Comparison of Telfa Rolling and a Closed Washing System for Autologous Fat Processing Techniques in Postmastectomy Breast Reconstruction

BACKGROUND

The purpose of this study was to compare the commonly used fat grafting techniques-Telfa rolling and a closed washing system-in breast reconstruction patients.

METHODS

Consecutive patients undergoing fat grafting were retrospectively reviewed and grouped by technique. Patients with less than 180 days of follow-up were excluded. Demographics, operative details, and complications were compared using univariate analysis with significance set at p < 0.05.

RESULTS

Between January of 2013 and September of 2017, 186 women underwent a total of 319 fat grafting procedures. There was no difference in demographics, number of procedures performed, volume of fat grafted, and number of days after reconstruction that fat grafting was performed between groups (p > 0.05). Telfa rolling patients had longer operative times for second fat grafting procedures (implant exchange often completed prior) [100.0 minutes (range, 60.0 to 150.0 minutes) versus 79.0 minutes (range, 64.0 to 94.0 minutes); p = 0.03]. Telfa rolling breasts had more palpable masses requiring imaging (26.0 percent versus 14.4 percent; p = 0.01) and an increased incidence of fat necrosis (20.6 percent versus 8.0 percent; p < 0.01). The closed washing system was found to be an independent predictor of decreased rates of imaging-confirmed fat necrosis (OR, 0.29; p = 0.048). There was no difference in fat necrosis excision or cancer recurrence between the groups.

CONCLUSION

The closed washing system was independently associated with decreased rates of imaging-confirmed fat necrosis compared to Telfa rolling without an increase in other complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Green Operating Room: Simple Changes to Reduce Cost and Our Carbon Footprint

Generating over four billion pounds of waste each year, the healthcare system in the United States is the second largest contributor of trash with one-third produced by operating rooms. Our objective is to assess improvement in waste reduction and recycling after implementation of a Green Operating Room Committee (GORC) at our institution. A surgeon and nurse-initiated GORC was formed with members from corporate leadership, nursing, anesthesia, and OR staff. Initiatives for recycling opportunities, reduction of energy and water use as well as solid waste were implemented and the results were recorded. Since formation of GORC in 2008, our OR has diverted 6.5 tons of medical waste. An effort to recycle all single-use devices was implemented with annual solid waste reduction of approximately 12,860 lbs. Disposable OR foam padding was replaced with reusable gel pads at greater than $50,000 per year savings. Over 500 lbs of previously discarded batteries were salvaged from the OR and donated to charity or redistributed in the hospital ($9,000 annual savings). A “Power Down” initiative to turn off all anesthesia and OR lights and equipment not in use resulted in saving $33,000 and 234.3 metric tons of CO2 emissions reduced per year. Converting from soap to alcohol-based waterless scrub demonstrated a potential saving of 2.7 million liters of water annually. Formation of an OR committee dedicated to ecological initiatives can provide a significant opportunity to improve health care's impact on the environment and save money.

Postoperative Quality of Life after Open Transinguinal Preperitoneal Inguinal Hernia Repair Using Memory Ring or Three-dimensional Devices

A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m2. MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different ( P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD ( P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation ( P = 0.02); 28.7 versus 14.8 per cent had movement limitations ( P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.

Diffusion tensor tractography to visualize axonal outgrowth and regeneration in a 4-cm reverse autograft sciatic nerve rabbit injury model

BACKGROUND

Diffusion tensor tractography (DTT) has recently been shown to accurately detect nerve injury and regeneration. This study assesses whether 7-tesla (7T) DTT imaging is a viable modality to observe axonal outgrowth in a 4 cm rabbit sciatic nerve injury model fixed by a reverse autograft (RA) surgical technique.

METHODS

Transection injury of unilateral sciatic nerve (4 cm long) was performed in 25 rabbits and repaired using a RA surgical technique. Analysis of the nerve autograft was performed at 3, 6, and 11 weeks postoperatively and compared to normal contralateral sciatic nerve, used as control group. High-resolution DTT from ex vivo sciatic nerves were obtained using 3D diffusion-weighted spin-echo acquisitions at 7-T. Total axons and motor and sensory axons were counted at defined lengths along the graft.

