Chao Tu

Is there an association between surgeon hat type and 30-day wound events following ventral hernia repair?

IntroductionWhile several patient and operative variables have been shown to be associated with an increased risk of postoperative wound events, the association between surgical hat type worn by surgeons and postoperative wound events remains controversial. The purpose of this study is to investigate the association between type of surgical hat worn by surgeons and the incidence of postoperative wound events following ventral hernia repair using the Americas Hernia Society Quality Collaborative database.MethodsAll surgeons who input at least ten patients with 30-day follow-up into the AHSQC were identified. These surgeons were sent a survey asking them to identify the type of surgical hat they wear in the operating room. The association of the type of surgical hat worn, patient variables, and operative factors with 30-day wound events was investigated using multivariate logistic regression.ResultsA total of 68 surgeons responded to the survey, resulting in 6210 cases available for analysis. The type of surgical hat worn by surgeons was not found to be associated with an increased risk of 30-day surgical site infections or surgical site occurrences requiring procedural intervention.ConclusionOur study is the first study to directly compare the association of surgical hat type with postoperative wound events. There is no association between the type of surgical hat worn and the incidence of postoperative wound events following ventral hernia repair. Our findings suggest that surgical hate type may be chosen at the discretion of operating room personnel without fear of detriment to their patients.

Comparative Outcomes of Bariatric Surgery in Patients With and Without Human Immunodeficiency Virus

BackgroundParadoxically, advances in anti-retroviral therapy that has increased survival for patients with human immunodeficiency virus (HIV) have resulted in greater numbers of HIV+ patients developing other chronic diseases, including obesity. Little comparative literature exists detailing perioperative or metabolic outcomes of bariatric surgery in the HIV+ population compared to HIV negative (HIV−) controls.MethodsThis is a retrospective case-control study with both HIV+ (case) and HIV− control patients. Individuals undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between January 1, 2006 and December 31, 2015 were included. HIV+ status was defined as any individual with documented history of HIV.ResultsEleven HIV+ patients underwent RYGB or SG during the study period. After matching (1:5 HIV+: HIV−) both cohorts had similar mean age (42 years), gender distribution (63% female), and preoperative BMI (48 kg/m2), as well as comorbidities. There were no differences in postoperative length of stay, or all cause 30-day morbidity. There were 63.7% HIV+ and 76.4% with 1-year follow-up available. Both percent excess weight loss (56% HIV+ vs. 60% HIV−) and BMI (32 HIV+ vs. 34xa0kg/m2 HIV−) were similar in both groups. There were minimal changes to CD4 count or HIV viral load in the patients during the follow-up period.ConclusionBariatric surgery is safe and feasible in HIV-infected population well controlled on anti-retroviral medication. The short-term surgical and metabolic outcomes are similar to HIV− controls with minimal effect on the CD4 count and viral load in HIV+ cohort for long-term follow-up.

Adjustments to warfarin dosing after gastric bypass and sleeve gastrectomy

BACKGROUNDnWarfarin dosing after bariatric surgery may be influenced by alterations in gastrointestinal pH, transit time, absorptive surface area, gut microbiota, food intake, and adipose tissue.nnnOBJECTIVESnThe aim of this study was to describe trends in warfarin dosing after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).nnnSETTINGnSingle academic center.nnnMETHODSnAll patients chronically on warfarin anticoagulation before RYGB or SG were retrospectively identified. Indications for anticoagulation, history of bleeding or thrombotic events, perioperative complications, and warfarin dosing were collected.nnnRESULTSnFifty-three patients (RYGB n = 31, SG n = 22) on chronic warfarin therapy were identified (56.6% female, mean 54.4 ± 11.7 yr of age). Of this cohort, 34.0% had prior venous thromboembolic events, 43.4% had atrial fibrillation, and 5.7% had mechanical cardiac valves. Preoperatively, the average daily dose of warfarin was similar in the RYGB group (8.3 ± 4.1 mg) and SG group (6.9 ± 2.8 mg). One month after surgery, mean daily dose of warfarin was reduced 24.1% in the RYGB group (P<.001) and 23.2% in the SG group (P = .002). At 12 months postoperatively, the required daily warfarin dose compared with baseline remained statistically different (RYGB: 6.8 ± 3.8 mg; SG: 6.1 ± 2.0 mg).nnnCONCLUSIONSnThe warfarin dose is expected to be decreased by approximately 25% from preoperative levels after both RYGB and SG. Lower dose requirement within the first month after bariatric surgery is followed by a trend toward increased warfarin dose requirements, but remain less than baseline. Because dose requirements change constantly over time, frequent postoperative monitoring of the international normalized ratio is recommended.

