR 1.00, 95% CI 0.975-1.03, p = 0.784). The correlation between patient predictions and ORACLE calculations for readmissions was weak ([Formula: see text] = 0.27). Patient predictions were on average 2.4 ± 14.6% different than ORACLE, and 56% underestimated their readmission probability. Additionally, a substantial proportion of the cohort believed that they had a 0% risk of SSI (28%) and a 0% risk of readmission (43%). Education, income and healthcare employment did not affect the accuracy of patient predictions. CONCLUSIONS Despite surgeon counseling, patients do not accurately estimate their risks after VHR when compared to ORACLE. Most patients overestimate their SSI risk and underestimate their 30-day readmission risk. Furthermore, several patients believed that they had a 0% risk of SSI and readmission. These findings persisted regardless of level of education, income level, or healthcare employment. Additional attention should be directed toward setting expectations prior to surgery and using applications such as ORACLE to assist in this process.
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Affiliation(s)
- K E Blake
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA.
- Department of General Surgery, University of Tennessee Medical Center, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
| | - B Perlmutter
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - G Saieed
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - S A Said
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - S M Maskal
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
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Kalekar T, Prabhu AS, Dilip D, Dolas A. A rare case of aorta-right atrial tunnel demonstrated on coronary computed tomography angiography. Afr J Thorac Crit Care Med 2023; 29:10.7196/AJTCCM.2023.v29i1.270. [PMID: 37476656 PMCID: PMC10354875 DOI: 10.7196/ajtccm.2023.v29i1.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Indexed: 07/22/2023] Open
Affiliation(s)
- T Kalekar
- Department of Radiodiagnosis, Dr D Y Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
| | - A S Prabhu
- Department of Radiodiagnosis, Dr D Y Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
| | - D Dilip
- Department of Radiodiagnosis, Dr D Y Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
| | - A Dolas
- Dr D Y Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
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Zolin SJ, Krpata DM, Petro CC, Prabhu AS, Rosenblatt S, Rosen S, Thompson R, Fafaj A, Thomas JD, Huang LC, Rosen MJ. Long-term Clinical and Patient-Reported Outcomes After Transversus Abdominis Release With Permanent Synthetic Mesh: A Single Center Analysis of 1203 Patients. Ann Surg 2023; 277:e900-e906. [PMID: 35793810 DOI: 10.1097/sla.0000000000005443] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to report long-term clinical and patient-reported outcomes of transversus abdominis release (TAR) with permanent synthetic mesh performed in a high-volume abdominal wall reconstruction practice. SUMMARY BACKGROUND DATA Despite increasing utilization of TAR in abdominal wall reconstruction, long-term clinical and patient-reported outcomes remain uncertain. METHODS Prospectively collected registry data from the Cleveland Clinic Center for Abdominal Core Health were analyzed retrospectively. Patients undergoing elective, open VHR with TAR and permanent synthetic mesh implantation between August 2014 and March 2020 with 30-day clinical and ≥1 year clinical or patient-reported outcome follow-up were included. Outcomes included composite hernia recurrence, characterized by patient-reported bulges and recurrent hernias noted on physical exam or imaging, as well as hernia-specific quality of life and pain. RESULTS A total of 1203 patients were included. Median age was 60 years [interquartile range (IQR): 52-67], median body mass index was 32 kg/m 2 (IQR: 28-36), median hernia width was 15 cm (IQR: 12-19), and 57% of hernias were recurrent. Fascial reapproximation was achieved in 92%. At a median follow-up of 2 years (IQR: 1-4), the overall composite hernia recurrence rate was 26%, with sensitivity analysis yielding best-case and worst-case estimates of 5% and 28%, respectively. Patients experienced improved hernia-specific quality of life and pain regardless of recurrence outcome; however, those who did not recur experienced more substantial improvement. CONCLUSIONS TAR with permanent synthetic mesh remains a valuable, versatile technique; however, surgeon and patient expectations should be tempered regarding long-term durability. Despite a high rate of recurrence, patients experience measurable improvements in quality of life.
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Affiliation(s)
- Samuel J Zolin
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - David M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Steven Rosenblatt
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Samantha Rosen
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Reid Thompson
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Aldo Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Jonah D Thomas
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
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Miller BT, Scheman J, Petro CC, Beffa LRA, Prabhu AS, Rosen MJ, Krpata DM. Psychological disorders in patients with chronic postoperative inguinal pain. Hernia 2023; 27:35-40. [PMID: 35960385 DOI: 10.1007/s10029-022-02662-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/30/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Chronic postoperative inguinal pain (CPIP), a complication of inguinal hernia repair, may negatively affect mental health. The rates of psychological disorders in patients with CPIP are unknown. We aimed to describe the prevalence of psychological disorders coinciding with CPIP. METHODS A retrospective chart review was performed of all patients seen at the Cleveland Clinic Center for Abdominal Core Health's inter-disciplinary Chronic Groin Pain Clinic. This clinic is unique in that all patients are evaluated by a surgeon, a sonographer and radiologist, and a behavioral medicine psychologist. Patient psychological history and treatment, Depression Anxiety and Stress Scale (DASS) scores, pain catastrophizing, and trauma or abuse history were captured. RESULTS From January 2018 to January 2022, 61 patients were evaluated and included in the study. Psychological treatment had been provided to 37 (61%) patients (present: 16 (27%), past: 21 (35%)). The most common psychological disorders represented were depression (N = 13, 22%), anxiety (N = 10, 17%), and post-traumatic stress disorder (N = 5, 8%). DASS scores indicated that 20 (33%) patients were reporting symptoms of depression and 16 (27%) patients were reporting symptoms of anxiety. Of the 40 patients assessed for pain catastrophizing, 28 (70%) reported rumination, 9 (23%) reported magnification, and 23 (58%) reported feelings of helplessness. A childhood history of emotional or physical abuse was reported by 11 (18%) patients. CONCLUSION An inter-disciplinary groin pain clinic has revealed that patients with CPIP frequently have pre-existing complex psychosocial issues. A multi-specialty approach to CPIP may improve preoperative assessments and identify patients who may benefit from further psychological evaluation and treatment.