RESULTS

At 11 weeks, histologically, the total axon count of the RA group was equivalent to the contralateral uninjured nerve control group. Similarly, by qualitative DTT visualization, the 11-week RA group showed increased fiber tracts compared to the 3 and 6 weeks counterparts. Upon immunohistochemical evaluation, 11-week motor axon counts did not significantly differ between RA and control; but significantly decreased sensory axon counts remained. Nerves explanted at 3 weeks and 6 weeks showed decreased motor and sensory axon counts.

DISCUSSION

7-T DTT is an effective imaging modality that may be used qualitatively to visualize axonal outgrowth and regeneration. This has implications for the development of technology that non-invasively monitors peripheral nerve regeneration in a variety of clinical settings.

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial

PURPOSE

To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis.

METHODS

This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared.

RESULTS

Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001).

CONCLUSION

Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

Image once, print thrice? Three-dimensional printing of replacement parts

OBJECTIVE

The last 20 years has seen an exponential increase in 3D printing as it pertains to the medical industry and more specifically surgery. Previous reviews in this domain have chosen to focus on applications within a specific field. To our knowledge, none have evaluated the broad applications of patient-specific or digital imaging and communications in medicine (DICOM) derived applications of this technology.

METHODS

We searched PUBMED and CINAHL from April 2012 to April 2017.

RESULTS

261 studies fulfilled the inclusion criteria. Proportions of articles reviewed: DICOM (5%), CT (38%), MRI (20%), Ultrasonography (28%), and Bio-printing (9%).

CONCLUSION

There is level IV evidence to support the use of 3D printing for education, pre-operative planning, simulation and implantation. In order to make this technology widely applicable, it will require automation of DICOM to standard tessellation language to implant. Advances in knowledge: Recent lapses in intellectual property and greater familiarity with rapid prototyping in medicine has set the stage for the next generation of custom implants, simulators and autografts. Radiologists may be able to help establish reimbursable procedural terminology.

Predictors and Outcomes of Nondiagnostic Ultrasound for Acute Appendicitis in Children

Ultrasound assessments of children with possible acute appendicitis (AA) are often nondiagnostic. We aimed to identify the predictors of nondiagnostic ultrasound and to investigate the outcomes. A retrospective review was conducted on children aged 4 to 17 years evaluated in 2013 for AAwith ultrasound at a tertiary hospital pediatric emergency department. Demographics, clinical data, and outcomes were analyzed. Of 528 children, 194 (36.7%) had diagnostic ultrasounds and 334 (63.3%) had nondiagnostic ultrasounds. Nondiagnostic ultrasounds were more common after-hours (7 pm–7 am weekdays and on weekends, 70.7%) than during business hours (7 am–7 pm weekdays; 29.3%). After-hours timing and female sex were identified as independent predictors of non-diagnostic ultrasounds (P < 0.05 for both). AA was diagnosed in 35 children with a nondiagnostic ultrasound (10.5%; P < 0.05). No child who underwent a nondiagnostic ultrasound was found to have AA with laboratory values of white blood cell < 11 x 103/μL and c-reactive protein (CRP) < 5 mg/dL. Children with nondiagnostic ultrasounds have a low likelihood of AA if white blood cell < 11 and CRP < 5. We propose a management algorithm that we hope will help reduce admissions and decrease the use of computed tomography scans.

Predictors and Outcomes of Nondiagnostic Ultrasound for Acute Appendicitis in Children

Ultrasound assessments of children with possible acute appendicitis (AA) are often nondiagnostic. We aimed to identify the predictors of nondiagnostic ultrasound and to investigate the outcomes. A retrospective review was conducted on children aged 4 to 17 years evaluated in 2013 for AA with ultrasound at a tertiary hospital pediatric emergency department. Demographics, clinical data, and outcomes were analyzed. Of 528 children, 194 (36.7%) had diagnostic ultrasounds and 334 (63.3%) had nondiagnostic ultrasounds. Nondiagnostic ultrasounds were more common after-hours (7 pm-7 am weekdays and on weekends, 70.7%) than during business hours (7 am-7 pm weekdays; 29.3%). After-hours timing and female sex were identified as independent predictors of nondiagnostic ultrasounds (P < 0.05 for both). AA was diagnosed in 35 children with a nondiagnostic ultrasound (10.5%; P < 0.05). No child who underwent a nondiagnostic ultrasound was found to have AA with laboratory values of white blood cell < 11 × 103/µL and c-reactive protein (CRP) < 5 mg/dL. Children with nondiagnostic ultrasounds have a low likelihood of AA if white blood cell < 11 and CRP < 5. We propose a management algorithm that we hope will help reduce admissions and decrease the use of computed tomography scans.

