nda T. Li

Development and Validation of a Risk-Stratification Score for Surgical Site Occurrence and Surgical Site Infection after Open Ventral Hernia Repair

BACKGROUND Current risk-assessment tools for surgical site occurrence (SSO) and surgical site infection (SSI) are based on expert opinion or are not specific to open ventral hernia repairs. We aimed to develop a risk-assessment tool for SSO and SSI and compare its performance against existing risk-assessment tools in patients with open ventral hernia repair. STUDY DESIGN A retrospective study of patients undergoing open ventral hernia repair (n = 888) was conducted at a single institution from 2000 through 2010. Rates of SSO and SSI were determined by chart review. Stepwise regression models were built to identify predictors of SSO and SSI and internally validated using bootstrapping. Odds ratios were converted to a point system and summed to create the Ventral Hernia Risk Score (VHRS) for SSO and SSI, respectively. Area under the receiver operating characteristic curve was used to compare the accuracy of the VHRS models against the National Nosocomial Infection Surveillance Risk Index, Ventral Hernia Working Group (VHWG) grade, and VHWG score. RESULTS The rates of SSO and SSI were 33% and 22%, respectively. Factors associated with SSO included mesh implant, concomitant hernia repair, dissection of skin flaps, and wound class 4. Predictors of SSI included concomitant repair, dissection of skin flaps, American Society of Anesthesiologists class ≥ 3, wound class 4, and body mass index ≥ 40. The accuracy of the VHRS in predicting SSO and SSI exceeded National Nosocomial Infection Surveillance and VHWG grade, but was not better than VHWG score. CONCLUSIONS The VHRS identified patients at increased risk for SSO/SSI more accurately than the National Nosocomial Infection Surveillance scores and VHWG grade, and can be used to guide clinical decisions and patient counseling.

Outcomes of laparoscopic vs open repair of primary ventral hernias

IMPORTANCE More primary ventral hernias (PVHs) are being repaired using the technique of laparoscopic ventral hernia repair (LVHR). Few studies exist comparing the outcomes of LVHR with the outcomes of open ventral hernia repair (OVHR) for PVHs. We hypothesize that LVHR of PVHs is associated with fewer surgical site infections (SSIs) but more hernia recurrences and more clinical cases of bulging (bulging not associated with recurrence or seroma). OBJECTIVE To compare the outcomes of patients who underwent LVHR with the outcomes of patients who underwent OVHR. DESIGN Retrospective study of 532 consecutive patients who underwent an elective PVH repair at a single institution from 2000 to 2010. The outcomes of the 2 procedures were compared using 2 statistical methods. Multivariable logistic regression was used to evaluate the association between outcomes and several independent factors, adjusting for treatment propensity, and the outcomes in the 2 groups of patients were compared using paired univariate analysis. SETTING Michael E. DeBakey VA Medical Center in Houston, Texas. PARTICIPANTS Seventy-nine patients who underwent LVHR and 79 patients who underwent OVHR. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were SSI, hernia recurrence, and bulging. The 2 groups of patients were matched by hernia size, American Society of Anesthesiologists class, age, and body mass index. RESULTS There were 91 patients who underwent an LVHR and 167 patients who underwent an OVHR with mesh, with a median follow-up period of 56 months (range, 1-156 months). Seventy-nine patients with an LVHR were matched to 79 patients with an OVHR. No significant differences in demographic data or confounding factors were detected between the 2 groups. Compared with OVHR, LVHR was significantly associated with fewer SSIs (7.6% vs 34.1%; P < .01) but more clinical cases of bulging (21.5% vs 1.3%; P < .01) and port-site hernia (2.5% vs 0.0%). No differences in recurrence at the site of the hernia repair were observed (11.4% vs 11.4%; P = .99). Propensity score-matched multivariate analysis corroborated that LVHR is associated with more clinical cases of bulging but fewer SSIs. CONCLUSIONS AND RELEVANCE Compared with OVHR of PVHs, LVHR of PVHs is associated with fewer SSIs but more clinical cases of bulging and with the risk of developing a port-site hernia. Further study is needed to clarify the role of LVHR of PVHs and to mitigate the risk of port-site hernia and bulging.

Causes and Prevalence of Unplanned Readmissions After Colorectal Surgery:: A Systematic Review and Meta-Analysis

A systematic review and meta‐analysis of the current literature was conducted to compare the overall and cause‐specific readmission rates after colorectal surgery of older adults with those of younger individuals. Potential predictors of unplanned readmission were also identified. Estimated pooled readmission rates were calculated and reported as pooled proportions with associated 95% confidence intervals (CI) in 60,131 total readmissions; 11.0% (95% CI = 10.0–12.0) of all admissions after colorectal surgery resulted in unplanned readmission at 30 days. Older adults had a lower rate of readmission than younger individuals. Bowel obstruction was the most common cause of unplanned readmission, accounting for 33.4% of all unplanned readmissions, followed by surgical site infection (15.7%) and intraabdominal abscess (12.6%). Several age‐related predictors of unplanned readmission were identified, such as poor functional capacity, multiple comorbidities, chronic obstructive pulmonary disease, and discharge to a nonhome destination. The findings of this review will help guide the development of future interventions to reduce preventable readmissions after colorectal surgery in older adults.