A Population-Based Study of Early Postoperative Outcomes in Patients with Heart Failure Undergoing Bariatric Surgery

BackgroundWeight loss following bariatric surgery can improve cardiac function among patients with heart failure (HF). However, perioperative morbidity of bariatric surgery has not been evaluated in patients with HF.Study DesignThe National Surgical Quality Improvement Project (NSQIP) database for 2006–2014 was queried to identify patients undergoing adjustable gastric band, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion-duodenal switch. Patients with HF were propensity matched to a control group without HF (1:5). Univariate analyses evaluated differences in complications, and multivariate analysis was completed to predict all-cause morbidity.ResultsThere were 237 patients identified with HF (mean age 52.8xa0years, 59.9% female, mean body mass index 50.6xa0kg/m2) matched to 1185 controls without HF who underwent bariatric surgery. Preoperatively, patients with HF were more likely to be taking antihypertensive medication and have undergone prior percutaneous cardiac intervention and cardiac surgery. There was no difference in operative time, surgical site infections, acute renal failure, re-intubation, or myocardial infarction. HF was associated with increased likelihood of length of stay more than 7xa0days, likelihood to remain ventilated >u200948xa0h, venous thromboembolism, and reoperation. For patients with HF, the adjusted odds ratio for all-cause morbidity was 2.09 (1.32–3.22).ConclusionThe NSQIP definition of HF, which includes recent hospitalization for HF exacerbation or new HF diagnosis 30xa0days prior to surgery, predicts a more than two-fold increase in odds of morbidity following bariatric surgery. This must be balanced with the longer-term potential benefits of weight loss and associated improvement in cardiac function in this population.

Which postoperative complications matter most after bariatric surgery? Prioritizing quality improvement efforts to improve national outcomes

BACKGROUNDnNational quality programs have been implemented to decrease the burden of adverse events on key outcomes in bariatric surgery. However, it is not well understood which complications have the most impact on patient health.nnnOBJECTIVEnTo quantify the impact of specific bariatric surgery complications on key clinical outcomes.nnnSETTINGnThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.nnnMETHODSnData from patients who underwent primary bariatric procedures were retrieved from the MBSAQIP 2015 participant use file. The impact of 8 specific complications (bleeding, venous thromboembolism [VTE], leak, wound infection, pneumonia, urinary tract infection, myocardial infarction, and stroke) on 5 main 30-day outcomes (end-organ dysfunction, reoperation, intensive care unit admission, readmission, and mortality) was estimated using risk-adjusted population attributable fractions. The population attributable fraction is a calculated measure taking into account the prevalence and severity of each complication. The population attributable fractions represents the percentage reduction in a given outcome that would occur if that complication were eliminated.nnnRESULTSnIn total, 135,413 patients undergoing sleeve gastrectomy (67%), Roux-en-Y gastric bypass (29%), adjustable gastric banding (3%), and duodenal switch (1%) were included. The most common complications were bleeding (.7%), wound infection (.5%), urinary tract infection (.3%), VTE (.3%), and leak (.2%). Bleeding and leak were the largest contributors to 3 of 5 examined outcomes. VTE had the greatest effect on readmission and mortality.nnnCONCLUSIONnThis study quantifies the impact of specific complications on key surgical outcomes after bariatric surgery. Bleeding and leak were the complications with the largest overall effect on end-organ dysfunction, reoperation, and intensive care unit admission after bariatric surgery. Furthermore, our findings suggest that an initiative targeting reduction of post-bariatric surgery VTE has the greatest potential to reduce mortality and readmission rates.

Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort.