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Affiliation(s)
- B T Miller
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - J Scheman
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C C Petro
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - L R A Beffa
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - M J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - D M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Fafaj A, Lo Menzo E, Alaedeen D, Petro CC, Rosenblatt S, Szomstein S, Massier C, Prabhu AS, Krpata DM, Cha W, Montelione K, Tastaldi L, Alkhatib H, Zolin SJ, Okida LF, Rosen MJ. Effect of Intraoperative Urinary Catheter Use on Postoperative Urinary Retention After Laparoscopic Inguinal Hernia Repair: A Randomized Clinical Trial. JAMA Surg 2022; 157:667-674. [PMID: 35704302 PMCID: PMC9201739 DOI: 10.1001/jamasurg.2022.2205] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Urinary catheters are commonly placed during laparoscopic inguinal hernia repair as a presumed protection against postoperative urinary retention (PUR), one of the most common complications following this operation. Data from randomized clinical trials evaluating the effect of catheters on PUR are lacking. Objective To investigate the effect of intraoperative catheters on PUR after laparoscopic inguinal hernia repair. Design, Setting, and Participants This 2-arm registry-based single-blinded randomized clinical trial was conducted at 6 academic and community hospitals in the US from March 2019 to March 2021 with a 30-day follow-up period following surgery. All patients who presented with inguinal hernias were assessed for eligibility, 534 in total. Inclusion criteria were adult patients undergoing laparoscopic, elective, unilateral, or bilateral inguinal hernia repair. Exclusion criteria were inability to tolerate general anesthesia and failure to understand and sign the written consent form. A total of 43 patients were excluded prior to intervention. Interventions Patients in the treatment arm had placement of a urinary catheter after induction of general anesthesia and removal at the end of procedure. Those in the control arm had no urinary catheter placement. Main Outcomes and Measures PUR rate. Results Of the 491 patients enrolled, 241 were randomized to catheter placement, and 250 were randomized to no catheter placement. The median (IQR) age was 61 (51-68) years, and 465 participants (94.7%) were male. Overall, 44 patients (9.1%) developed PUR. There was no difference in the rate of PUR between the catheter and no-catheter groups (23 patients [9.6%] vs 21 patients [8.5%], respectively; P = .79). There were no intraoperative bladder injuries. In the catheter group, there was 1 incident of postoperative urethral trauma in a patient who presented to the emergency department with PUR leading to a suprapubic catheter placement. Conclusions and Relevance Intraoperative urinary catheters did not reduce the risk of PUR after laparoscopic inguinal hernia repair. While their use did not appear to be associated with a high rate of iatrogenic complications, there may be a low rate of catastrophic complications. In patients who voided urine preoperatively, catheter placement did not appear to confer any advantage and thus their use may be reconsidered. Trial Registration ClinicalTrials.gov Identifier: NCT03835351.