Bladder Fill after Laparoscopic Inguinal Hernia Repair Reduces Time to Discharge

Laparoscopic inguinal herniorrhaphy (LIH) has a relatively high risk of urinary retention. Bladder dysfunction may delay discharge after LIH. We hypothesized that filling the bladder before Foley catheter removal decreases time to discharge (TTD) after LIH. A secondary aim was to determine incidence of postoperative urinary retention (POUR) after bladder fill (BF). We reviewed a consecutive series of total extraperitoneal and transabdominal preperitoneal LIH procedures performed by a single surgeon at our institution from 2010 to 2013. All patients were catheterized during LIH, and selected patients received a 200-mL saline BF before Foley catheter removal. Patients were required to void >250 mL before discharge. TTD and incidence of POUR were compared between the BF and no-BF groups. A total of 161 LIH cases were reviewed. BF was performed in 89/161 (55%) of cases. TTD was significantly shorter in the BF versus the no-BF group (222 vs 286 minutes, respectively; P < 0.01). Patient and operative characteristics were similar between the BF and no-BF groups (P > 0.05). Incidence of POUR in the BF and the no-BF group was 10.1 and 16.7 per cent, respectively; however, this difference was not significant (P = 0.22). No postoperative urinary tract infection occurred in either group. In conclusions, postoperative BF significantly reduces TTD after LIH. Further studies may help to determine whether shorter postanesthesia care unit time and lower POUR rates associated with BF can lower LIH procedural costs and increase patient satisfaction.

Bladder Fill after Laparoscopic Inguinal Hernia Repair Reduces Time to Discharge

Laparoscopic inguinal herniorrhaphy (LIH) has a relatively high risk of urinary retention. Bladder dysfunction may delay discharge after LIH. We hypothesized that filling the bladder before Foley catheter removal decreases time to discharge (TTD) after LIH. A secondary aim was to determine incidence of postoperative urinary retention (POUR) after bladder fill (BF). We reviewed a consecutive series of total extraperitoneal and transabdominal preperitoneal LIH procedures performed by a single surgeon at our institution from 2010 to 2013. All patients were catheterized during LIH, and selected patients received a 200-mL saline BF before Foley catheter removal. Patients were required to void >250 mL before discharge. TTD and incidence of POUR were compared between the BF and no-BF groups. A total of 161 LIH cases were reviewed. BF was performed in 89/161 (55%) of cases. TTD was significantly shorter in the BF versus the no-BF group (222 vs 286 minutes, respectively; P < 0.01). Patient and operative characteristics were similar between the BF and no-BF groups (P > 0.05). Incidence of POUR in the BF and the no-BF group was 10.1 and 16.7 per cent, respectively; however, this difference was not significant (P = 0.22). No postoperative urinary tract infection occurred in either group. In conclusions, postoperative BF significantly reduces TTD after LIH. Further studies may help to determine whether shorter postanesthesia care unit time and lower POUR rates associated with BF can lower LIH procedural costs and increase patient satisfaction.

Acute Colonic Pseudo-obstruction: Defining the Epidemiology, Treatment, and Adverse Outcomes of Ogilvie's Syndrome

Acute colonic pseudo-obstruction (ACPO) is a rare but often fatal disease. Herein, we present the largest study to date on ACPO. The National Inpatient Sample was queried for ACPO diagnoses from 1998 to 2011. Patients were analyzed by treatment into four groups: medical management (MM), colonoscopy alone [(endoscopy-only group) ENDO], surgery alone (SURG), or surgery and colonoscopy (SAC). Logistic regression was used to identify predictors of adverse outcomes by treatment group. There were 106,784 cases of ACPO: 96,657 (90.5%) MM, 2,915 (2.7%) ENDO, 6,731 (6.3%) SURG, and 481 (0.5%) SAC. The medical complication (45.7%), procedural complication (15.9%), and mortality rates (7.7%) were high. Increasing procedure invasiveness was independently associated with higher odds of medical complications, procedural complications, and death (P < 0.0125). The odds of death were significantly higher in the ENDO [odds ratio (OR) = 1.2], SURG (OR 1.4), and SAC (OR = 1.8) groups (P < 0.0125). Those who fail MM and require procedures have increasing morbidity and mortality with increasing invasiveness, likely reflecting the severity of their conditions.

