Accessibility to ERCP-performing hospitals among patients with pancreatic cancer living in SEER regions

BACKGROUND AND AIMS

The two most common interventions used to treat painless jaundice from pancreatic cancer are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD). Our study aimed to characterize the geographic distribution of ERCP-performing hospitals among patients with pancreatic cancer in the United States and the association between geographic accessibility to ERCP-performing hospitals and biliary interventions patients receive.

METHODS

This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database for pancreatic cancer from 2005 to 2013. Multilevel models were used to examine the association between accessibility to ERCP hospitals within a 30- and 45-min drive from the patient's residential ZIP Code and the receipt of ERCP treatment. A two-step floating catchment area model was used to calculate the measure of accessibility based on the distribution across SEER regions.

RESULTS

7464 and 782 patients underwent ERCP and PTBD, respectively, over the study period. There were 808 hospitals in which 8246 patients diagnosed with pancreatic cancer in SEER regions from 2005 to 2013 received a procedure. Patients with high accessibility within both 30- and 45-min drive to an ERCP-performing hospital were more likely to receive an ERCP (30-min adjusted odds ratio [aOR]: 1.53, 95% confidence interval [CI]: 1.17-2.01; 45-min aOR: 1.31, 95% CI: 1.01-1.70). Furthermore, in the adjusted model, Black patients (vs. White) and patients with stage IV disease were less likely to receive ERCP than PTBD.

CONCLUSIONS

Patients with pancreatic cancer and high accessibility to an ERCP-performing hospital were more likely to receive ERCP. Disparities in the receipt of ERCP persisted for Black patients regardless of their access to ERCP-performing hospitals.

Contemporary Trends in Reviewing Test Results Through the Electronic Patient Portal Among Patients With Cancer

This cohort study among patients with cancer examines changes in the time from posting of test results in the electronic health record to patient viewing in the patient portal before and after implementation of the 21st Century Cures Act.

Retrieval of Renal Function After Renal Artery Stenting Improves Event-Free Survival in a Sub-group Analysis of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions Trial

OBJECTIVE

The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) Trial, a multicenter randomized controlled trial with 947 patients, concluded that there was no benefit of renal artery stenting (RAS) over medical therapy. However, patients with chronic kidney disease (CKD) were not analyzed separately in the CORAL trial. CKD is a risk factor for cardiovascular and renal morbidity. We hypothesized that improved renal function after RAS would be associated with increased long-term survival and a lower risk of cardiovascular and renal events in patients with CKD.

METHODS

This post hoc analysis of the CORAL Trial included 842 patients with CKD stages 2-4 at baseline who were randomized to optimal medical therapy alone (OMT; n= 432) or RAS plus OMT (RAS+OMT; n = 410). Patients were categorized as "responders" or "non-responders" based on change in estimated glomerular filtration rate (eGFR) from baseline to last follow-up (median 3.6 years, interquartile range 2.6-4.6 years). Responders were defined by a 20% or greater increase in eGFR from baseline; all others were non-responders. Event-free survival was defined as freedom from death and multiple cardiovascular and renal complications. Event-free survival was analyzed using the Kaplan-Meier method and log-rank test. Multivariable Cox proportional hazards regression analysis was used to identify independent predictors of event-free survival.

RESULTS

The RAS+OMT group had a higher proportion of patients with improved renal function (≥20% increase in eGFR over baseline), compared to the OMT group (25.6% vs. 17.1%; P = .003). However, event-free survival was no different for the two cohorts (P = .18 by log-rank test). Multivariable Cox proportional hazards regression analysis identified four variables that independently correlated with event-free survival for the stented cohort. Higher preoperative eGFR (Hazard Ratio [HR] = 0.98, 95% Confidence Interval [CI] 0.96-0.99; P = .002) and being a responder to stenting (HR = 0.49, 95% CI 0.26-0.95; P = .033) increased event-free survival, while history of congestive heart failure (HR 2.52, 95% CI 1.46-4.35; P < .001) and higher preoperative systolic BP (HR 1.02, 95% CI 1.01-1.03; P = .002) decreased event-free survival. Within the stented group, 105 of 410 patients (25.6%) were responders. Event-free survival was superior for responders, compared to non-responders (P=0.009 by log-rank test). The only independent preoperative negative predictor of improved renal function after stenting was diabetes (Odds Ratio 0.37, 95% CI 0.16-0.84; P = 0.017), which decreased the probability of improved renal function after RAS+OMT. A subset of patients (23.4%) after RAS had worsened renal function, but OMT alone produced an equivalent incidence of worsened renal function. Increased urine albumin/creatinine ratio was an independent predictor of worsened renal function after RAS.

CONCLUSIONS

CORAL participants who demonstrated improved kidney function after RAS+OMT demonstrated improved event-free survival. This finding reinforces the need for predictors of outcome to guide patient selection for RAS.

Endovascular Thrombectomy Reduces Risk of Poor Functional Outcomes in Patients Presenting within 0-6 Hours with Large Ischemic Core Volumes on Computed Tomography Perfusion

INTRODUCTION

Patients presenting with large ischemic core volumes (LICVs) on computed tomography perfusion (CTP) are at high risk for poor functional outcomes. We sought to identify predictors of outcome in patients with an internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion and LICV.

METHODS

A large healthcare system's prospectively collected code stroke registry was utilized for this retrospective analysis of patients presenting within 6 hours with at least 50 ml of CTP reduced relative cerebral blood flow (CBF) < 30%. A multivariable logistic regression model was constructed to identify independent predictors (p < 0.05) of poor discharge outcome (modified Rankin scale score 4-6).