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Affiliation(s)
- Aldo Fafaj
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Emanuele Lo Menzo
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston Hospital, Weston
| | - Diya Alaedeen
- Department of General Surgery, Fairview Hospital, Cleveland, Ohio
| | - Clayton C. Petro
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven Rosenblatt
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samuel Szomstein
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston Hospital, Weston
| | - Christian Massier
- Department of General Surgery, Marymount Hospital, Garfield Heights, Ohio
| | - Ajita S. Prabhu
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Walter Cha
- Department of General Surgery, Hillcrest Hospital, Mayfield Heights, Ohio
| | - Katherine Montelione
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Luciano Tastaldi
- Department of General Surgery, University of Texas Medical Branch, Galveston
| | - Hemasat Alkhatib
- Department of General Surgery, MetroHealth System, Cleveland, Ohio
| | - Samuel J. Zolin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Luis Felipe Okida
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston Hospital, Weston
| | - Michael J. Rosen
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Center for Abdominal Core Health, The Cleveland Clinic Foundation, Cleveland, Ohio
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Blake KE, Zolin SJ, Tu C, Baier KF, Beffa LR, Alaedeen D, Krpata DM, Prabhu AS, Rosen MJ, Petro CC. Comparing anterior gastropexy to no anterior gastropexy for paraesophageal hernia repair: a study protocol for a randomized control trial. Trials 2022; 23:616. [PMID: 35907909 PMCID: PMC9338471 DOI: 10.1186/s13063-022-06571-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND More than half of patients undergoing paraesophageal hernia repair (PEHR) will have radiographic hernia recurrence at 5 years after surgery. Gastropexy is a relatively low-risk intervention that may decrease recurrence rates, but it has not been studied in a prospective manner. Our study aims to evaluate the effect of anterior gastropexy on recurrence rates after PEHR, compared to no anterior gastropexy. METHODS This is a two-armed, single-blinded, registry-based, randomized controlled trial comparing anterior gastropexy to no anterior gastropexy in PEHR. Adult patients (≥18 years) with a symptomatic paraesophageal hernia measuring at least 5 cm in height on computed tomography, upper gastrointestinal series, or endoscopy undergoing elective minimally invasive repair are eligible for recruitment. Patients will be blinded to their arm of the trial. All patients will undergo laparoscopic or robotic PEHR, where some operative techniques (crural closure techniques and fundoplication use or avoidance) are left to the discretion of the operating surgeon. During the operation, after closure of the diaphragmatic crura, participants are randomized to receive either no anterior gastropexy (control arm) or anterior gastropexy (treatment arm). Two hundred forty participants will be recruited and followed for 1 year after surgery. The primary outcome is radiographic PEH recurrence at 1 year. Secondary outcomes are symptoms of gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular, and pulmonary symptoms as well as patient satisfaction in the immediate postoperative period and at 1-year follow-up. Outcome assessors will be blinded to the patients' intervention. DISCUSSION This randomized controlled trial will examine the effect of anterior gastropexy on radiographic PEH recurrence and patient-reported outcomes. Anterior gastropexy has a theoretical benefit of decreasing PEH recurrence; however, this has not been proven beyond a suggestion of effectiveness in retrospective series. If anterior gastropexy reduces recurrence rates, it would likely become a routine component of surgical PEH management. If it does not reduce PEH recurrence, it will likely be abandoned. TRIAL REGISTRATION ClinicalTrials.gov NCT04007952 . Registered on July 5, 2019.
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Affiliation(s)
- K E Blake
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA.
| | - S J Zolin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - C Tu
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - K F Baier
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - L R Beffa
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - D Alaedeen
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - A S Prabhu
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - M J Rosen
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
| | - C C Petro
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-133, Cleveland, OH, 44195, USA
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Miller BT, Fafaj A, Tastaldi L, Alkhatib H, Zolin S, AlMarzooqi R, Tu C, Alaedeen D, Prabhu AS, Krpata DM, Rosen MJ, Petro CC. Capturing Surgical Data: Comparing a Quality Improvement Registry to Natural Language Processing and Manual Chart Review. J Gastrointest Surg 2022; 26:1490-1494. [PMID: 35229252 DOI: 10.1007/s11605-022-05282-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/19/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Collecting accurate operative details remains a limitation of surgical research. Surgeon-entered data in clinical registries offers one solution, but natural language processing (NLP) has emerged as a modality for automating manual chart review (MCR). This study aims to compare the accuracy and efficiency of NLP and MCR with a surgeon-entered, prospective registry data in determining the rate of gross bile spillage (GBS) during cholecystectomy. METHODS Bile spillage rates were abstracted from an institutional, surgeon-entered clinical registry from July 2018 to January 2019. These rates were compared to those documented in the electronic medical record (EMR) using NLP and MCR to determine the sensitivity, specificity, and efficiency of each approach. RESULTS Of the 782 registry entries, 191 cases (24.4%) had surgeon-reported bile spillage. MCR identified bile spillage in 121 cases (15.6%); however, bile spillage information was either missing or ambiguous in 454 cases (58.1%). NLP identified 99 cases (12.7%) of bile spillage. Data abstraction times for the registry, NLP, and MCR were 3 min, 5 min, and 12 h, respectively. When compared to the registry, MCR was 45% sensitive and 94% specific, while NLP was 27.2% sensitive and 92% specific for detecting bile spillage. These differences were significant (X2 = 19.446, P = < 0.001). CONCLUSION Operative details, such as GBS, may not be abstracted by NLP or MCR if not clearly documented in the EMR. Clinical registries capture operative details, but they rely on surgeons to input the data.