A prospective randomized double-blinded controlled trial evaluating indocyanine green fluorescence angiography on reducing wound complications in complex abdominal wall reconstruction

BACKGROUND

The purpose of this prospective, randomized, double-blinded controlled trial was to investigate the utility of indocyanine green fluorescence angiography (ICG-FA) in reducing wound complications in complex abdominal wall reconstruction.

MATERIALS AND METHODS

All consented patients underwent ICG-FA with SPY Elite after hernia repair and before flap closure. They were randomized into the control group, in which the surgical team was blinded to ICG-FA images and performed surgery as they normally would, or the experimental group, in which the surgery team viewed the images and could modify tissue flaps according to their findings. Patient variables and wound complications were compared with standard statistical methods.

RESULTS

Among 95 patients, n = 49 control versus n = 46 experimental, preoperative characteristics were similar including age (58.3 versus 56.7 y; P = 0.4), body mass index (34.9 versus 33.6 kg/m(2); P = 0.8), tobacco use (8.2% versus 8.7%; P = 0.9), diabetes (30.6% versus 37.0%; P = 0.5), and previous hernia repair (71.4% versus 60.9%; P = 0.3). Operative characteristics were also similar, including rate of panniculectomy (69.4% versus 58.7%; P = 0.3) and component separation (73.5% versus 69.6%; P = 0.6). The experimental group more often had advancement flaps modified (37% versus 4.1%, P < 0.0001). There was no difference between groups in rates of skin necrosis (6.1% versus 2.2%; P = 0.3), fat necrosis (10.2% versus 13.0%, P = 0.7), reoperation (14.3% versus 26.1%, P = 0.7), wound infection (10.2% versus 21.7%; P = 0.12), or overall wound-related complications (32.7% versus 37.0%, P = 0.7). Skin/subcutaneous hypoperfusion on ICG-FA was associated with higher rates of wound infection (28% versus 9.4%, P < 0.02), but flap modification after viewing images did not prevent wound-related complications (15.6% versus 12.5%, P = 0.99).

CONCLUSIONS

This is the first randomized, double-blinded, controlled trial to evaluate ICG-FA in abdominal wall reconstruction. Although ICG-FA guidance and intraoperative modification of flaps did not prevent wound-related complications or reoperation, it did identify at risk patients.

National Trends in the Surgical Treatment of Ovarian Torsion in Children: An Analysis of 2041 Pediatric Patients Utilizing the Nationwide Inpatient Sample

The aim of this study was to evaluate the national trends in surgical management of ovarian torsion (OT) in children. The Nationwide Inpatient Sample was queried from 1998 to 2011 for females less than 18 years of age with OT. Patients were stratified into three treatment groups: oophorectomy (OO), oophoropexy, or release of torsion (RT) alone. There were 2041 patients with OT, of which 1598 (78%) underwent OO, 126 (6%) oophoropexy, and 317 (15%) RT. RT significantly increased from 1998 to 2011 (9% vs 25%; P < 0.05). At nonteaching hospitals, there were higher rates of OO (89.3% vs 79.5%; P < 0.05) and lower rates of RT (10.7% vs 20.5%; P < 0.05) compared with teaching hospitals. RT was performed at a higher rate in Northeast United States compared with the South (22.7% vs 14.2%; P < 0.05). Girls presenting at nonteaching hospitals and the South had increased odds of undergoing OO compared with those presenting at teaching hospitals and the Northeast ( P < 0.05). Although ovarian conservation for OT in children is more often performed in the Northeast United States and at teaching hospitals, this large population-based study demonstrates OO remains the most common surgical management for OT in the United States.