RESULTS

Over a 38-month period, we identified 104 patients meeting inclusion criteria, with a mean age of 65.4 ± 16.2 years, median presenting National Institutes of Health Stroke Scale score 20 (IQR 16-24), median ischemic core volume (CBF < 30%) 82 ml (IQR 61-118), and median mismatch volume 80 ml (IQR 56-134). Seventy-five patients (72.1%) had a discharge modified Rankin scale score of 4-6. Sixty-six of 104 (63.5%) patients were treated with endovascular thrombectomy (EVT). In the multivariable regression model, EVT (OR 0.303; 95% CI 0.080-0.985; p = 0.049) and lower blood glucose (per 1-point increase, OR 1.014; 95% CI 1.003-1.030; p = 0.030) were independently protective against poor discharge outcome.

CONCLUSIONS

EVT is independently associated with a reduced risk of poor functional outcome in patients presenting within 6 hours with ICA or MCA occlusions and LICV.

Visualization of the Anterior Temporal Artery as a Predictor of Outcome in Middle Cerebral Artery Occlusion Patients Achieving Successful Recanalization After Transfer

Introduction

Anterior temporal artery (ATA) visualization on computed tomography angiography (CTA) has been previously associated with good outcomes in middle cerebral artery (MCA) occlusions, but not in the setting of patients who initially present to non-thrombectomy centers.

Methods

We retrospectively identified acute MCA (M1) occlusion patients who underwent mechanical thrombectomy after transfer from non-thrombectomy-capable centers. Neuroradiologists confirmed the MCA (M1) as the most proximal site of occlusion on CTA and assessed for visualization of the ATA. Thrombolysis in Cerebral Infarction (TICI) 2b or greater revascularization scores were confirmed by neurointerventionalists blinded to patient outcomes. Ninety-day modified Rankin scale (mRS) scores were obtained via a structured telephone questionnaire.

Results

We identified 102 M1 occlusion patients over a three-and-a-half-year period presenting to a non-thrombectomy-capable center who underwent transfer and mechanical thrombectomy. There were no significant differences in age, gender, race, comorbidities, or median National Institute of Health Stroke Scale (NIHSS) scores between the ATA visualized (n = 47) versus non-visualized (n = 55) cohort, and no significant differences in baseline Alberta Stroke Program Early Computed Tomography (ASPECT) scores, post-intervention TICI scores, or interval from last known well to revascularization. There was a strong trend in functional independent outcome (mRS ≤ 2) for patients with ATA visualization (63.8% vs. 45.5%, p = 0.064).

Conclusion

For patients presenting to non-thrombectomy centers without CT perfusion capability, ATA visualization should be further investigated as an outcome predictor, given its association with functional independence after successful recanalization.

This article was previously presented as a meeting abstract at the 2021 International Stroke Conference on March 17-19, 2021.

Abstract TMP71: Optimizing Stroke Outcome Prediction: Derivation And Validation Of The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score

Introduction: Prognostic scores for large artery occlusion patients treated with endovascular intervention have not incorporated CTP parameters. We derived the Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS) to optimize outcome prediction after mechanical thrombectomy.

Methods: Patients presenting with an ICA or MCA occlusion treated with thrombectomy from November 2016-July 2020 were included from our health system’s prospectively collected, code stroke registry in the derivation analysis. Prognostic factors independently associated with poor outcomes (90-day mRS score 4-6) were combined with CTP parameters in a regression model. Internal cross-validation was performed. A separate, prospective validation cohort was included from the registry with patients from December 2020-April 2021. The final scale was compared to previously reported scales using Area Under the Curve-Receiver Operator Characteristic analysis.

Results: 646 patients were included in the derivation analysis and 60 patients in the separate validation cohort. CLEOS = (6 x Age) + (13 x NIHSS) + Glucose - (162 x CBV Index). CLEOS predicted poor 90-day outcomes (AUC 0.74, 95% CI 0.71-0.78) better than the Stroke Prognostication using Age and National Institute of Health Stroke Scale-100 Index (AUC 0.63, p < 0.0001), the Houston Intra-Arterial Therapy 2 score (AUC 0.69, p = 0.0029), and the Pittsburgh Response to Endovascular therapy score (AUC 0.71, p = 0.0240) in a combined analysis of the derivation and validation cohorts. Patients with CLEOS scores ≥ 850 did not have a lower risk of poor 90-day outcomes despite excellent revascularization (modified TICI 2c-3).

Conclusions: CLEOS can predict poor 90-day outcomes after an ICA or MCA occlusion and help identify patients unlikely to benefit from endovascular thrombectomy despite excellent revascularization.

Abstract TP104: Agreement Of Hypoperfusion Intensity Ratio On CTP Derived By Rapid AI And Viz AI

Background: For anterior circulation large vessel occlusion acute ischemic stroke patients, Hypoperfusion Intensity Ratio (HIR) derived from automated Computerized Tomography Perfusion (CTP) software has been shown to predict the rate of collateral flow, speed of infarct growth, and clinical outcome. Published data have proposed an HIR threshold derived by RAPID AI (Menlo Park, CA) of either <0.5 or <0.4 as best predicting robust collaterals. The agreement between HIR derived from VIZ AI (San Mateo, CA) compared to RAPID AI is unknown.

Methods: We identified 107 cases in which the middle cerebral artery was the most proximal site of occlusion on Computerized Tomography Angiography as confirmed by a neuroradiologist, and for whom a CTP performed on RAPID AI was diagnostic (e.g. lacking artifact from head motion, a failed bolus injection, poor scan timing, or low signal-to-noise). Those CTP acquisition data were subsequently processed on VIZ AI. We measured the agreement for HIR dichotomized at both <0.5 and <0.4 between RAPID AI and VIZ AI, along with the overall agreement.

Results: For the HIR dichotomized at <0.5, the simple kappa coefficient between HIR derived from VIZ AI compared to RAPID AI was 0.714 (95% CI 0.581-0.846), versus 0.636 (95% CI 0.500-0.772) for the HIR dichotomized at <0.4. The intraclass correlation coefficient (ICC) between HIR derived from VIZ AI compared to RAPID AI was 0.78 (95% CI 0.694-0.844).

