Bridget Ermlich

A 5-Year Clinical Experience With Single-Staged Repairs of Infected and Contaminated Abdominal Wall Defects Utilizing Biologic Mesh

Objective:Our objective was to evaluate the safety and durability of biologic mesh for single-staged reconstruction of contaminated fields. Introduction:The presence of contamination during ventral hernia repair (VHR) poses a significant challenge. Some advocate for a multistaged reconstructive approach with delayed definitive repair, whereas others perform definitive repair at the initial operation. Methods:Patients undergoing single-staged VHR in a contaminated field with biologic mesh over a 5-year period were retrospectively reviewed from a prospectively maintained database. Outcome measures included wound complication and hernia recurrence. Results:A total of 128 patients (76 F, 52 M) were identified, with a mean age of 58.2 years, mean American Society of Anesthesiologist (ASA) score 3.1, and mean body mass index (BMI) 34.1 ± 9.7 kg/m2. Comorbidities included COPD (n = 29), diabetes (n = 65), smoking (n = 29), and immunosuppression (n = 8). Mean hernia defect size was 431 cm2 (range 40–2450 cm2). Reasons for contamination included the presence of infected mesh (n = 45), stoma (n = 24), concomitant gastrointestinal (GI) surgery (n = 17), enterocutaneous fistula (n = 25), open nonhealing wound(s) (n = 6), enterotomy/colotomy (n = 5), and chronic draining sinus (n = 6). Postoperative wound complications were identified in 61 (47.7%) patients. Predictors of wound complications included ASA score, diabetes, smoking, number of previous abdominal surgeries or hernia repairs, hernia defect size, and operative time. With a mean follow-up time of 21.7 months, hernia recurrence was identified in 40 (31.3%) patients. The majority of recurrent hernias were asymptomatic and 7 patients underwent repair. Conclusions:Despite the high rate of wound morbidity associated with single-staged reconstruction of contaminated fields, it can safely be performed with biologic mesh reinforcement. Although biologic mesh in these situations is safe, the long-term durability seems to be less favorable.

Discharge within 24 to 72 Hours of Colorectal Surgery Is Associated with Low Readmission Rates when Using Enhanced Recovery Pathways

BACKGROUND Enhanced Recovery Pathways (ERPs) have demonstrated reduced hospital length of stay and improved outcomes after colorectal surgery. Concerns exist about increases in readmission rates. Laparoscopic colorectal surgery with an ERP can permit earlier discharge without compromising safety or increasing readmission rates. STUDY DESIGN A review of a prospective database was performed for major elective colorectal procedures by a single surgeon. All patients followed a standardized ERP and discharge criteria. Patients were categorized by approach and day of discharge (DoD) of ≤ 1, ≤ 2, ≤ 3, ≤ 7, and >7 days. Main outcomes measures were length of stay and 30-day readmission rates in each group. RESULTS Eight hundred and six cases (609 laparoscopic, 197 open) were identified during a 64-month period. Mean age was similar for the laparoscopic (59.1 years) and open (58.3 years) groups. Mean overall DoD was at 5 days (± 4.8 days); by approach, the mean laparoscopic DoD was at 3.9 days and open DoD was at 8.4 days. Twenty-nine percent were discharged within 48 hours (38% laparoscopic and 8% open) and 50% were discharged within 72 hours (62% laparoscopic and 19% open). Only 8.9% of all patients (n = 72) were readmitted (7.2% laparoscopic, 14.2% open). The cumulative readmission rate for laparoscopic patients in early DoD groups postoperative days 1, 2, and 3 were 0.2%, 1.6%, and 3.4%, respectively. CONCLUSIONS Combining laparoscopy with an ERP optimizes patient care in colorectal surgery. The combination permits early discharge; 38% were discharged within 2 days and 62% within 3 days of surgery, with low readmission rates. These results support that early DoD is possible without compromising patient safety or increasing readmission rates. This might be a marker for low readmission rate, and suggests that readmission rate alone might not be an adequate marker of quality.

Design and initial implementation of HerQLes: A hernia-related quality-of-life survey to assess abdominal wall function

BACKGROUND Success of a surgical intervention is often measured by hard clinical outcomes. In ventral hernia repair (VHR) these include wound morbidity and hernia recurrence. These outcomes fail to account for a surgical interventions effect on a patients quality of life (QofL). Our objective was to design a hernia-specific QofL instrument with a focus on abdominal wall function, evaluate its measurement properties, and assess the impact of VHR on QofL using this new instrument. STUDY DESIGN A 16-question QofL survey tool, HerQLes, was constructed. Patients presenting for elective VHR completed the survey. Rasch modeling was used to evaluate the items; fit statistics, person-item mapping, separation index, and reliability were examined. Associations between baseline characteristics and QofL were assessed. RESULTS Eighty-eight patients completed the survey before assessment for VHR. Mean age was 57.2 years (±12.4 years), mean American Society of Anesthesiologists score was 2.8 (±0.5), and mean body mass index was 34.9 kg/m(2) (±9.3 kg/m(2)). Based on Rasch modeling, 12 of 16 items met model fit criteria. The 4 poorly fitting items were eliminated from further analysis. The 12 items retained have good internal consistency reliability (0.86). On a 0- to 100-point scale, mean QofL score was 47.2 (±15.6). Patients with higher grade hernias had lower HerQLes scores (p = 0.06). Patients showed significant improvement in abdominal wall function and QofL 6 months after VHR (p < 0.01). CONCLUSIONS Quality-of-life is an important component of surgical management of ventral hernias. The 12-question QofL survey, HerQLes, is reliable and valid. At baseline, patients with more complex hernias tended to have a decreased abdominal wall function and QofL. Six months after surgical repair, HerQLes scores change in the predicted direction. We believe HerQLes is potentially a valuable tool to assess patient-centered abdominal wall functional improvements after VHR.