National Trends in the Surgical Treatment of Ovarian Torsion in Children: An Analysis of 2041 Pediatric Patients Utilizing the Nationwide Inpatient Sample

The aim of this study was to evaluate the national trends in surgical management of ovarian torsion (OT) in children. The Nationwide Inpatient Sample was queried from 1998 to 2011 for females less than 18 years of age with OT. Patients were stratified into three treatment groups: oophorectomy (OO), oophoropexy, or release of torsion (RT) alone. There were 2041 patients with OT, of which 1598 (78%) underwent OO, 126 (6%) oophoropexy, and 317 (15%) RT. RT significantly increased from 1998 to 2011 (9% vs 25%; P < 0.05). At nonteaching hospitals, there were higher rates of OO (89.3% vs 79.5%; P < 0.05) and lower rates of RT (10.7% vs 20.5%; P < 0.05) compared with teaching hospitals. RT was performed at a higher rate in Northeast United States compared with the South (22.7% vs 14.2%; P < 0.05). Girls presenting at nonteaching hospitals and the South had increased odds of undergoing OO compared with those presenting at teaching hospitals and the Northeast (P < 0.05). Although ovarian conservation for OT in children is more often performed in the Northeast United States and at teaching hospitals, this large population-based study demonstrates OO remains the most common surgical management for OT in the United States.

Defining surgical outcomes and quality of life in massive ventral hernia repair: an international multicenter prospective study

BACKGROUND

Our goal was to set criteria for massive ventral hernia and to compare surgical outcomes and quality of life after ventral hernia repair (VHR).

METHODS

The International Hernia Mesh Registry was queried for patients undergoing VHR from 2007 to 2013. Defect was categorized as massive if the width or length was greater than 15 cm or area greater than 150 cm(2). Massive VHR was compared to regular VHR.

RESULTS

A total of 878 patients underwent VHR: 436 open, 442 laparoscopic with 13 deaths (1.5%) and 45 hernia recurrences (5.1%). Of those, 158 patients (18%) met criteria for massive VHR. Massive VHR patients had longer length of stay (LOS) and operative time and more hematomas, wound infections, wound complications, and pneumonias (P < .05). On multivariate analysis, LOS was longer, and early postoperative pain and activity limitation were greater in massive VHRs (P < .01). Massive VHR in the laparoscopic approach resulted in greater long-term mesh sensation (P < .01).

CONCLUSIONS

VHR in massive hernias have increased rates of complications and longer LOS.

Intraoperative indocyanine green fluorescence angiography to predict wound complications in complex ventral hernia repair

INTRODUCTION

Complex ventral hernia repair (VHR) is associated with a greater than 30% wound complication rate. Perfusion mapping using indocyanine green fluorescence angiography (ICG-FA) has been demonstrated to predict skin and soft tissue necrosis in many reconstructive procedures; however, it has yet to be evaluated in VHR.

METHODS

Patients undergoing complex VHR involving component separation and/or extensive subcutaneous advancement flaps were included in a prospective, blinded study. Patients with active infection were excluded. ICG-FA was performed prior to incision and prior to closure, but the surgeon was not allowed to view it. An additional blinded surgeon documented wound complications and evaluated postoperative photographs. The operative ICG-FA was reviewed blinded, and investigators were then unblinded to determine its ability to predict wound complications.

RESULTS

Fifteen consecutive patients were enrolled with mean age of 56.1 years and average BMI of 34.9, of which 60% were female. Most (73.3%) had prior hernia repairs (average of 1.8 prior repairs). Mean defect area was 210.4 cm2, mean OR time was 206 min, 66.6% of patients underwent concomitant panniculectomy, and 40% had component separation. Mean follow-up was 7 months. Two patients developed wound breakdown requiring reoperation, while 1 had significant fat necrosis and another a wound infection, requiring operative intervention. ICG-FA was objectively reviewed and predicted all 4 wound complications. Of the 12 patients without complications, 1 had an area of low perfusion on ICG-FA. This study found a sensitivity of 100% and specificity of 90.9% for predicting wound complications using ICG-FA.

CONCLUSION

In complex VHR patients, subcutaneous perfusion mapping with ICG-FA is very sensitive and has the potential to reduce cost and improve patient quality of life by reducing wound complications and reoperation.