Conclusions: In our sample of 107 cases, the level of agreement for the HIR derived from RAPID and VIZ dichotomized at <0.5 was in the moderate to very good range (Landis & Koch, 1977), versus in the moderate to good range when dichotomized at <0.4. Based on the ICC, agreement was in the moderate to good range. Further investigation of the agreement of HIR derived from RAPID AI and VIZ AI should be conducted before applying HIR thresholds derived from RAPID AI to CTP studies analyzed by VIZ AI to predict favorable collateralization.

Factors Predicting Increased Length of Stay in Abdominal Wall Reconstruction

BACKGROUND

Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)-specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol.

METHODS

A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8).

RESULTS

Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (β0.04,SE0.02), BMI (β0.06,SE0.03), hernia defect size (β0.003,SE0.001), active mesh infection or mesh fistula (β1.8,SE0.72), operative time (β0.02,SE0.002), and ASA score >4 (β3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence (P = .06).

CONCLUSIONS

Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.

Unseen Burden of Injury: Post-Hospitalization Mortality in Geriatric Trauma Patients

BACKGROUND/OBJECTIVES

Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients.

METHODS

Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics.

RESULTS

Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001.

CONCLUSION

Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.

Cerebral blood volume index as a predictor of functional independence after basilar artery thrombectomy

BACKGROUND AND PURPOSE

The role of CT perfusion (CTP)in the evaluation of acute basilar artery occlusion (aBAO) patients undergoing endovascular thrombectomy (EVT) is unclear. We investigated the association of individual CTP parameters with functional outcomes in aBAO patients undergoing EVT.

METHODS

A health system's prospectively collected code stroke registry was used in this retrospective analysis of aBAO patients treated with EVT presenting between January 2017 and February 2021 with pre-EVT CTP. The primary outcome measure was modified Rankin Scale (mRS) score 0-2 at 90 days. Factors with a univariate association (p < .05) with mRS 0-2 were combined in a multivariable regression model to determine independent predictors of 90-day favorable functional outcome.

RESULTS

Forty-six subjects, with median age 67 years and median National Institutes of Health Stroke Scale 16, were included, of whom 17 (37%) achieved mRS 0-2 at 90 days. In the multivariable logistic regression model, CTP cerebral blood volume (CBV) index (per 0.1-point increase, odds ratio = 1.843; 95% confidence interval: 1.039, 3.268; p-value .0365) was independently associated with a favorable 90-day outcome.

CONCLUSIONS

CBV index was independently associated with a favorable 90-day outcome in aBAO patients treated with EVT, a novel finding in this patient population. CBV index may assist in treatment and prognosis discussions and inform future studies investigating the role of CTP in aBAO.

Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair

Introduction

Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair.

Methods

A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software.

Results

Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm³, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm², p < 0.001). In multivariate analysis, HSV increase of 100cm³ (OR 1.17 CI 1.02–1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence.

Conclusions

Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.

Abstract P361: Visualization of the Anterior Temporal Artery as a Predictor of Outcome in Middle Cerebral Artery Occlusion Patients Achieving Successful Recanalization After Interfacility Transfer

Introduction: Many non-thrombectomy centers lack Computerized Tomography Perfusion (CTP) capability. Anterior temporal artery (ATA) visualization on Computerized Tomography Angiography (CTA) has been previously associated with good outcomes in middle cerebral artery (MCA) occlusions, but not in the context of recanalization after interfacility transfer for thrombectomy. We hypothesized that independent functional outcome at 90 days would be greater for MCA occlusion patients initially presenting to non-thrombectomy centers with a visualized ATA on CTA who achieved TICI 2b or greater recanalization after transfer.

Methods: We conducted a retrospective cohort study of patients transferred for mechanical thrombectomy. A neuroradiologist blinded to patient outcomes confirmed the MCA as the most proximal site of occlusion on CTA, and assessed for visualization of the ATA. TICI 2b or greater revascularization scores were confirmed by neurointerventionalists blinded to patient outcomes. Ninety-day mRS scores were obtained via telephone utilizing a structured questionnaire.

Results: We identified a total of 107 MCA occlusion patients over a 3 ½ year period meeting our inclusion criteria. There were no significant differences in age, gender, race, comorbidities, median NIHSS, or time-to-revascularization variables between the ATA visualized (n=50) versus non-visualized (n=57) group, with the exception of significantly more wake-up strokes in the ATA visualized group (34.7% vs 16.1%, p=0.03). There was a non-significant trend for independent outcome (mRS ≤2) at 90 days for patients with ATA visualization compared to those for whom the ATA was not visualized on the CTA (63.8% vs 45.5%, p=0.06).

Conclusion: For MCA occlusion patients initially presenting to non-thrombectomy centers achieving successful recanalization via mechanical thrombectomy, there is a strong trend for visualization of the anterior temporal artery on the CTA performed at the non-thrombectomy center as being a predictor of independent functional outcome. Especially for institutions without CTP capability, this association with ATA visualization should be further investigated as a predictor for good outcome after transfer for successful mechanical thrombectomy.

Abstract P86: The Temporal Relationship of the First Reported Covid Case and Statewide Executive Orders to Regional Code Stroke Activation Trends During North Carolina’s First Covid Surge

Introduction: A decline in suspected acute stroke (“code stroke”) presentations in the United States (US) during the first COVID surge has been previously reported. While state emergency declarations may have contributed to the decline and rebound of weekly code stroke activations in our region, the exact temporal relationship of those declarations relative to weekly code stroke volumes is unclear.

Methods: We conducted an interrupted time series analysis (ITSA) to identify the impact of the first reported COVID case in North Carolina (NC) and subsequent statewide executive orders (SEOs) on weekly code stroke activation trends across our regional stroke network’s 20 facilities during a 33-week period (December 8, 2019 to July 25, 2020). We included the following time epochs: the first reported COVID case in NC, the NC SEO prohibiting mass gatherings and closing public schools, the stay-at-home NC SEO, and the NC phase 1 and phase 2 reentry orders, which eased restrictions.