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Affiliation(s)
- Benjamin T Miller
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
| | - Aldo Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - Luciano Tastaldi
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - Hemasat Alkhatib
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - Samuel Zolin
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - Raha AlMarzooqi
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Diya Alaedeen
- Department of General Surgery, Digestive Disease and Surgery Institute, Fairview Hospital, The Cleveland Clinic Foundation, 18101 Lorain Avenue, Cleveland, OH, 44111, USA
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - David M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
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Rosen MJ, Petro C, Prabhu AS. Comment on Use of Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias-Reply. JAMA Surg 2022; 157:854-855. [PMID: 35583878 DOI: 10.1001/jamasurg.2022.1553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Miller BT, Thomas JD, Tu C, Costanzo A, Beffa LRA, Krpata DM, Prabhu AS, Rosen MJ, Petro CC. Comparing Sugarbaker versus keyhole mesh technique for open retromuscular parastomal hernia repair: study protocol for a registry-based randomized controlled trial. Trials 2022; 23:251. [PMID: 35379311 PMCID: PMC8978433 DOI: 10.1186/s13063-022-06207-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/26/2022] [Indexed: 12/04/2022] Open
Abstract
Background Parastomal hernia, common after stoma creation, negatively impacts patient quality of life. For patients with a permanent stoma, durable parastomal hernia repair remains a challenge, with few high-quality studies for guidance. An alternative to open retromuscular parastomal hernia repair with retromuscular “keyhole” mesh is the recent Sugarbaker modification. We aim to compare these two techniques in a head-to-head prospective study. Methods This is a registry-based randomized controlled trial designed to investigate whether the retromuscular Sugarbaker technique is superior to the retromuscular keyhole technique for parastomal hernia repair. The primary study endpoint is parastomal hernia recurrence at 2 years. Secondary endpoints include hospital length-of-stay, readmission, wound morbidity, mesh-related complications, re-operation, all 30-day morbidity, and patient-reported outcomes, including hernia-related quality of life, stoma-specific quality of life, pain, and decision regret. Discussion Based on the post hoc analysis of a recent randomized controlled trial, we hypothesize that the retromuscular Sugarbaker technique will reduce parastomal hernia recurrence by 20% at 2 years compared to the retromuscular keyhole mesh technique. The results of this study may provide evidence-based guidance for surgeons repairing parastomal hernias. Trial registration ClinicalTrials.gov NCT03972553. Registered on 3 June 2019
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Rosen MJ, Krpata DM, Petro CC, Carbonell A, Warren J, Poulose BK, Costanzo A, Tu C, Blatnik J, Prabhu AS. Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial. JAMA Surg 2022; 157:293-301. [PMID: 35044431 PMCID: PMC8771431 DOI: 10.1001/jamasurg.2021.6902] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Biologic mesh is widely used for reinforcing contaminated ventral hernia repairs; however, it is expensive and has been associated with high rates of long-term hernia recurrence. Synthetic mesh is a lower-cost alternative but its efficacy has not been rigorously studied in individuals with contaminated hernias. OBJECTIVE To determine whether synthetic mesh results in superior reduction in risk of hernia recurrence compared with biologic mesh during the single-stage repair of clean-contaminated and contaminated ventral hernias. DESIGN, SETTING, AND PARTICIPANTS This multicenter, single-blinded randomized clinical trial was conducted from December 2012 to April 2019 with a follow-up duration of 2 years. The trial was completed at 5 academic medical centers in the US with specialized units for abdominal wall reconstruction. A total of 253 adult patients with clean-contaminated or contaminated ventral hernias were enrolled in this trial. Follow-up was completed in April 2021. INTERVENTIONS Retromuscular synthetic or biologic mesh at the time of fascial closure. MAIN OUTCOMES AND MEASURES The primary outcome was the superiority of synthetic mesh vs biologic mesh at reducing risk of hernia recurrence at 2 years based on intent-to-treat analysis. Secondary outcomes included mesh safety, defined as the rate of surgical site occurrence requiring a procedural intervention, and 30-day hospital direct costs and prosthetic costs. RESULTS A total of 253 patients (median [IQR] age, 64 [55-70] years; 117 [46%] male) were randomized (126 to synthetic mesh and 127 to biologic mesh) and the follow-up rate was 92% at 2 years. Compared with biologic mesh, synthetic mesh significantly reduced the risk of hernia recurrence (hazard ratio, 0.31; 95% CI, 0.23-0.42; P < .001). The overall intent-to-treat hernia recurrence risk at 2 years was 13% (33 of 253 patients). Recurrence risk with biologic mesh was 20.5% (26 of 127 patients) and with synthetic mesh was 5.6% (7 of 126 patients), with an absolute risk reduction of 14.9% with the use of synthetic mesh (95% CI, -23.8% to -6.1%; P = .001). There was no significant difference in overall 2-year risk of surgical site occurrence requiring a procedural intervention between the groups (odds ratio, 1.22; 95% CI, 0.60-2.44; P = .58). Median (IQR) 30-day hospital direct costs were significantly greater in the biologic group vs the synthetic group ($44 936 [$35 877-$52 656] vs $17 289 [$14 643-$22 901], respectively; P < .001). There was also a significant difference in the price of the prosthetic device between the 2 groups (median [IQR] cost biologic, $21 539 [$20 285-$23 332] vs synthetic, $105 [$105-$118]; P < .001). CONCLUSIONS AND RELEVANCE Synthetic mesh demonstrated superior 2-year hernia recurrence risk compared with biologic mesh in patients undergoing single-stage repair of contaminated ventral hernias, and both meshes demonstrated similar safety profiles. The price of biologic mesh was over 200 times that of synthetic mesh for these outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02451176.