Local Anesthesia in Open Inguinal Hernia Repair Improves Postoperative Quality of Life Compared to General Anesthesia: A Prospective, International Study

The choice of general (GA) versus local anesthesia (LA) in open inguinal hernia repair (OIHR) has a substantial financial impact and may influence clinical outcomes. Our study compares postoperative quality of life (QOL) in patients undergoing OIHR under LA versus GA. A cooperative prospective study from centers in 10 countries was performed through the International Hernia Mesh Registry from 2007 to 2012. QOL was compared at one, six, 12, and 24 months for LA versus GA with univariate and multivariate analysis controlling for known confounding variables. Of 1128 patients who underwent OIHR, 585(52%) used GA and 533(48%) used LA. Most were male (92%) with unilateral (94%), primary (91%) repairs with a mean age 57 ± 16 years. There was no difference ( P > 0.05) in age, gender, operative time, mesh size, length of stay, infection, recurrence, reoperation, or death. Multivariate analysis demonstrated significant QOL differences between groups: GA had higher odds of discomfort at one and six months [odds ratio (OR) 3.3, 2.0], movement limitation at one and six months (OR 3.5, 2.8), and mesh sensation at one and 12 months (OR 2.9, 1.8). Overall, patients undergoing OIHR under LA had improved postoperative QOL in the short and long term compared with GA.

Local Anesthesia in Open Inguinal Hernia Repair Improves Postoperative Quality of Life Compared to General Anesthesia: A Prospective, International Study

The choice of general (GA) versus local anesthesia (LA) in open inguinal hernia repair (OIHR) has a substantial financial impact and may influence clinical outcomes. Our study compares postoperative quality of life (QOL) in patients undergoing OIHR under LA versus GA. A cooperative prospective study from centers in 10 countries was performed through the International Hernia Mesh Registry from 2007 to 2012. QOL was compared at one, six, 12, and 24 months for LA versus GA with univariate and multivariate analysis controlling for known confounding variables. Of 1128 patients who underwent OIHR, 585(52%) used GA and 533(48%) used LA. Most were male (92%) with unilateral (94%), primary (91%) repairs with a mean age 57 ± 16 years. There was no difference (P > 0.05) in age, gender, operative time, mesh size, length of stay, infection, recurrence, reoperation, or death. Multivariate analysis demonstrated significant QOL differences between groups: GA had higher odds of discomfort at one and six months [odds ratio (OR) 3.3, 2.0], movement limitation at one and six months (OR 3.5, 2.8), and mesh sensation at one and 12 months (OR 2.9, 1.8). Overall, patients undergoing OIHR under LA had improved postoperative QOL in the short and long term compared with GA.

Impact of Implementing an Electronic Health Record on Surgical Resident Work Flow, Duty Hours, and Operative Experience

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means ( P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation ( P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation ( P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

Impact of implementing an electronic health record on surgical resident work flow, duty hours, and operative experience

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means (P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation (P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation (P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events

INTRODUCTION

Laparoscopic Heller myotomy (LHM) has supplanted an open approach due to decreased operative morbidity. Our goal was to quantify the incidence of peri-operative complications and identify risk factors for adverse outcomes in LHM.

METHODS

All LHM were queried from 2005 to 2011 from the National Surgical Quality Improvement Program database. Adverse outcomes were identified, and univariate and stepwise logistic regression (MVR) was then performed to quantify association.

RESULTS

There were 1,237 LHM in the study period. Patient averages were: age 51.9 ± 16.8 years, BMI 27.3 ± 6.6 kg/m(2), Charlson comorbidity index (CCI) 0.2 ± 0.6. 15.3 % had >10 % body mass loss in the preoperative 6 months. During surgery, 10.2 % underwent concomitant EGD, and mean operative time was 141.6 ± 63.4 min. There were 7(0.06 %) wound complications, 22(1.8 %) general complications, and 30(2.4 %) major complications. Average length of stay (LOS) was 2.8 ± 5.5 days. The rate of readmission and reoperation were 3.1 and 2.3 %, respectively, and there were 4(0.03 %) deaths. General and major complications were associated with alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times (p < 0.05); however, these factors did not remain significant on MVR (p > 0.05). Operative time was found to be significantly longer by 35.3 min for inpatients, 43.1 min in functionally dependent patients, 50.0 min in preoperative septic patients, and 17.2 min with concomitant EGD (p < 0.01 for all). LOS was found to be longer by 1.9 days for inpatients, 1.8 days in ASA category ≥3, and 1.2 days per one point increase in CCI (p < 0.001 for all).