Results: Utilizing our integrated healthcare network’s code stroke registry, we evaluated 3740 code stroke activations over a 33-week period. We performed two ITSA considering different starting points for the first intervention—one defined as the first COVID case and the other the first SEO. For both models the end of the first-time interval ended with the second SEO. Most of the downward trend in code stroke activation volume was temporally after the first COVID case (p=0.0029), not after the first SEO. After the second SEO, which increased social restrictions, there was a significant increased trend in code stroke activation volume (p=0.0047), while the phase 1 and 2 reopening SEOs were not associated with a significant increase in weekly code stroke activations.

Conclusion: Our data indicate that in our region, the decreased trend in code stroke activations preceded the first SEO and started temporally after the first reported COVID case in NC. The overall decrease in code stroke volume was not significantly associated with increasing statewide restrictions and lessening of those restrictions was not significantly associated with a rebounding trend. Restrictive and reentry SEOs do not explain changes in weekly code stroke activation trends our region experienced during its first COVID surge.

Abstract P557: Hypoperfusion Intensity Ratio and Cerebral Blood Volume Index as Predictors of Outcome for Recanalized Middle Cerebral Artery Occlusions

Introduction: Preliminary data suggest the Hypoperfusion Intensity Ratio (HIR) and the Cerebral Blood Volume Index (CBVI) derived from Computerized Tomography Perfusion (CTP) imaging predict the rate of collateral flow, speed of infarct growth, and clinical outcome. We hypothesized that functional outcomes at hospital discharge would be significantly better for middle cerebral artery (MCA) occlusion patients achieving Thrombolysis in Cerebral Infarction (TICI) 2b or greater recanalization with presenting hospital CTPs consistent with “good” (HIR <0.5 and CBVI >0.7) versus “poor” (HIR ≥0.5 and CBVI ≤0.7) indices.

Methods: We conducted a retrospective cohort study. A neuroradiologist confirmed the MCA occlusion based on the initial Computerized Tomography Angiogram (CTA). All TICI scores were confirmed by neurointerventionalists blinded to patient outcomes. We defined independent outcome as mRS ≤2, and favorable outcome as an mRS ≤3. We additionally stratified patients as initially presenting to thrombectomy versus non-thrombectomy centers.

Results: We identified a total of 162 patients over a 3 ½ year period with an MCA occlusion achieving TICI 2b recanalization or greater, of whom 67 had good indices and 48 had poor indices. For patients with good compared to poor indices, there was a trend for achieving independent outcome (55% vs 37%, p=0.061) that reached significance for favorable outcome (69% vs 50%, p=0.043). Limiting the analysis to only patients presenting to non-thrombectomy centers (n=67), these findings were consistent, with a trend for achieving independent outcome for good versus poor collaterals (48% vs 30% p=0.173), which was again significant for a favorable outcome (66% vs 39%, p=0.036). Across all patients, HIR <0.5 (n=86) or CBVI >0.7 (n=95) were not independently associated with independent outcomes, but for patients presenting to non-thrombectomy centers, an HIR <0.5 alone (n=51) was significantly associated with favorable outcome.

Conclusion: For MCA occlusion patients achieving TICI 2b recanalization, the combination of good HIR and CBVI is significantly associated with a favorable functional outcome. For patients presenting to non-thrombectomy centers, HIR alone may be sufficient to predict favorable outcome.

Perceptions and understanding about mesh and hernia surgery: What do patients really think?

BACKGROUND

Surgical mesh and hernia repair have come under increasing scrutiny with large amounts of press, Internet, and social media reportage regarding ongoing mesh litigation, recalls, and patient testimonials. The aim of this study was to evaluate patient perceptions of mesh in hernia surgery.

METHODS

A 16-question survey was given to patients presenting for hernia surgery at a tertiary hernia center by trained data analysts before surgeon interaction.

RESULTS

Two hundred and two patients were surveyed. Patients believed mesh caused complications (45.1%) and reported concerns about mesh (38.2%). Those who performed their own research, females, and patients with recurrent hernias were more likely to have concerns about mesh (P ≤ 0.03). Most patients (81.7%) thought they were at average risk or less for complications; patients with recurrent hernias (versus primary hernias) and incisional hernias (compared with inguinal or umbilical hernias) had more negative outlooks on complications (all P < .05). Recovery expectations varied, but the failed repair and incisional hernia groups were more likely to expect prolonged recovery (>3 months) (all P < .05). After surgeon-directed education and a mesh education handout, all but one patient agreed to and underwent a mesh repair as indicated.

CONCLUSION

Patients had concerns about mesh and were aware of mesh related complications. Patients performing their own research, as well as females and recurrent hernia patients, had worse perceptions of mesh. Recurrent and incisional hernia patients had greater concerns about complications, recurrence, and recovery. Preoperative education concerning mesh and mesh choice for each operation eased patient anxiety.

Age and discharge modified Rankin score are associated with 90-Day functional outcome after basilar artery occlusion treated with endovascular therapy

INTRODUCTION

Prognostic factors for functional outcome after basilar artery occlusion (BAO) treated with modern endovascular therapy (EVT) are sparse. We investigated the association between clinical characteristics, readily available imaging variables, and outcome in BAO patients treated with EVT.

METHODS

Retrospective analysis from a large healthcare system's prospectively collected code stroke registry of acute BAO patients treated with EVT between January 2017-January 2020. The primary outcome measure was a favorable 90-day modified Rankin score (mRS) of 0-2.

RESULTS

65 patients (median age 67 years, 57% male, median NIHSS 16) met the study inclusion criteria. Thrombolysis in Cerebral Infarction (TICI) 2 b-3 revascularization was achieved in 57/65 patients (88%) with a median time to revascularization of 445 minutes [IQR 302-840]. Ninety-day good outcome was seen in 35% (23/65) of patients. In a univariate analysis, age, history of ischemic stroke, baseline NIHSS, BAO site, and discharge mRS were associated with significant differences between the good and poor outcome groups. A multivariable logistic regression analysis demonstrated an independent association with 90-day good outcome and younger age (per 1-year, OR 0.79, 95% CI 0.64, 0.98) and good discharge mRS (0-2) (OR > 999.99, 95% CI 13.26, > 999.99).

