Jason M. Souza

Risk factors for 30-day readmission in patients undergoing ventral hernia repair

BACKGROUND Ventral hernia repair (VHR), an increasingly common procedure, may have a greater impact on health care costs than is currently appreciated. Readmissions have the potential to further increase these costs and negatively impact patient outcomes. New national registry data allows for an in-depth look at the predictors and rates of readmission after VHR. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent only an incisional or VHR in 2011. Patients who had any concomitant procedure were excluded. Using readmission as the dependent variable, a multivariate logistic regression model was created to identify independent predictors of readmission. RESULTS VHR had a 4.9% 30-day readmission rate in 2011. Deep/incisional (12.6%) and superficial site infections (10.5%) were the most common wound complications seen in readmitted patients (both P < .001), whereas sepsis/septic shock (10.14%; P < .001) was the most common systemic complication. Higher class body mass index is not associated with readmission (P = .320). Smoking and chronic obstructive pulmonary disease function as predictors of readmission independently from their association with complications (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.6; and OR, 1.6, 95% CI, 1.1-2.3, respectively). Operative factors such as the use of mesh (OR, 1.3; 95% CI, 0.995-1.7) or laparoscopy (OR, 1.2; 95% CI, 0.96-1.6) do not increase likelihood of readmission. CONCLUSION There is room for improvement in VHR readmission rates. Although complications are the main driver of readmission, surgeons must be aware of comorbidities that independently increase the odds of readmission, even when a complication does not occur.

Targeted Muscle Reinnervation in the Upper Extremity Amputee: A Technical Roadmap

Targeted muscle reinnervation (TMR) offers the potential for improved prosthetic function by reclaiming the neural control information that is lost as a result of upper extremity amputation. In addition to the prosthetic control benefits, TMR is a potential treatment for postamputation neuroma pain. Here, we present our surgical technique for TMR nerve transfers in transhumeral and shoulder disarticulation patients.

Targeted muscle reinnervation in the initial management of traumatic upper extremity amputation injury

Targeted muscle reinnervation (TMR) was initially designed to provide cortical control of upper limb prostheses through a series of novel nerve transfers. Early experience has suggested that TMR may also inhibit symptomatic neuroma formation. We present the first report of TMR performed at the time of a traumatic shoulder disarticulation. The procedure was done to prevent painful neuroma pain and allow for myoelecteric prosthetic use in the future. Eight months post-operatively, the patient demonstrates multiple successful nerve transfers and exhibits no evidence of neuroma pain on clinical exam. Using the Patient Reported Outcomes Measurement Information System (PROMIS), the patient demonstrates minimal pain interference or pain behavior. Targeted muscle reinnervation may be considered in the acute trauma setting to prevent neuroma pain and to prepare patients for myoelectric prostheses in the future.

Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts.

BACKGROUND Management of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field. METHODS A retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011. RESULTS The median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae. CONCLUSIONS With proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.

In vivo evaluation of a novel mesh suture design for abdominal wall closure

Background: The authors present a novel mesh suture design aimed at minimizing the early laparotomy dehiscence that drives ventral hernia formation. The authors hypothesized that modulation of the suture-tissue interface through use of a macroporous structure and increased aspect ratio (width-to-height ratio) would decrease the suture pull-through that leads to laparotomy dehiscence. Methods: Incisional hernias were produced in 30 rats according to an established hernia model. The rat hernias were randomized to repair with either two 5-0 polypropylene sutures or two midweight polypropylene mesh sutures. Standardized photographs were taken before repair and 1 month after repair. Edge-detection software was used to define the border of the hernia defect and calculate the defect area. Histologic analysis was performed on all mesh suture specimens. Results: Seventeen hernias were repaired with mesh sutures and 13 were repaired with conventional sutures. The mean area of the recurrent defects following repair with mesh suture was 177.8 ± 27.1 mm2, compared with 267.3 ± 34.1 mm2 following conventional suture repair. This correlated to a 57.4 percent reduction in defect area after mesh suture repair, compared with a 10.1 percent increase in defect area following conventional suture repair (p < 0.0007). None (zero of 34) of the mesh sutures pulled through the surrounding tissue, whereas 65 percent (17 of 26) of the conventional sutures demonstrated complete pull-through. Excellent fibrocollagenous ingrowth was observed in 13 of 17 mesh suture specimens. Conclusions: Mesh sutures better resisted suture pull-through than conventional polypropylene sutures. The design elements of mesh sutures may prevent early laparotomy dehiscence by more evenly distributing distracting forces at the suture-tissue interface and permitting tissue incorporation of the suture itself.