BackgroundThe advent of newer second-line medical therapies (SLMT) for immune thrombocytopenia (ITP) has contributed to decreased rates of splenectomy, following a trend to avoid or delay surgery. We aimed to characterize the long-term outcomes of laparoscopic splenectomy (LS) for ITP at our institution, examining differences in LS efficiency when performed before or after SLMTs.MethodsAdults with primary ITP who underwent LS between 2002 and 2016 were identified. Retrospective review of electronic medical records was supplemented with telephone interviews. Treatment response was defined according to current guidelines as complete responders (CR), responders (R), and non-responders (NR). Kaplan–Meier estimates assessed relapse-free rates, and predictors of long-term response were investigated using logistic regression.Results109 patients met inclusion criteria, from which 42% were treated with an SLMT before referral to LS. LS was completed in all cases, with no conversions or intraoperative complications. The perioperative morbidity was 7.3%, including 3 deep vein and 2 portal vein thrombosis, one reoperation for bleeding, and no mortalities. Splenectomy was initially effective in 99 patients (CRu2009+u2009Ru2009=u200990.8%), and 10 patients were NR. At a median 62-month follow-up, 25 patients relapsed, resulting in a 68% CRu2009+u2009R rate. Proportion of CRu2009+u2009R was similar in patients who previously received SLMT and those who did not (61 vs. 76.7%, pu2009=u20090.08). CRu2009+u2009R patients were younger (45 vs. 53, pu2009=u20090.03), had higher preoperative platelet counts (36 vs. 19, pu2009=u20090.01), and experienced a higher increment in platelet counts during hospital stay (117 vs. 38, pu2009<u20090.001) as well as 30-days postoperatively (329 vs. 124, pu2009<u20090.001). Only a robust response in platelet count at 30-days postoperatively was independently associated with long-term response (OR 1.005, pu2009=u20090.006).ConclusionLS was curative in 68% of patients, with no statistically significant difference when performed before or after SLMTs. Outcomes remain challenging to predict preoperatively, with only a robust increase in platelet counts on short term being associated with long-term response.

Bariatric surgery in patients with interstitial lung disease

BackgroundPerioperative pulmonary complications are frequent in patients with interstitial lung diseases (ILD). Limited literature exists regarding the safety of bariatric procedures in patients with ILD. This study aims to assess the safety, feasibility, and outcomes of patients with ILD who underwent bariatric surgery at our institution.MethodsAfter IRB approval, all patients with preoperative diagnosis of ILD who had bariatric surgery at an academic center between 2004 and 2014 were retrospectively reviewed.ResultsA total of 25 patients with ILD underwent bariatric surgery: Roux-en-Y gastric bypass (nu2009=u200917, 68%), sleeve gastrectomy (nu2009=u20097, 28%), and adjustable gastric banding (nu2009=u20091, 4%). Twenty-one patients (84%) were females. The median age and preoperative body mass index (BMI) were 53 (IQR 42–58) years and 39 (IQR 37–44)xa0kg/m2, respectively. The median operative time and length of stay was 137 (IQR 110–187)xa0min and 3 (IQR 2–5)xa0days, respectively. The 30-day complications were reported in four patients (16%) but there was no pulmonary complication or unplanned admission to thexa0intensive care unit. At 1-year follow-up (85%), the median BMI and excess weight loss were 30 (IQR 25–36)xa0kg/m2 and 67% (IQR 45–100), respectively. Compared to preoperative values, there was significant improvement in the pulmonary function test (PFT) variables at 1xa0year with respect to forced vital capacity (62% vs 74%; nu2009=u200913, pu2009=u20090.003), and diffusing capacity of the lungs for carbon monoxide (53% vs 66%; nu2009=u200910, pu2009=u20090.003). Six out of the seven potential lung transplant candidates became eligible for transplantation after weight loss, and one of them had successful lung transplant at 88xa0months after bariatric surgery.ConclusionIn our experience, bariatric patients with ILD achieved significant weight loss and improvement in PFT. Bariatric surgery in these higher risk ILD patients appears relatively safe with acceptable perioperative morbidity and improved candidacy for lung transplantation.

Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis

BackgroundGastroparesis is a debilitating functional disorder of the stomach characterized by delayed gastric emptying absent an obstructive etiology. Surgical or endoscopic disruption of the pylorus has been utilized to treat this disease, but there is little evidence comparing laparoscopic pyloroplasty (LP) with endoscopic per-oral pyloromyotomy (POP). Herein we describe our experience at our institution using a propensity-matched cohort study to compare outcomes between these procedures.MethodsAll patients who underwent LP for the treatment of gastroparesis from October 2014 through September 2017xa0at our institution were retrospectively reviewed. Propensity scoring was used to match these patients 1:1 to patients undergoing POP during this time period based on gender, age, and etiology of gastroparesis. Symptom scores using the Gastroparesis Cardinal Symptom Index (GCSI), scintigraphic gastric emptying studies (GES), and perioperative outcomes were compared between matched cohorts. Thirty patients underwent LP for gastroparesis during the study period which were matched 1:1 with patients undergoing POP. The etiology of gastroparesis was 63.3% idiopathic (nu2009=u200919), 20.0% post-surgical (nu2009=u20096), and 16.7% diabetic (nu2009=u20095) in both cohorts.ResultsPatients who underwent LP had a longer average length of stay (4.6 vs. 1.4 days, pu2009=u20090.003), operative time (99.3 vs. 33.9xa0min, pu2009<u20090.001), and estimated blood loss (12.9 vs. 0.4xa0mL, pu2009<u20090.001). There were more complications in the LP cohort (16.7 vs. 3.3%, pu2009=u20090.086), which included surgical site infection (6.7 vs. 0%, pu2009=u20090.153), pneumonia (6.7 vs. 0.0%, pu2009=u20090.153), and unplanned ICU admission (10.0 vs. 0.0%, pu2009=u20090.078). LP and POP both resulted in similar, significant improvements in both in GCSI scores and objective gastric emptying.ConclusionsPer-oral endoscopic pyloromyotomy (POP) is safe and effective for the treatment of medical refractory gastroparesis. POP has less perioperative morbidity compared to LP with comparative functional outcomes.

Effect of transversus abdominis release on core stability: Short-term results from a single institution

Introduction: Transversus abdominis release is an increasingly used procedure in complex abdominal wall reconstruction. The transversus abdominis muscle is a primary stabilizer of the spine, yet little is known regarding the effect of transversus abdominis release on core stability, back pain, or hernia‐specific quality of life. The purpose of our study was to investigate the effect of complex abdominal wall reconstruction using transversus abdominis release on patient quality of life and core stability function. Methods: All patients undergoing complex abdominal wall reconstruction requiring transversus abdominis release from June 2016 through October 2016 at our institution were eligible for study inclusion. Back and hernia quality‐of‐life measures, including the Quebec Back Pain Scale and the Hernia Quality of Life Survey (HerQLes), in addition to patient core stability, as measured using the prone test and the Sahrmann Core Stability Test, were collected at the preoperative evaluation and at 6 months after surgery. Students t test was used to determine the effect of complex abdominal wall reconstruction on quality of life and core stability. Results: Twenty‐one patients completed the preoperative and 6‐month postoperative evaluations. Back pain scores significantly improved postoperatively overall and in each of the 6 subcategories measured using the Quebec Back Pain Scale (P = .001). There was also a statistically significant improvement in abdominal wall function as reflected by Hernia Quality of Life Survey scores (P < .001). There was no statistically significant difference in core stability as reflected in the average prone score (P = .6) or the Sahrmann Core Stability Test average score (P = .4). Conclusion: Abdominal wall reconstruction with transversus abdominis release leads to improved back pain and hernia quality of life and does not appear to negatively affect core stability in the short term.

Immunosuppression is not a risk factor for 30-day wound events or additional 30-day morbidity or mortality after open ventral hernia repair: An analysis of the Americas Hernia Society Quality Collaborative

Background: Some form of immunosuppression is relatively common in patients undergoing ventral hernia repair. Nevertheless, the association of immunosuppression with 30‐day wound events and additional outcomes of morbidity and mortality remains unknown. The purpose of our study was to investigate the association of immunosuppression with 30‐day wound events and additional morbidity and mortality after ventral hernia repair by evaluating the database of the Americas Hernia Society Quality Collaborative. Methods: All patients undergoing open, elective, incisional ventral hernia surgery from July 2013 through April 2017 were identified within the database of the Americas Hernia Society Quality Collaborative. Patients on immunosuppression within the 3 months before operative intervention were compared with patients not on immunosuppression with respect to the incidence of 30‐day wound events, using a 1:5 propensity matched analysis. Results: A total of 3,537 patients met inclusion criteria; 200 (5.7%) patients were on some form of immunosuppression at the time of ventral hernia repair. After propensity matching, 1,200 patients remained for analysis; 200 (16.7%) patients were in the immunosuppression group. There were no statistically significant differences between the 2 groups with respect to the incidence of 30‐day surgical site infection, surgical site occurrence requiring procedural intervention, or additional 30‐day morbidity or mortality outcomes. Patients in the immunosuppression group had a greater rate of surgical site occurrences, the majority of which were seromas (P = .03). Conclusion: Immunosuppression is associated with an increased risk of 30‐day surgical site occurrence but not surgical site infection, surgical site occurrence requiring procedural intervention, or additional 30‐day morbidity or mortality. Additional studies are needed to determine the clinical importance of these surgical site occurrences with respect to long‐term durability of the hernia repair.