CONCLUSIONS

Patients presenting with an acute BAO treated with modern EVT have a good 90-day outcome in over one-third of cases. Age and discharge mRS are independently associated with good 90-day outcome. Additional studies may focus on factors that can enhance discharge function after BAO, a novel prognostic indicator for favorable 90-day outcome in our study.

Laparoscopic Ventral Hernia Repair in the Geriatric Population : An Assessment of Long-Term Outcomes and Quality of Life

OBJECTIVES

Laparoscopic ventral hernia repair (LVHR) has been shown to decrease wound complications and length of stay (LOS) but results in more postoperative discomfort. The benefits of LVHR for the growing geriatric population are unclear. The aim of our study is to evaluate long-term outcomes and quality of life (QOL) after LVHR in the geriatric population.

METHODS

A prospectively collected single-center database was queried for all patients who underwent LVHR (1999-2019). Age groups were defined as <40 (young), 40-64 (middle age), and ≥65 years (geriatric). QOL was assessed with the Carolinas Comfort Scale.

RESULTS

LVHR was performed in 1181 patients, of which 13.4% were young, 61.6% middle aged, and 25.0% geriatric. Hernia defect size (64.2 ± 94.4 vs 79.9 ± 102.4 vs 84.7 ± 110.0 cm²) and number of comorbidities (2.2 ± 2.1 vs 3.2 ± 2.2 vs 4.3 ± 2.2) increased with age (all P < .05). LOS increased with age (2.9 ± 2.5 vs 3.8 ± 2.9 vs 5.2 ± 5.3 days, P < .0001). Rates of postoperative cardiac events, pneumonia, respiratory failure, wound complication, reoperation, and death were similar (P > .05). Geriatric patients had increased rate of ileus and urinary retention (all P < .05). Overall recurrence rate was 5.7% with an average follow-up of 43.5 months, with no differences in recurrence between groups (P > .05). Geriatric patients had better overall QOL at 2 weeks (P = .0008) and similar QOL at 1, 6, and 12 months.

DISCUSSION

LVHR offers excellent results in the geriatric population. Despite having increased rates of comorbidities and larger hernia defects, which may relate to LOS, rates of complications and recurrence were similar compared with younger cohorts, with better short-term QOL.

Sarcopenia in Patients Undergoing Open Ventral Hernia Repair

Radiologic indicators of sarcopenia have been associated with adverse operative outcomes in some surgical populations. This study assesses the association of radiologic indicators of frailty with outcomes after open ventral hernia repair (OVHR). A prospective, institutional, herniaspecific database was queried for patients undergoing OVHR from 2007 to 2018 with preoperative CT. Psoas muscle cross-sectional area at L3 was measured and adjusted for height (skeletal muscle index (SMI)). L3 vertebral body density (L3 VBD) was measured. Demographics and outcomes were evaluated as related to SMI and L3 VBD. Of 1178 patients, 9.7 per cent of females and 15.8 per cent of males had sarcopenia and 11.6 per cent of females and 9.2 per cent of males had osteopenia. Neither sarcopenia nor osteopenia were associated with outcomes of wound infection, read-mission, reoperation, hernia recurrence, or major complications. When examined as continuous variables or by quartile, SMI and L3 VBD were not associated with adverse outcomes, including in subsets of male or female patients, the elderly, contaminated cases, and the obese. Radiologic markers of sarcopenia and osteopenia are not associated with adverse outcomes after OVHR. Further study should examine age or other potential predictors of outcomes in this patient population, such as independent status.

The impact of weight change on intra-abdominal and hernia volumes

BACKGROUND

Weight loss is often encouraged or required before open ventral hernia repair. This study evaluates the impact of weight change on total, intra-abdominal, subcutaneous, and hernia volume.

METHODS

Patients who underwent open ventral hernia repair from 2007 to 2018 with two preoperative computed tomography scans were identified. Scans were reviewed using 3D volumetric software. Demographics, operative characteristics, and outcomes were evaluated. The impact of weight change on intra-abdominal, subcutaneous, and hernia volume was assessed using Spearman's correlation coefficients and linear regression models.

RESULTS

A total of 250 patients met the criteria with a mean defect area of 155.6 ± 155.4 cm², subcutaneous volume of 6,800.0 ± 3,868.8 cm³, hernia volume of 915.7 ± 1,234.5 cm³, intra-abdominal volume equaling 4,250.2 ± 2,118.1 cm³, and time between computed tomography scans 13.9 ± 11.0 months. Weight change was associated with change in hernia, intra-abdominal, total, and subcutaneous volume (Spearman's correlation coefficients 0.17, 0.48, 0.51, 0.45, respectively, P ≤ 0.03 all values) and not associated in hernia length, width, or area (P ≥ 0.18 all values). A Δ5 kg was significantly associated with Δintra-abdominal volume (164.1 ± 30.0 cm³/Δ5 kg,P < .0001), Δtotal volume (209.9 ± 33.0 cm³/Δ5 kg, P < .0001), and Δsubcutaneous volume (234.4 ± 50.8 cm³/Δ5 kg, P < .0001). Per Δ5 kg, male patients had more than double the Δintra-abdominal, Δtotal, and Δsubcutaneous volume than did female patients. A weight change of 5 kg to10 kg was associated with approximately double the change in computed tomography parameters/Δ5 kg than any weight change after 10 kg. Regardless of weight change, all measured hernia parameters increased over time, with mean hernia volume of +40.6 ± 94.9 cm³/mo and area of +7.8 ± 13.3 cm²/mo (Spearman's correlation coefficient -0.03 to 0.07, P value 0.37-0.96).

CONCLUSION

Weight change is linearly correlated with intra-abdominal and subcutaneous fat gain or loss. Males show greater abdominal-related response to weight gain or loss. Hernia dimensions increase over time regardless of weight change.