The Effect of Transversus Abdominis Plane Blocks on Postoperative Pain in Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind Trial

BACKGROUND:Superior early pain control has been suggested with transversus abdominis plane blocks, but evidence-based recommendations for transversus abdominis plane blocks and their effects on patient outcomes are lacking. OBJECTIVE:The aim of this study was to determine whether transversus abdominis plane blocks improve early postoperative outcomes in patients undergoing laparoscopic colorectal resection already on an optimized enhanced recovery pathway. DESIGN:This study is based on a prospective, randomized, double-blind controlled trial. SETTINGS:The trial was conducted at a tertiary referral center. PATIENTS:Patients undergoing elective laparoscopic colorectal resection were selected. INTERVENTIONS(S):Patients were randomly assigned to receive either a transversus abdominis plane block or a placebo placed intraoperatively under laparoscopic guidance. All followed a standardized enhanced recovery pathway. Patient demographics, perioperative procedures, and postoperative outcomes were collected. MAIN OUTCOME MEASURES:Postoperative pain and nausea/vomiting scores in the postanesthesia care unit and department, opioid use, length of stay, and 30-day readmission rates were measured. RESULTS:The trial randomly assigned 41 patients to the transversus abdominis plane block group and 38 patients to the control group. Demographic, clinical, and procedural data were not significantly different. In the postanesthesia care unit, the transversus abdominis plane block group had significantly lower pain scores (p < 0.01) and used fewer opioids (p < 0.01) than the control group; postoperative nausea/vomiting scores were comparable (p = 0.99). The transversus abdominis plane group had significantly lower pain scores on postoperative day 1 (p = 0.04) and throughout the study period (p < 0.01). There was no significant difference between groups in postoperative opioid use (p = 0.65) or nausea/vomiting (p = 0.79). The length of stay (median, 2 days experimental, 3 days control; p = 0.50) and readmission rate (7% experimental, 5% control, p = 0.99) was similar across cohorts. LIMITATIONS:This study was conducted a single center. CONCLUSIONS:Transversus abdominis plane blocks improved immediate short-term opioid use and pain outcomes. Pain improvement was durable throughout the hospital stay. However, the blocks did not translate into less overall narcotic use, shorter length of stay, or lower readmission rates.

Demonstrating the Benefits of Transversus Abdominis Plane Blocks on Patient Outcomes in Laparoscopic Colorectal Surgery: Review of 200 Consecutive Cases

BACKGROUND Quality improvement in colorectal surgery (CRS) requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections. STUDY DESIGN Two hundred consecutive laparoscopic CRS patients received TAP blocks under laparoscopic guidance at the end of their operation. All were managed with a standardized ERP. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcomes measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates. RESULTS Of 200 cases, 194 were elective and 6 emergent. The main diagnosis was colorectal cancer (45%). The mean patient age was 61.2 years, mean body mass index was 29.2 kg/m(2), and the majority (63%) were American Society of Anesthesiologists (ASA) class III. The main procedure performed was a segmental colectomy (64%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The median LOS was 2 days (range 1 to 8 days). Twenty-one percent were discharged by postoperative day (POD) 1, 41% by POD 2, and 77% by POD 3. By POD 7, 99% were discharged. Twelve percent (n = 24) had complications, and 6.5% (n = 13) were readmitted. There were 3 unplanned reoperations and no mortalities. Comparing the first and second groups of 100 consecutive patients further tested the consistency of the TAP block benefit. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series. CONCLUSIONS Adding TAP blocks to an ERP facilitated shorter LOS with low readmission and reoperation rates when compared to previously published series. The effect appears durable and consistent in a large case series. Transversus abdominis plane blocks may be an efficient, cost-effective method for improving laparoscopic CRS results.

Prospective Case Series of a Novel Minimally Invasive Bipolar Coagulation System in the Treatment of Grade i and II Internal Hemorrhoids

Background. Existing nonsurgical procedures for the treatment of grade I and II internal hemorrhoids are often painful, technically demanding, and often necessitate multiple applications. This study prospectively assessed the safety and efficacy of the HET Bipolar System, a novel minimally invasive device, in the treatment of symptomatic grade I and II internal hemorrhoids. Methods. Patients with symptomatic grade I or II internal hemorrhoids despite medical management underwent hemorrhoidal ligation with the HET Bipolar System. Endpoints included resolution or improvement of hemorrhoidal bleeding and/or prolapse from baseline, recurrent or refractory symptoms, and pain. Results. Twenty patients were treated with the HET Bipolar System. Two were lost to follow-up. Refractory or recurrent bleeding was present in 8 of 18 (44.4%), 4 of 11 (36.4%), and 4 of 8 (50.0%) patients, and prolapse was reported by 1 of 18 (5.6%), 4 of 11 (36.4%), and 1/7 (14.3%) of patients at 1, 3, and 6 months, respectively. Bleeding improved from baseline in 88.2%, 81.8%, and 87.5% of patients, and resolution of baseline prolapse was seen in 11 of 11 (100%), 4 of 7 (57.1%), and 5 of 5 (100%) patients at the same intervals. Thirteen of 18 (72.2%) patients did not require additional treatment for their symptoms. Conclusions. The HET Bipolar System is safe and easy to use with short-term effectiveness comparable to that of currently used techniques for the treatment of symptomatic grade I and II internal hemorrhoids. It may be an effective alternative to rubber band ligation in patients with larger internal hemorrhoids and those with hemorrhoids close to the dentate line in which banding may produce debilitating pain.