CONCLUSION

LHM is being performed nationally with a low incidence of operative complications and mortality. General and major complications following LHM are associated with patient alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times. Additionally, independent predictors of longer operative time and LOS were identified.

Outcomes of pancreatic debridement in acute pancreatitis: analysis of the nationwide inpatient sample from 1998 to 2010

BACKGROUND

The objective of this study was to perform a national review of patients with acute pancreatitis (AP) who undergo pancreatic debridement (PD) to evaluate for risk factors of in-hospital mortality.

METHODS

The Nationwide Inpatient Sample was used to identify patients with AP who underwent PD between 1998 and 2010. Risk factors for in-hospital mortality were assessed with multivariate logistic regression.

RESULTS

From 1998 to 2010, there were 585,978 nonelective admissions with AP, of which 1,783 (.3%) underwent PD. From 1998 to 2010, the incidence of PD decreased from .44% to .25% (P < .01) and PD in-hospital mortality decreased from 29.0% to 15% (P < .05). Of patients undergoing PD, independent factors associated with increased odds of mortality were increased age (odds ratio [OR] 1.04, confidence interval [CI] 1.03 to 1.05; P < .01), sepsis with organ failure (OR 1.76, CI 1.24 to 2.51; P < .01), peptic ulcer disease (OR 1.83, CI 1.02 to 3.30; P < .05), liver disease (OR 2.27, CI 1.36 to 3.78; P < .01), and renal insufficiency (OR 1.78, CI 1.14 to 2.78; P < .05).

CONCLUSIONS

The incidence and operative mortality of PD have decreased significantly over the last decade in the United States with higher odds of dying in patients who are older, with chronic liver, renal, or ulcer disease, and higher rates of sepsis with organ failure.

The first nationwide evaluation of robotic general surgery: a regionalized, small but safe start

BACKGROUND

The purpose of this study was to evaluate the outcomes of the most commonly performed robotic-assisted general surgery (RAGS) procedures in a nationwide database and compare them with their laparoscopic counterparts.

METHODS

The Nationwide Inpatient Sample was queried from October 2008 to December 2010 for patients undergoing elective, abdominal RAGS procedures. The two most common, robotic-assisted fundoplication (RF) and gastroenterostomy without gastrectomy (RG), were individually compared with the laparoscopic counterparts (LF and LG, respectively).

RESULTS

During the study, 297,335 patients underwent abdominal general surgery procedures, in which 1,809 (0.6 %) utilized robotic-assistance. From 2009 to 2010, the incidence of RAGS nearly doubled from 573 to 1128 cases. The top five RAGS procedures by frequency were LG, LF, laparoscopic lysis of adhesions, other anterior resection of rectum, and laparoscopic sigmoidectomy. Eight of the top ten RAGS were colorectal or foregut operations. RG was performed in 282 patients (0.9 %) and LG in 29,677 patients (99.1 %). When comparing RG with LG there was no difference in age, gender, race, Charlson comorbidity index (CCI), postoperative complications, or mortality; however, length of stay (LOS) was longer in RG (2.5 ± 2.4 vs. 2.2 ± 1.5 days; p < 0.0001). Total cost for RG was substantially higher ($60,837 ± 28,887 vs. $42,743 ± 23,366; p < 0.0001), and more often performed at teaching hospitals (87.2 vs. 50.9 %; p < 0.0001) in urban areas (100 vs. 93.0 %; p < 0.0001). RF was performed in 272 patients (3.5 %) and LF in 7,484 patients (96.5 %). RF patients were more often male compared with LF (38.2 vs. 32.3 %; p < 0.05); however, there was no difference in age, race, CCI, LOS, or postoperative complications. RF was more expensive than LF ($37,638 ± 21,134 vs. $32,947 ± 24,052; p < 0.0001), and more often performed at teaching hospitals (72.4 vs. 54.9 %; p < 0.0001) in urban areas (98.5 vs. 88.7 %; p < 0.0001).