Correction to: Impact of age on morbidity and mortality following bariatric surgery

This article was updated to correct the spelling of Nicholas Dugan's first name: it is correct as displayed here.

The association of penicillin allergy with outcomes after open ventral hernia repair

BACKGROUND

Up to 11% of patients report a penicillin allergy (PA), with 1-2% demonstrating a true IgE mediated allergy upon testing. PA patients often receive non-beta-lactam antibiotic surgical prophylaxis (non-BLP). This study evaluates the relationship of PA to outcomes after open ventral hernia repair (OVHR).

METHODS

A prospective institutional database was queried for patients undergoing OVHR. Demographics, operative characteristics, and outcomes were evaluated by the reported PA and the administration of beta-lactam prophylaxis (BLP).

RESULTS

Allergy histories were reviewed in 1178 patients. PA was reported in 21.6% of patients, with 55.5% reporting rash or hives, 15.0% airway compromise or anaphylaxis, and 29.5% no specific reaction. BLP was administered to 76.3% of patients, including 22.1% of PA patients and 89.9% of patients without PA. PA patients were more often female (64.6% PA patients vs. 56% non-PA, p = 0.01), with higher rates of chronic steroids, MRSA, anxiety, asthma, COPD, chronic pain, and sleep apnea (p < 0.03 all values). PA patients had higher rates of contaminated cases, including mesh infection and fistula. Of the 683 clean cases, 82.1% received BLP. Of the 117 clean contaminated cases (CDC wound class 2), 82.9% received BLP, which was associated with reduced long-term readmission for hernia complications (21.5 vs. 55%, p = 0.002, OR 0.27, CI 0.09-0.83). In the 120 CDC wound class 3 and 4 patients, 65.8% received BLP. In multivariate analysis, BLP was associated with lower rates of reoperation (OR 0.31, CI 0.12-0.76) and recurrence (OR 0.32, CI 0.11-0.86). BLP was given to 22.1% of the PA patients with no adverse reactions noted.

CONCLUSION

PA patients had more comorbidities and complex ventral hernias. When controlling for contamination and MRSA history, BLP is associated with improved outcomes particularly in contaminated cases. PA may be a risk factor for patient complexity, and further studies are warranted to determine if allergy testing can be warranted in known or anticipated contaminated cases.

The impact of abnormal BMI on surgical complications after pediatric colorectal surgery

BACKGROUND/PURPOSE

While childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after elective colorectal procedures.

METHODS

Children ages 2-18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts.

RESULTS

858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p=0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p=0.04). Incremental increase in BMI by 1.0kg/m² was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS.

CONCLUSIONS

Increasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications.

LEVEL OF EVIDENCE

III.

Recent updates on drug resistance in Mycobacterium tuberculosis

Tuberculosis (TB) along with acquired immune deficiency syndrome and malaria rank among the top three fatal infectious diseases which pose threat to global public health, especially in middle and low income countries. TB caused by Mycobacterium tuberculosis (Mtb) is an airborne infectious disease and one-third of the world's population gets infected with TB leading to nearly 1·6 million deaths annually. TB drugs are administered in different combinations of four first-line drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) which form the core of treatment regimens in the initial treatment phase of 6-9 months. Several reasons account for the failure of TB therapy such as (i) late diagnosis, (ii) lack of timely and proper administration of effective drugs, (iii) lower availability of less toxic, inexpensive and effective drugs, (iv) long treatment duration, (v) nonadherence to drug regimen and (vi) evolution of drug-resistant TB strains. Drug-resistant TB poses a significant challenge to TB therapy and control programs. In the background of worldwide emergence of 558 000 new TB cases with resistance to rifampicin in the year 2017 and of them, 82% becoming multidrug-resistant TB (MDR-TB), it is essential to continuously update the knowledge on the mechanisms and molecular basis for evolution of Mtb drug resistance. This narrative and traditional review summarizes the progress on the anti-tubercular agents, their mode of action and drug resistance mechanisms in Mtb. The aim of this review is to provide recent updates on drug resistance mechanisms, newly developed/repurposed anti-TB agents in pipeline and international recommendations to manage MDR-TB. It is based on recent literature and WHO guidelines and aims to facilitate better understanding of drug resistance for effective TB therapy and clinical management.

Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair

INTRODUCTION

Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR.

METHODS

OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables.

RESULTS

There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7 kg/m², age of 58.5 ± 12.4 years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24 h respiratory support with ezPAP, CPAP, or biPAP (RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1 kg/m², p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4 years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9 cm², p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7 cm³, p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI.

CONCLUSION

The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.

The use of component separation during abdominal wall reconstruction in contaminated fields: A case-control analysis

BACKGROUND

Component separation technique (CST) allows fascial medialization during abdominal wall reconstruction (AWR). Wound contamination increases the incidence of wound complications, which multiplies the incidence of repair failure. The aim of this study was to compare the impact of CST on AWR outcomes in contaminated fields in comparison to those operations without CST.

METHODS

A prospective, single institution hernia database was queried for patients undergoing AWR with CST and contamination. A case control cohort was identified using propensity score matching.

RESULTS

There were 286 CSTs performed in contaminated cases. After propensity score matching, 61 CSTs were compared to 61 No-CSTs. These groups were matched by defect area (CST:287.1 ± 150.4 vs No-CST:277.6 ± 218.4 cm², p = 0.156), BMI (32.0 ± 7.0 vs 32.2 ± 6.0 kg/m², p = 0.767), diabetes (26.2% vs 32.8%, p = 0.427), and panniculectomy (52.5% vs 36.1%, p = 0.068). Groups had similar rates of wound complications (42.6% vs 40.7%, p = 0.829) and recurrence (4.9% vs 13.1%, p = 0.114).

CONCLUSIONS

The use of CST in the face of contamination is not associated with an increase in wound complications, mesh complications, or recurrence.

