Dimitrios Xourafas

Impact of Mesh Use on Morbidity Following Ventral Hernia Repair With a Simultaneous Bowel Resection

OBJECTIVE To evaluate the impact of mesh use on outcomes following ventral hernia repairs and simultaneous bowel resection. DESIGN Retrospective review. SETTING Teaching academic hospital. PATIENTS We studied 177 patients who underwent a ventral hernia repair with a bowel resection between May 1, 1992, and May 30, 2007. A prosthesis was used in 51 repairs (mesh group), while 126 repairs were primary (mesh-free group). MAIN OUTCOME MEASURES Demographic characteristics, comorbidities, mesh type, bowel resection type (colon vs small bowel), defect size, drain use, and length of hospital stay were compared between groups with Fisher exact test and multivariate analysis. RESULTS There were no statistically significant differences between patient characteristics and relevant comorbidities. The incidence of postoperative infection (superficial or deep) was 22% in the mesh group vs 5% in the mesh-free group (P = .001). Other complications (fistula, seroma, hematoma, bowel obstruction) occurred in 24% of patients in the mesh group vs 8% of patients in the mesh-free group (P = .009). Focusing on the patients who developed an infection, prosthetic mesh use was the only significant risk factor on multivariate regression analysis, irrespective of drain use, defect size, and type of bowel resection. CONCLUSIONS We recommend caution in using mesh when performing a ventral hernia repair with a simultaneous bowel resection because of significantly increased postoperative infectious complications. Drain use, defect size, and bowel resection type did not influence outcomes.

Distal pancreatic resection for neuroendocrine tumors: is laparoscopic really better than open?

BackgroundThe latest studies on surgical and cost-analysis outcomes after laparoscopic distal pancreatectomy (LDP) highlight mixed and insufficient results. Whereas several investigators have compared surgical outcomes of LDP vs. open distal pancreatectomy (ODP) for adenocarcinomas, few similar studies have focused on pancreatic neuroendocrine tumors (PNETs).MethodsWe reviewed the medical records of PNET patients undergoing distal pancreatectomy between 2004 and 2014. Patients were divided into LDP vs. ODP groups. Demographics, relevant comorbidities, oncologic variables, and cost-analysis data were assessed. Survival and Cox proportional hazards analyses were used to evaluate outcomes.ResultsOf the 171 distal pancreatectomies for PNETs, 73 were laparoscopic, whereas 98 were open. Patients undergoing LDP demonstrated significantly lower rates of postoperative complications (P = 0.028) and had significantly shorter hospital stays (P = 0.008). On multivariable analysis, positive resection margins (P = 0.046), G3 grade (P = 0.036), advanced WHO classification (P = 0.016), TNM stage (P = 0.018), and readmission (P = 0.019) were significantly associated with poor survival; however, method of resection (LDP vs. ODP) was not (P = 0.254). The median total direct costs of LDP vs. ODP did not differ significantly.ConclusionsIn response to the recent considerable controversy surrounding the costs and surgical outcomes of LDP vs. ODP, our results show that LDP for PNETs is cost-neutral and significantly reduces postoperative morbidity without compromising oncologic outcomes and survival.

Investigating Transitional Care to Decrease Post-pancreatectomy 30-Day Hospital Readmissions for Dehydration or Failure to Thrive

BackgroundCurrent literature emphasizes post-operative complications as a leading cause of post-pancreatectomy readmissions. Transitional care factors associated with potentially preventable conditions such as dehydration and failure to thrive (FTT) may play a significant role in readmission after pancreatectomy and have not been studied.MethodsThirty-one post-pancreatectomy patients, who were readmitted for dehydration or FTT between 2009 and 2014, were compared to 141 nonreadmitted patients. Medical record review and a questionnaire-based survey, specifically designed to assess transitional care, were used to identify predictors of readmissions for dehydration or FTT. Logistic regression models were used to evaluate outcomes.ResultsOn multivariable analysis, the strongest predictors of readmission for dehydration and FTT were the patient’s lower educational level (P = 0.0233), the absence of family during the delivery of discharge instructions (P = 0.0098), episodic intermittent nausea at discharge (P = 0.0019), uncertainty about quantity, quality, or frequency of fluid intake (P = 0.0137), and the inability or failure to adhere to the clinician’s instructions in the outpatient setting (P = 0.0048).ConclusionTransitional-care-related factors are found to be associated with post-pancreatectomy readmission for dehydration and FTT. Using these results to identify high-risk patients and implement focused preventive measures combining efficient communication and optimal inpatient and outpatient management could potentially decrease readmission rates.

Hepatocellular Carcinoma in Transplantable Child-Pugh A Cirrhotics: Should Cost Affect Resection vs Transplantation?

BackgroundThere is no consensus regarding the optimal surgical treatment for transplantable hepatocellular carcinoma (HCC) patients with well-compensated cirrhosis. Our aim was to compare outcomes between Child-Pugh A (CPA) cirrhotics who underwent liver resection or transplantation for HCC.MethodsClinicopathologic data were retrospectively collected for all surgically treated HCC patients between 7/1992 and 12/2015. Disease-free survival (DFS) and overall survival (OS) were calculated from the time of operation or diagnosis (intention-to-treat analysis including patients removed from the transplant list). The average overall cost including pre-operative and post-operative procedures was calculated for each group.ResultsOf the 513 surgically treated HCC patients, 184 had CPA cirrhosis and fulfilled the Milan criteria (MC). Of those, 95 (52%) were resected and 89 (48%) were transplanted. Twenty-two patients were removed from the transplant list. Transplanted patients were younger (p < 0.001), had a higher MELD score (p < 0.001) and a higher frequency of hepatitis C (p < 0.001). Length of stay and postoperative complication rates were similar between groups. DFS was longer for transplanted patients (3-, 5-, and 10-year DFS rates 48, 44, 31% vs 96, 94, 94%, respectively, p < 0.001). OS was similar between groups (3-, 5-, and 10-year OS rates 76, 62, 41% vs 82, 77, 53%, respectively, p = 0.07). Only size of greatest lesion and T stage were independent predictors of OS. The cost was much higher for the transplant group, even when accounting for the treatment of recurrences (

Noninvasive intraductal papillary mucinous neoplasms and mucinous cystic neoplasms: Recurrence rates and postoperative imaging follow-up

37,391 vs

Impact of Weight-Loss Surgery and Diabetes Status on Serum ALT Levels

137,996).ConclusionsSince OS is similar between CPA cirrhotics within the MC undergoing resection or transplantation for HCC, but cost is significantly higher for transplantation. Resection should be considered for first-line treatment.