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Affiliation(s)
- Michael J. Rosen
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C. Petro
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alfredo Carbonell
- Department of Surgery, Prisma Health Upstate, Greenville, South Carolina
| | - Jeremy Warren
- Department of Surgery, Prisma Health Upstate, Greenville, South Carolina
| | - Benjamin K. Poulose
- Department of Surgery, Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus
| | - Adele Costanzo
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeffrey Blatnik
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ajita S. Prabhu
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
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Han AY, French JC, Tu C, Obiri-Yeboah D, Lipman JM, Prabhu AS. Don't Judge a Letter by its Title: Linguistic Analysis of Letters of Recommendation by Author's Academic Rank. J Surg Educ 2021; 78:e19-e27. [PMID: 34011478 DOI: 10.1016/j.jsurg.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This study analyzed the linguistic differences in letters of recommendation (LORs) for general surgery residency applicants written by authors of various academic ranks. Given that many general surgery residency programs require a LOR from the Chair of surgery, this study also examined whether LORs written by the Chair demonstrate linguistic differences to support this practice. DESIGN A single institution, retrospective review analyzed LORs from two application cycles of general surgery residency applicants who were selected for interview at a large academic institution. Word count (WC) and linguistic characteristics of LORs were analyzed with a previously developed institution-specific dictionary using the Linguistic Inquiry and Word Count software (LIWC2015; Pennebaker Conglomerates, Inc., Austin, Texas). WC and linguistic characteristics of LORs reported as frequencies of terms within twenty-four categories were examined based on the letter authors' academic rank. Further examination compared LORs written by a Chair of surgery with those written by non-Chairs. SETTING A single large, Midwestern academic general surgery residency program PARTICIPANTS: Four hundred and sixty-five letters of recommendation received during two interview cycles were included for analysis. RESULTS A total of 465 LORs written by assistant (n = 82), associate (n = 94), and full professors (n = 289) were included in the study. No statistically significant difference was noted in the WC of LORs based on the letter writers' academic ranks (p = 0.95). Assistant professors utilized grindstone, communal, and technical skill terms with higher frequencies compared to associate professors and full professors. LORs written by assistant professors demonstrated the highest authentic variable score followed by associate professors then full professors (4.94, 3.92, 3.28, p < 0.01). LORs written by Chairs (n = 128) had lower authentic variable scores compared to LORs written by non-Chairs (n = 337; 2.71 vs. 3.91, p = 0.001). Only 50 (39%) LORs written by Chairs indicated working directly with the applicant, and sub-group analysis demonstrated a higher authentic variable score in this group compared with LORs written by Chairs who did not indicate having worked directly with the applicant (3.51 vs. 2.5, p = 0.01). CONCLUSIONS Linguistic analysis of LORs for general surgery residency applicants demonstrated minor yet statistically significant differences based on the author's academic rank. If applicants can obtain linguistically similar LORs from surgeons of any academic rank, but less authentic LORs from writers with higher academic ranks, these LORs may be less valuable for the residency programs when evaluating applicants. Based on the subgroup analysis, less than 40% of Chair LORs indicated that the Chair worked directly with the applicant, calling into question the utility of the Chair LORs as meaningful evaluation of applicants. Further study to compare LORs of applicants selected and not selected for interview may add additional insight into linguistic differences in LORs written by authors of different academic ranks.
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Affiliation(s)
- Amy Y Han
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
| | - Judith C French
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Chao Tu
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Derrick Obiri-Yeboah
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Jeremy M Lipman
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Ajita S Prabhu
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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Zolin SJ, Krpata DM, Petro CC, Prabhu AS, Rosen SH, Thompson RD, Fafaj A, Thomas JD, Huang LC, Rosen MJ. No Winning in the Battle of the Bulge: Hernia Recurrence after Abdominal Wall Reconstruction. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Thomas JD, Petro CC, Montelione KC, Zolin SJ, Krpata DM, Tu C, Rosen MJ, Prabhu AS. Laparoscopic vs Robotic Ventral Hernia Repair: 1-Year Postoperative Outcomes from the PROVE-IT Trial. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Krpata DM, Petro CC, Prabhu AS, Tastaldi L, Zolin S, Fafaj A, Rosenblatt S, Poulose BK, Pierce RA, Warren JA, Carbonell AM, Goldblatt MI, Stewart TG, Olson MA, Rosen MJ. Effect of Hernia Mesh Weights on Postoperative Patient-Related and Clinical Outcomes After Open Ventral Hernia Repair: A Randomized Clinical Trial. JAMA Surg 2021; 156:1085-1092. [PMID: 34524395 DOI: 10.1001/jamasurg.2021.4309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although multiple versions of polypropylene mesh devices are currently available on the market for hernia repair, few comparisons exist to guide surgeons as to which device may be preferable for certain indications. Mesh density is believed to impact patient outcomes, including rates of chronic pain and perception of mesh in the abdominal wall. Objective To examine whether medium-weight polypropylene is associated with less pain at 1 year compared with heavy-weight mesh. Design, Setting, and Participants This multicenter randomized clinical trial was performed from March 14, 2017, to April 17, 2019, with 1-year follow-up. Patients undergoing clean, open ventral hernia repairs with a width 20 cm or less were studied. Patients were blinded to the intervention. Interventions Patients were randomized to receive medium-weight or heavy-weight polypropylene mesh during open ventral hernia repair. Main Outcomes and Measures The primary outcome was pain measured with the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity Short Form 3a. Secondary outcomes included quality of life and pain measured at 30 days, quality of life measured at 1 year, 30-day postoperative morbidity, and 1-year hernia recurrence. Results A