Sarcopenia in Patients Undergoing Open Ventral Hernia Repair

Radiologic indicators of sarcopenia have been associated with adverse operative outcomes in some surgical populations. This study assesses the association of radiologic indicators of frailty with outcomes after open ventral hernia repair (OVHR). A prospective, institutional, hernia-specific database was queried for patients undergoing OVHR from 2007 to 2018 with preoperative CT. Psoas muscle cross-sectional area at L3 was measured and adjusted for height (skeletal muscle index (SMI)). L3 vertebral body density (L3 VBD) was measured. Demographics and outcomes were evaluated as related to SMI and L3 VBD. Of 1178 patients, 9.7 per cent of females and 15.8 per cent of males had sarcopenia and 11.6 per cent of females and 9.2 per cent of males had osteopenia. Neither sarcopenia nor osteopenia were associated with outcomes of wound infection, readmission, reoperation, hernia recurrence, or major complications. When examined as continuous variables or by quartile, SMI and L3 VBD were not associated with adverse outcomes, including in subsets of male or female patients, the elderly, contaminated cases, and the obese. Radiologic markers of sarcopenia and osteopenia are not associated with adverse outcomes after OVHR. Further study should examine age or other potential predictors of outcomes in this patient population, such as independent status.

“Death Knell” for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group ( P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

"Death Knell" for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

Mesh reinforcement of paraesophageal hernia repair: Trends and outcomes from a national database

BACKGROUND

Placement of paraesophageal type of "mesh" in paraesophageal hernia repair is controversial. This study examines the trends and outcomes of mesh placement in paraesophageal hernia repair.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent paraesophageal hernia repair with or without mesh (2010-2017). Demographics, operative approach, and outcomes were compared over time.

RESULTS

Of 25,801, most paraesophageal hernia repair cases were elective (89.3%), without mesh (61.9%), and performed laparoscopically (91.3%).When compared with open paraesophageal hernia repair patients, the patients undergoing laparoscopic paraesophageal hernia repair had lesser rates of reoperation, readmission, mortality, overall complications and major complications (2.7% vs 4.8%, 6.2% vs 9.6%, 0.6% vs 2.9%, 7.1% vs 21.3%, 3.8% vs 11.1%, respectively; all P < .0001). Mesh placement was more common in laparoscopic paraesophageal hernia repair (38.9 vs 29.7, P < .0001) than opern paraesophageal hernia repair. During 2010-2017, mesh placement decreased from 46.2% to 35.2% of laparoscopic paraesophageal hernia repair (P < .0001). Operative times for laparoscopic paraesophageal hernia repair decreased over time, and laparoscpic paraesophageal hernia repair without mesh was consistently less (with mesh: 176.0 ± 71.0 to 149.9 ± 72.5 min, without mesh: 148.6 ± 71.4 to 134.6 ± 70.4). We observed no changes in comorbidities or adverse outcomes over time. Using multivariate analysis to control for potential confounding factors, chronic obstructive pulmonary disease was associated most strongly with adverse outcomes, including mortality (OR 2.53, CI 1.55-4.14), any complications (OR 1.80, CI 1.51-2.16), major complications (OR 1.80, CI 1.51-2.16), readmission (OR 1.63, CI 1.33-1.99) and reoperation (OR 1.49, CI 1.10-2.02). Mesh placement was not associated with adverse outcomes.

CONCLUSION

The placement of mesh during laparoscopic paraesophageal hernia repair is not associated with adverse outcomes. Use of mesh with laparoscopic paraesophageal hernia repair is decreasing with no apparent adverse impact on short-term patient outcomes. Further research is needed to investigate patient factors not captured by this national database, such as characteristics of the hernia, patient symptoms, and hernia recurrence.

Comparison of Outcomes After Partial Versus Complete Mesh Excision

OBJECTIVE

Evaluate outcomes of patients undergoing mesh explantation following partial mesh excision (PME) and complete mesh excision (CME).

BACKGROUND

Ventral hernia repair (VHR) with mesh remains one of the most commonly performed procedures worldwide. Management of previously placed mesh during reexploration remains unclear. Studies describing PME as a feasible alternative have been limited.

METHODS

The AHSQC registry was queried for VHR patients who underwent mesh excision. Variables used for propensity-matching included age, BMI, race, diabetes, COPD, OR time>2 hours, immunosuppressants, smoking, active infection, ASA class, elective case, wound classification, and history of abdominal wall infection.

RESULTS

A total of 1904 VHR patients underwent excision of prior mesh. After propensity matching, complications were significantly higher (35% vs 29%, P = 0.01) after PME, including SSI/SSO, SSOPI, and reoperation. No differences were observed in patients with clean wounds, however in clean-contaminated, PME more frequently resulted in SSOPI (24% vs 9%, P = 0.02). In mesh infection/fistulas, higher rates of SSOPI (46% vs 24%, P = 0.04) and reoperation (21% vs 6%, P = 0.03) were seen after PME. Odds-ratio analysis showed increased likelihood of SSOPI (OR 1.5, 95% CI 1.05-2.14; P = 0.023) and reoperation (OR 2.2, 95% CI 1.13-4.10; P = 0.015) with PME.

CONCLUSIONS

With over 350,000 VHR performed annually and increasing mesh use, guidelines for management of mesh during reexploration are needed. This analysis of a multicenter hernia database demonstrates significantly increased postoperative complications in PME patients with clean-contaminated wounds and mesh infections/fistulas, however showed similar outcomes in those with clean wounds.

Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open

BACKGROUND

The decision to perform laparoscopic or open ventral hernia repair (VHR) is multifactorial. This study evaluates the impact of operative approach, BMI, and hernia size on outcomes after VHR.

STUDY DESIGN

The International Hernia Mesh Registry was queried for VHR (2007-2017). A predictive algorithm was constructed, factoring the impact of BMI, hernia size, age, sex, diabetes, and operative approach on outcomes.