Insulin dependence as an independent predictor of perioperative morbidity after ventral hernia repair: a National Surgical Quality Improvement Program analysis of 45,759 patients

BACKGROUND Although diabetes mellitus has been identified as a predictor of perioperative morbidity after ventral hernia repair (VHR), it is unclear whether insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) confer the same degree of risk. We examined the variable effect of IDDM and NIDDM on 30-day medical and surgical complications after VHR. METHODS We performed a retrospective analysis of patients in the National Surgical Quality Improvement Program database from 2005 to 2012 undergoing VHR. After perioperative variable comparison, regression analysis was performed to determine whether IDDM and/or NIDDM independently predicted increased complications after proper risk adjustment. RESULTS A total of 45,759 patients were identified to have undergone VHR. Of these, 38,026 patients (83.1%) were not diabetic, 5,252 (11.5%) were NIDDM patients, and 2,481 (5.4%) were IDDM patients. After controlling for other risk factors, we found that IDDM independently predicted increased rates of overall, surgical, and medical complications (odds ratio, 1.284, 1.251, 1.263, respectively) in open repair. IDDM independently predicted increased overall and medical complications (odds ratio, 1.997, 1.889, respectively) but not surgical complications in laparoscopic repair. NIDDM was not significantly associated with any complication type in either procedure type. CONCLUSIONS Our present study suggests that much of the perioperative risk associated with diabetes is attributable to IDDM. The effect of IDDM on laparoscopic and open repair is subtly different. IDDM demonstrates increased overall and medical complications in laparoscopic repair and increased overall, medical, and surgical complications in open repair. Of note, IDDM does not independently predict increased risk for surgical complications in laparoscopic repair.

Advances in Transfemoral Amputee Rehabilitation: Early Experience with Targeted Muscle Reinnervation

While myoelectric prosthetic devices have been used for decades in the upper extremities, only recently have motorized knee and ankle components proven durable and effective enough for use in the lower extremity amputee. The control schemes developed to capitalize on these prosthetic advances must take into account the biomechanical differences between upper and lower extremity function. Already a valuable adjunct for the myoelectric control of upper extremity prostheses, targeted muscle reinnervation in the transfemoral amputee offers the potential to further enhance lower extremity prosthesis control and may simultaneously address post-amputation neuroma pain. Current strategies for lower extremity prosthesis control are discussed, along with a review of the transfemoral TMR technique and early clinical experience.

Repair of recurrent hernia after biologic mesh failure in abdominal wall reconstruction.

BACKGROUND Biologic mesh is commonly used in abdominal wall reconstruction but may result in increased hernia recurrence. There are minimal data on repair of these recurrent hernias. METHODS We conducted a retrospective chart review of 24 patients presenting to a single surgeon with recurrent ventral hernia, previously repaired with biologic mesh. RESULTS Seventeen of 24 study patients underwent open repair, including 5 revisions of incomplete external oblique release. Mesh was polypropylene in 11 patients and fenestrated condensed polytetrafluoroethylene in 3 patients. In 1 patient, no mesh was used. In 2 patients, bridged biologic mesh was used because of risk of exposure. All biologic repairs have since recurred. Complications occurred in 3 of 15 prosthetic mesh patients and in all biologic mesh patients. CONCLUSIONS Prior components release can be repeated if computed tomography scan reveals incomplete release. Recurrence is common after bridged biologic mesh repair. Conventional mesh can be used safely in many recurrent abdominal hernias after biologic mesh failure.

Treatment of Foot and Ankle Neuroma Pain With Processed Nerve Allografts.

Background: Localized nerve pain in the foot and ankle can be a chronic source of disability after trauma and has been identified as the most common complication following operative interventions in the foot and ankle. The superficial location of the injured nerves and lack of suitable tissue for nerve implantation make this pain refractory to conventional methods of neuroma management. We describe a novel strategy for management using processed nerve allografts to bridge nerve gaps created by resection of both end neuromas and neuromas-in-continuity. Methods: A retrospective review of a prospectively maintained database was performed of all patients who received a processed nerve allograft for treatment of painful neuromas in the foot and ankle between May 2010 and June 2015. Patient demographic and operative information was obtained, as well as preoperative and postoperative pain assessments using a conventional ordinal scale and PROMIS (Patient Reported Outcomes Measurement Information System) Pain Behavior and Pain Interference assessments. Twenty-two patients were identified, with postoperative pain assessments occurring at a mean of 15.5 months after surgery. Results: Neuromas of the sural and superficial peroneal nerves were the most common diagnoses, with 3-cm nerve allografts being used as the interposition graft in the majority of cases. Eight patients had end neuromas and 18 patients had neuromas in continuity. Analysis of paired data demonstrated a mean ordinal pain score decrease of 2.6, with 24 and 31 percentage-point decreases in PROMIS Pain Behavior and Pain Interference measures, respectively. All changes were significant (P < .002). Conclusion: The painful sequelae of superficial nerve injuries in the foot and ankle was significantly improved with complete excision of the involved nerve segment followed by bridging of the resulting nerve gap with a processed nerve allograft. This approach limits surgery to the site of injury and reconstitutes the peripheral nerve anatomy. Level of Evidence: Level IV, retrospective case series.

Patient-guided peripheral nerve exploration for the management of chronic localized pain

Summary: This technique represents a surgical adjunct for the management of chronic, localized pain in patients who continue to have pain despite exhaustive prior evaluation and treatment. The patient-guided approach was used in 10 patients referred with “intractable pain” and yielded good to excellent results in all but one patient. When applied selectively to cases with significantly distorted anatomy or previous failed interventions, this simple technique can minimize dissection and unnecessary resection, while offering relief to a patient population otherwise resigned to a life with chronic pain. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.