total of 350 patients participated in the study, with 173 randomized to receive heavy-weight polypropylene mesh (84 [48.6%] female; mean [SD] age, 59.2 [11.4] years) and 177 randomized to receive medium-weight polypropylene mesh (91 [51.4%] female; mean [SD] age, 59.3 [11.4] years). No significant differences were found in demographic characteristics (mean [SD] body mass index of 32.0 [5.4] in both groups [calculated as weight in kilograms divided by height in meters squared] and American Society of Anesthesiologists classes of 2-4 in both groups), comorbidities (122 [70.5%] vs 93 [52.5%] with hypertension, 44 [25.4%] vs 43 [24.3%] with diabetes, 17 [9.8%] vs 12 [6.8%] with chronic obstructive pulmonary disease), or operative characteristics (modified hernia grade of 2 in 130 [75.1] vs 140 [79.1] in the heavy-weight vs medium-weight mesh groups). Pain scores for patients in the heavy-weight vs medium-weight mesh groups at 30 days (46.3 vs 46.3, P = .89) and 1 year (30.7 vs 30.7, P = .59) were identical. No significant differences in quality of life (median [interquartile range] hernia-specific quality of life score at 1 year of 90.0 [67.9-96.7] vs 86.7 [65.0-93.3]; median [interquartile range] hernia-specific quality of life score at 30 days, 45.0 [24.6-73.8] vs 43.3 [28.3-65.0]) were found for the heavy-weight mesh vs medium-weight mesh groups. Composite 1-year recurrence rates for patients in the heavy-weight vs medium-weight polypropylene groups were similar (8% vs 7%, P = .79). Conclusions and Relevance Medium-weight polypropylene did not demonstrate any patient-perceived or clinical benefit over heavy-weight polypropylene after open retromuscular ventral hernia repair. Long-term follow-up of these comparable groups will elucidate any potential differences in durability that have yet to be identified. Trial Registration ClinicalTrials.gov Identifier: NCT03082391.
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Affiliation(s)
- David M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Luciano Tastaldi
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sam Zolin
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Aldo Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven Rosenblatt
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Richard A Pierce
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Jeremy A Warren
- Department of Surgery, University of South Carolina School of Medicine, Greenville.,Department of Surgery, Prisma Health, Greenville, South Carolina
| | - Alfredo M Carbonell
- Department of Surgery, University of South Carolina School of Medicine, Greenville.,Department of Surgery, Prisma Health, Greenville, South Carolina
| | | | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Molly A Olson
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
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Perlmutter BC, Alkhatib H, Lightner AL, Fafaj A, Zolin SJ, Petro CC, Krpata DM, Prabhu AS, Holubar SD, Rosen MJ. Short-term outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease. Hernia 2021; 25:1557-1564. [PMID: 34342743 DOI: 10.1007/s10029-021-02476-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/16/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE While the use of synthetic mesh for incisional hernia repair reduces recurrence rates, little evidence exists regarding the impact of this practice on the disease burden of a Crohn's patient. We aimed to describe the post-operative outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease. METHODS A retrospective review of adult patients with Crohn's disease who underwent elective open incisional hernia repair with extra-peritoneal synthetic mesh from 2014 to 2018 at a single large academic hospital with surgeons specializing in hernia repair was conducted. Primary outcomes included 30-day post-operative complications and long-term rates of fistula formation and hernia recurrence. The secondary outcome compared healthcare resource utilization during a standardized fourteen-month period before and after hernia repair. RESULTS Among the 40 patients included, six (15%) required readmission, 4 (10%) developed a surgical site occurrence, 3 (7.5%) developed a surgical site infection, and one (2.5%) required reoperation within the first 30 days. The overall median follow-up time was 42 months (IQR = 33-56), during which time one (2.5%) patient developed an enterocutaneous fistula and eight (20%) experienced hernia recurrence. Healthcare resource utilization remained unchanged or decreased across every category following repair. CONCLUSION The use of extra-peritoneal synthetic mesh during incisional hernia repair in patients with Crohn's disease was not associated with a prohibitively high rate of post-operative complications or an increase in healthcare resource utilization to suggest worsening disease during the first 4 years after repair. Future studies exploring the long-term outcomes of this technique are needed.
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Affiliation(s)
- B C Perlmutter
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - H Alkhatib
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - A L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - A Fafaj
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - S J Zolin
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - S D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA.
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
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Thomas JD, Fafaj A, Zolin SJ, Rosen MJ, Lipman JM, French JC, Prabhu AS, Krpata DM, Rosenblatt S, Horne CM, Khandelwal C, Petro CC. Registry-based Trainee Assessments: Leveraging a Quality Collaborative for Surgical Education. J Surg Res 2021; 268:136-144. [PMID: 34311295 DOI: 10.1016/j.jss.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We present our experience developing and embedding a registry-based module for resident feedback. METHODS At our institution, entering operative data into the institutional quality collaborative registry is standard practice. In February 2019, a surgical education module was embedded into the registry to capture procedure-specific resident operative assessments. Faculty engagement with the sugical education module was assessed during its first year in existence (February 2019-February 2020). RESULTS In total, 1074 of 1269 (85%) operative assessments were completed by 27 faculty via the surgical education registry module. Median faculty engagement rate with the module following resident-assisted procedures was 91% [IQR 76%-100%]. Residents received a median of 7 operative assessments [IQR 2-19] over the study period. CONCLUSION By embedding a surgical education module into an existing surgical quality collaborative registry, procedure-specific operative assessments can be routinely captured.