RESULTS

Of the 1,906 VHRs, 58.8% were performed open, patient mean age was 54.9 ± 13.5 years, BMI was 31.2 ± 6.8 kg/m², and defect area was 44.8 ± 88.1 cm². Patients undergoing open VHRs were more likely to have an infection develop (3.1% vs 0.3%; p < 0.0001), but less likely to have a seroma develop (6.8% vs 15.3%; p < 0.0001) at mean follow-up 23.2 ± 12.0 months. With multivariate regression controlling for confounding variables, patients undergoing laparoscopic VHR had increased risk of seroma (odds ratio [OR] 1.78; 95% CI 1.05 to 3.03), a decreased risk of infection (OR 0.05; 95% CI 0.01 to 0.42), and had worse quality of life at 1, 6, 12, and 24 months postoperatively compared with patients undergoing open repair. Recurrent hernias were associated with subsequent recurrence (OR 2.69; 95% CI 1.24 to 5.81) and need for reoperation (OR 4.93; 95% CI 2.24 to 10.87). Multivariate predictive models demonstrated independent predictors of infection, including open approach, recurrent hernias, and low ratio of BMI to defect size.

CONCLUSIONS

Ideal outcomes are dependent on both patient and operative factors. Open repair in thin patients with large defects should be considered due to reduced complications and improved quality of life. Laparoscopic repair in obese patients and recurrent hernias can decrease the associated risk of infection.

Emergent Laparoscopic Ventral Hernia Repairs

BACKGROUND

Emergent repairs of incarcerated and strangulated ventral hernia repairs (VHR) are associated with higher perioperative morbidity and mortality than those repaired electively. Despite increasing utilization of minimally invasive techniques in elective repairs, the role for laparoscopy in emergent VHR is not well defined, and its feasibility has been demonstrated only in single center studies.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2009-2016) was queried for emergent VHR. Laparoscopic and open techniques were compared using univariate and multivariate analyses.

RESULTS

A total of 11,075 patients who underwent emergent ventral and incisional hernia repairs were identified: 85.5% open ventral hernia repair (OVHR), 14.5% laparoscopic ventral hernia repair (LVHR). Patients who underwent emergent OVHRs were older, more comorbid, and more likely to be septic at the time of surgery than those undergoing emergent LVHRs. Emergent OVHR patients were more likely to have minor complications (22.1% versus 11.0%; OR 1.7; 95% CI 1.069-2.834). After controlling for confounding variables, LVHR and OVHR had similar outcomes, with the exception of higher rates of superficial surgical site infection in OVHR (5.0% versus 1.8%; odd's ratio (OR) 2.7; 95% confidence interval (CI) 1.176-6.138). Following multivariate analysis, laparoscopic approach demonstrated similar outcomes in major complications, reoperation, and 30-d mortality compared to open repairs. However, when controlling for other confounding factors, LVHR had reduced length of stay compared to OVHR (6.7 versus 4.0 d; 1.6 d longer, standard error 0.77, P < 0.03).

CONCLUSIONS

Emergent LVHR is associated with fewer superficial surgical site infection and shorter length of stay than OVHR but no difference in major complications, reoperation or 30-d mortality is associated with LVHR in the emergency setting.

Epiphrenic Diverticulum: 20-Year Single-Institution Experience

Epiphrenic diverticula are pulsion-type outpouchings of the distal esophagus associated with motility disorders. They can present with chronic symptoms of dysphagia, regurgitation, reflux, and aspiration. A prospectively collected surgical outcomes database was queried for patients who underwent surgical treatment of epiphrenic diverticula at a single institution between August 1997 and August 2018. Patient demographics, presenting symptoms, operative intervention, and perioperative data were retrospectively reviewed. Twenty-seven patients with a symptomatic epiphrenic diverticulum were identified. Abnormal esophageal motility was diagnosed in 16 patients (59.2%), most commonly achalasia (29.6%). All patients had a minimally invasive (26 laparoscopic, one thoracoscopic) diverticulectomy with no conversions to open required. Concurrent myotomy was performed in 88.9 per cent patients and anti-reflux procedure in 85.2 per cent patients. There was minimal morbidity with no esophageal leaks, mortalities, or recurrent diverticula noted after 35.8 months of follow-up. Dysphagia was the most common persistent symptom and occurred in 11.1 per cent; overall resolution of symptoms was achieved with surgery in 89.9 per cent of patients. As minimally invasive techniques have advanced, laparoscopic diverticulectomy seems to be an excellent surgical approach for symptomatic epiphrenic diverticula. Long-term resolution of symptoms was achieved in most patients, with a very low complication rate.

Epiphrenic Diverticulum: 20-Year Single-Institution Experience

Epiphrenic diverticula are pulsion-type outpouchings of the distal esophagus associated with motility disorders. They can present with chronic symptoms of dysphagia, regurgitation, reflux, and aspiration. A prospectively collected surgical outcomes database was queried for patients who underwent surgical treatment of epiphrenic diverticula at a single institution between August 1997 and August 2018. Patient demographics, presenting symptoms, operative intervention, and perioperative data were retrospectively reviewed. Twenty-seven patients with a symptomatic epiphrenic diverticulum were identified. Abnormal esophageal motility was diagnosed in 16 patients (59.2%), most commonly achalasia (29.6%). All patients had a minimally invasive (26 laparoscopic, one thoracoscopic) diverticulectomy with no conversions to open required. Concurrent myotomy was performed in 88.9 per cent patients and anti-reflux procedure in 85.2 per cent patients. There was minimal morbidity with no esophageal leaks, mortalities, or recurrent diverticula noted after 35.8 months of follow-up. Dysphagia was the most common persistent symptom and occurred in 11.1 per cent; overall resolution of symptoms was achieved with surgery in 89.9 per cent of patients. As minimally invasive techniques have advanced, laparoscopic diverticulectomy seems to be an excellent surgical approach for symptomatic epiphrenic diverticula. Long-term resolution of symptoms was achieved in most patients, with a very low complication rate.