CONCLUSIONS

This nationwide study of RAGS exemplifies its low but increasing incidence across the country. RAGS is regionalized to urban teaching centers compared with conventional laparoscopic techniques. Despite similar postoperative outcomes, there is significantly increased cost associated with RAGS.

Postoperative quality of life after open transinguinal preperitoneal inguinal hernia repair using memory ring or three-dimensional devices

A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m(2). MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different (P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD (P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation (P = 0.02); 28.7 versus 14.8 per cent had movement limitations (P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.

Emphysematous gastritis with delayed gastric perforation

INTRODUCTION

Emphysematous gastritis (EG) is a rare infection of the stomach caused by gas-producing organisms. It is often associated with high mortality, and operative intervention is avoided unless medical management fails to control sepsis, or patients develop gastric perforation.

DISCUSSION

We present the case of a 24-year-old female with poorly controlled diabetes who presented with persistent vomiting and severe hyperglycemia. Prompt diagnosis of EG was obtained when computed tomography of the abdomen revealed gas throughout her stomach wall and portal venous system. She was treated with antibiotics, bowel rest, and close observation. The patient returned with contained gastric perforation and was successfully managed without surgery. This case demonstrates that delayed gastric perforation as a complication of EG can be successfully managed without surgery, and in selected cases, gastric perforation is not an absolute indication for surgery.

The green operating room: simple changes to reduce cost and our carbon footprint

Generating over four billion pounds of waste each year, the healthcare system in the United States is the second largest contributor of trash with one-third produced by operating rooms. Our objective is to assess improvement in waste reduction and recycling after implementation of a Green Operating Room Committee (GORC) at our institution. A surgeon and nurse-initiated GORC was formed with members from corporate leadership, nursing, anesthesia, and OR staff. Initiatives for recycling opportunities, reduction of energy and water use as well as solid waste were implemented and the results were recorded. Since formation of GORC in 2008, our OR has diverted 6.5 tons of medical waste. An effort to recycle all single-use devices was implemented with annual solid waste reduction of approximately 12,860 lbs. Disposable OR foam padding was replaced with reusable gel pads at greater than $50,000 per year savings. Over 500 lbs of previously discarded batteries were salvaged from the OR and donated to charity or redistributed in the hospital ($9,000 annual savings). A "Power Down" initiative to turn off all anesthesia and OR lights and equipment not in use resulted in saving $33,000 and 234.3 metric tons of CO2 emissions reduced per year. Converting from soap to alcohol-based waterless scrub demonstrated a potential saving of 2.7 million liters of water annually. Formation of an OR committee dedicated to ecological initiatives can provide a significant opportunity to improve health care's impact on the environment and save money.

Preliminary results of surgical and quality of life outcomes of Physiomesh in an international, prospective study

Physiomesh is a novel, lightweight, large pore, polypropylene mesh designed to have flexibility that matches the compliance of the abdominal wall in an effort to improve patient quality of life (QOL). The International Hernia Mesh Registry was queried for ventral hernia repair (VHR) and inguinal hernia repair (IHR) with Physiomesh. Demographics, operative and postoperative details, and the Carolinas Comfort Scale (CCS) as a measure of QOL were recorded. Physiomesh was used in 100 patients, 29 IHR and 71 VHR. Their average age was 56.8 +/- 13.7, and BMI was 34.0 +/- 21.0 kg/m2. For IHR, preoperative pain (CCS > or = 2) was present in 41%, but decreased at 1, 6, and 12 months postoperatively to 25.9%, 0%, and 1.6%, while movement limitation decreased from 42.9% to 18.5%, 1.6%, and 3.1%. There were no complications or recurrences. The average VHR measured 66.4 cm2; 93% underwent a laparoscopic repair. Pain was present in 59.1% preoperatively but 21% at 12 months. Movement limitations reduced from 43.2% to 15.8% at 12 months. Mesh sensation was reported in only 10.5% at 1 year. There was 1 recurrence. Physiomesh is well tolerated by patients undergoing IHR and VHR. It is associated with a very favorable long-term QOL.