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Affiliation(s)
- Jonah D Thomas
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Aldo Fafaj
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samuel J Zolin
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J Rosen
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeremy M Lipman
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Judith C French
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajita S Prabhu
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M Krpata
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven Rosenblatt
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Charlotte M Horne
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Cathleen Khandelwal
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C Petro
- Department of General Surgery, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, Ohio.
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Prabhu AS. Response to the Paradox of Exceptionalism: Setting Priorities Straight. Surg Innov 2021; 28:796. [PMID: 33980100 DOI: 10.1177/15533506211018434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Horne CM, Augenstein V, Malcher F, Yunis J, Huang LC, Zolin SJ, Fafaj A, Thomas JD, Krpata DM, Petro CC, Rosen MJ, Prabhu AS. Understanding the benefits of botulinum toxin A: retrospective analysis of the Abdominal Core Health Quality Collaborative. Br J Surg 2021; 108:112-114. [PMID: 33711107 DOI: 10.1093/bjs/znaa050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/14/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022]
Abstract
This was a retrospective analysis of a prospectively maintained database that objectively evaluated the benefit of preoperative chemical component separation with botulinum toxin A in complex hernia repairs.
Continued evaluation.
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Affiliation(s)
- C M Horne
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - V Augenstein
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - F Malcher
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - J Yunis
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - L-C Huang
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - S J Zolin
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - A Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - J D Thomas
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - D M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - C C Petro
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - M J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - A S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
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Affiliation(s)
- Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio
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Fafaj A, Thomas J, Zolin SJ, Poli de Figueiredo SM, Tastaldi L, Liu PS, Petro CC, Krpata DM, Prabhu AS, Rosen MJ. Can Hernia Sac to Abdominal Cavity Volume Ratio Predict Fascial Closure Rate for Large Ventral Hernia? Reliability of the Tanaka Score. J Am Coll Surg 2021; 232:948-953. [PMID: 33831538 DOI: 10.1016/j.jamcollsurg.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias. METHODS Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values). RESULTS A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049). CONCLUSIONS In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.
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Affiliation(s)
- Aldo Fafaj
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH.
| | - Jonah Thomas
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Samuel J Zolin
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Luciano Tastaldi
- Department of General Surgery, University of Texas Medical Branch, University Boulevard, Galveston, TX
| | - Peter S Liu
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Clayton C Petro
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - David M Krpata
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Ajita S Prabhu
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Michael J Rosen
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
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Prabhu AS. Transversus Abdominis Plane Block: Worth the Hype, or Simply Tapped Out? J Am Coll Surg 2021; 231:603-604. [PMID: 33491656 DOI: 10.1016/j.jamcollsurg.2020.08.737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/28/2022]
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Prabhu AS, Carbonell A, Hope W, Warren J, Higgins R, Jacob B, Blatnik J, Haskins I, Alkhatib H, Tastaldi L, Fafaj A, Tu C, Rosen MJ. Robotic Inguinal vs Transabdominal Laparoscopic Inguinal Hernia Repair: The RIVAL Randomized Clinical Trial. JAMA Surg 2021; 155:380-387. [PMID: 32186683 DOI: 10.1001/jamasurg.2020.0034] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Despite rapid adoption of the robotic platform for inguinal hernia repair in the US, to date, no level I trials have ever compared robotic inguinal hernia repair to laparoscopic repair. This multicenter randomized clinical trial is the first to compare the robotic platform to laparoscopic approach for minimally invasive inguinal hernia repair. Objective To determine whether the robotic approach to inguinal hernia repair results in improved postoperative outcomes compared with traditional laparoscopic inguinal hernia repairs. Design, Setting, and Participants This multicenter, single-blinded, prospective randomized clinical pilot study was conducted from April 2016 to April 2019, with a follow-up duration of 30 days in 6 academic and academic-affiliated sites. Enrolled in this study were 113 patients with a unilateral primary or recurrent inguinal hernia. After exclusions 102 remained for analysis. Interventions Standard laparoscopic transabdominal preperitoneal repair or robotic transabdominal preperitoneal repair. Main Outcomes and Measures Main outcomes included postoperative pain, health-related quality of life, mobility, wound morbidity, and cosmesis. Secondary outcomes included cost, surgeon ergonomics, and surgeon mental workload. A primary outcome was not selected because this study was designed as a pilot study. The hypothesis was formulated prior to data collection. Results A total of 102 patients were included in the study (54 in the laparoscopic group, mean [SD] age, 57.2 [13.3] years and 48 [88.9%] male; 48 in the robotic group, mean [SD] age, 56.1 [14.1] years and 44 [91.6%] male). There were no differences at the preoperative, 1-week, or 30-day points between the groups in terms of wound events, readmissions, pain as measured by the Visual Analog Scale, or quality of life as measured by the 36-Item Short Form Health Survey. Compared with traditional laparoscopic inguinal hernia repair, robotic transabdominal preperitoneal repair was associated with longer median (interquartile range) operative times (75.5 [59.0-93.8] minutes vs 40.5 [29.2-63.8] minutes, respectively; P < .001), higher median (interquartile range) cost ($3258 [$2568-$4118] vs $1421 [$1196-$1930], respectively; P < .001), and higher mean (SD) frustration levels on the NASA Task Load Index Scale (range, 1-100, with lower scores indicating lower cognitive workload) (32.7 [23.5] vs 20.1 [19.2], respectively; P = .004). There were no differences in ergonomics of the surgeons between the groups as measured by the Rapid Upper Limb Assessment instrument. Conclusions and Relevance Results of this study showed no clinical benefit to the robotic approach to straightforward inguinal hernia repair compared with the laparoscopic approach. The robotic approach incurred higher costs and more operative time compared with the laparoscopic approach, with added surgeon frustration and no ergonomic benefit to surgeons. Trial Registration ClinicalTrials.gov Identifier: NCT02816658.
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Affiliation(s)
- Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alfredo Carbonell
- Comprehensive Hernia Center, Department of Surgery, University of South Carolina School of Medicine Greenville, Greenville
| | - William Hope
- Department of Surgery, New Hanover Regional Medical Center, University of North Carolina Wilmington, Wilmington
| | - Jeremy Warren
- Comprehensive Hernia Center, Department of Surgery, University of South Carolina School of Medicine Greenville, Greenville
| | - Rana Higgins
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Brian Jacob
- Department of Surgery, Mount Sinai Hospital, New York, New York
| | - Jeffrey Blatnik
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ivy Haskins
- Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Hemasat Alkhatib
- Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Luciano Tastaldi
- Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Surgery, University of Texas Medical Branch, Galveston
| | - Aldo Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Chao Tu
- Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio
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Fafaj A, Tastaldi L, Alkhatib H, Zolin SJ, Rosenblatt S, Huang LC, Phillips S, Krpata DM, Prabhu AS, Petro CC, Rosen MJ. Management of ventral hernia defect during enterocutaneous fistula takedown: practice patterns and short-term outcomes from the Abdominal Core Health Quality Collaborative. Hernia 2021; 25:1013-1020. [PMID: 33389276 DOI: 10.1007/s10029-020-02347-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/16/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND An enterocutaneous fistula (ECF) with an associated large hernia defect poses a significant challenge for the reconstructive surgeon. We aim to describe operative details and 30-day outcomes of elective hernia repair with an ECF when performed by surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC). STUDY DESIGN Patients undergoing concomitant hernia and ECF elective repair were identified within the ACHQC. Outcomes of interest were operative details and 30-day rates of surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), medical complications, and mortality. RESULTS 170 patients were identified (mean age 60 years, 52.4% females, mean BMI 32.3 kg/m2). 106 patients (62%) had small-bowel ECFs, mostly managed with resection without diversion. 30 patients (18%) had colonic ECFs, which were managed with resection without diversion (14%) or resection with diversion (6%). 100 (59%) had a prior mesh in place, which was removed in 90% of patients. Hernias measured 14 cm ± 7 in width, and 68 (40%) had a myofascial release performed (41 TARs). Mesh was placed in 115 cases (68%), 72% as a sublay, and more frequently of biologic (44%) or permanent synthetic (34%) material. 30-day SSI was 18% (37% superficial, 40% deep), and 30-day SSOPI was 21%. 19 patients (11%) were re-operated: 8 (8%) due to a wound complication and 4 (2%) due to a missed enterotomy. Two infected meshes were removed, one biologic and one synthetic. CONCLUSIONS Surgeons participating in the ACHQC predominantly resect ECFs and repair the associated hernias with sublay mesh with or without a myofascial release. Morbidity remains high, most closely related to wound complications, as such, concomitant definitive repairs should be entertained with caution.
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Affiliation(s)
- A Fafaj
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
| | - L Tastaldi
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.,Department of General Surgery, University of Texas Medical Branch, 3100 University Boulevard, Galveston, TX, 77555, USA
| | - H Alkhatib
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - S J Zolin
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - S Rosenblatt
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - L-C Huang
- Department of Biostatistics, Vanderbilt University Medical Center, 1211 Medical Center Dr., Nashville, TN, 37232, USA
| | - S Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, 1211 Medical Center Dr., Nashville, TN, 37232, USA
| | - D M Krpata
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - A S Prabhu
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - C C Petro
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
| | - M J Rosen
- Department of General Surgery, Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA
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Prabhu AS, Rosen MJ. Robo FOMO (Fear of Missing Out), But at What Cost? The Unintended Consequences of Robotics for General Surgery Operations at Rural Hospitals. Surg Innov 2020; 27:561-563. [PMID: 33381985 DOI: 10.1177/1553350620984341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ajita S Prabhu
- 2569Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic, OH, USA
| | - Michael J Rosen
- 2569Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic, OH, USA
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Zolin SJ, Petro CC, Prabhu AS, Fafaj A, Thomas JD, Horne CM, Tastaldi L, Alkhatib H, Krpata DM, Rosenblatt S, Rosen MJ. Registry-Based Randomized Controlled Trials: A New Paradigm for Surgical Research. J Surg Res 2020; 255:428-435. [DOI: 10.1016/j.jss.2020.05.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/26/2020] [Accepted: 05/11/2020] [Indexed: 01/02/2023]
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