Outcomes and Predictors of Incisional Surgical Site Infection in Stoma Reversal

IMPORTANCE Surgical site infection following stoma reversal (SR) poses a substantial burden to the patient and health care system. Its overall incidence is likely underreported and poorly characterized. Improving our understanding of surgical site infection following stoma reversal may help us identify methods to decrease this complication. OBJECTIVE To evaluate the incidence of surgical site infection (SSI) and identify predictors of SSI following SR. DESIGN A review of computerized hospital records on SR performed from January 1, 2005, until February 27, 2011. SETTING An integrated medical system at the Michael E. DeBakey Veterans Affairs Medical Center. PARTICIPANTS AND INTERVENTION All adults undergoing SR during the study period. MAIN OUTCOME MEASURES Rates of SSI and characteristics of patients with and without SSI were compared. A logistic regression model was developed to identify predictors of SSI. RESULTS One hundred twenty-eight patients underwent SR; 46 patients (36.0%) had an SSI. In comparison with no SSI, the infection was associated with seromas (17.4% vs 2.4%, P = .004), fascial dehiscence (15.2% vs 2.4%, P = .01), intensive care unit admission (34.8% vs 17.1%, P = .03), increased hospital length of stay (20 vs 9 days, P = .02), readmission (32.6% vs 13.4%, P = .01), delayed wound healing (91 vs 66 days, P = .02), and reoperation (32.6% vs 13.4%, P = .01). On multivariate analysis, history of fascial dehiscence (odds ratio, 16.9; 95% CI, 1.94-387), colostomy (5.07; 2.12-13.0), thicker subcutaneous fat (2.02; 1.33-3.21), and black race (0.35; 0.13-0.86) were associated with incisional SSI. There was no significant difference in patient satisfaction or functional status in late follow-up (1-73 months). CONCLUSIONS AND RELEVANCE Surgical site infection is common following SR and is associated with significant morbidity. Four factors are strongly associated with increased risk of SSI in SR: history of fascial dehiscence, thicker subcutaneous fat, colostomy, and white race. Patients with none of these risk factors had a 0% SSI risk; patients with all 4 risk factors had a 100% risk of SSI.

Abdominal reoperation and mesh explantation following open ventral hernia repair with mesh

BACKGROUND This study sought to identify the incidence, indications, and predictors of abdominal reoperation and mesh explantation following open ventral hernia repair with mesh (OVHR). METHODS A retrospective cohort study of all patients at a single institution who underwent an OVHR from 2000 to 2010 was performed. Patients who required subsequent abdominal reoperation or mesh explantation were compared with those who did not. Reasons for reoperation were recorded. The 2 groups were compared using univariate and multivariate analysis (MVA). RESULTS A total of 407 patients were followed for a median (range) of 57 (1 to 143) months. Subsequent abdominal reoperation was required in 69 (17%) patients. The most common reasons for reoperation were recurrence and surgical site infection. Only the number of prior abdominal surgeries was associated with abdominal reoperation on MVA. Twenty-eight patients (6.9%) underwent subsequent mesh explantation. Only the Ventral Hernia Working Group grade was associated with mesh explantation on MVA. CONCLUSIONS Abdominal reoperation and mesh explantation following OVHR are common. Overwhelmingly, surgical complications are themost common causes for reoperation and mesh explantation.

Outcomes with Porcine Acellular Dermal Matrix versus Synthetic Mesh and Suture in Complicated Open Ventral Hernia Repair

BACKGROUND Mesh reinforcement as part of open ventral hernia repair (OVHR) has become the standard of care. However, there is no consensus on the ideal type of mesh to use. In many clinical situations, surgeons are reluctant to use synthetic mesh. Options in these complicated OVHRs include suture repair or the use of biologic mesh such as porcine acellular dermal matrix (PADM). There has been a paucity of controlled studies reporting long-term outcomes with biologic meshes. We hypothesized that compared with synthetic mesh in OVHR, PADM is associated with fewer surgical site infections (SSI) but more seromas and recurrences. Additionally, compared with suture repair, we hypothesized that PADM is associated with fewer recurrences but more SSIs and seromas. METHODS A retrospective study was performed of all complicated OVHRs performed at a single institution from 2000-2011. All data were captured from the electronic medical records of the service network. Data were compared in two ways. First, patients who had OVHR with PADM were case-matched with patients having synthetic mesh repairs on the basis of incision class, Ventral Hernia Working Group (VHWG) grade, hernia size, American Society of Anesthesiologists (ASA) class, and emergency status. The PADM cases were also matched with suture repairs on the basis of incision class, hernia grade, duration of the operation, ASA class, and emergency status. Second, we developed a propensity score-adjusted multi-variable logistic regression model utilizing internal resampling to identify predictors of primary outcomes of the overall cohort. The U.S. Centers for Disease Control and Prevention (CDC) definition of SSI was utilized; seromas and recurrences were defined and tracked similarly for all patients. Data were analyzed using the McNemar, X(2), paired two-tailed Student t, or Mann-Whitney U test as appropriate. RESULTS A total of 449 complicated OVHR cases were reviewed for a median follow up of 61 mos (range 1-143 mos): 94 patients had PADM repairs, whereas 154 patients underwent synthetic mesh repairs, and 201 had suture repairs. The 40 PADM repairs were matched to synthetic repairs and 59 were matched to suture repairs. The PADM repairs that could not be well matched (n=54 unmatched for synthetic repairs, 35 unmatched for suture repairs) were characterized generally by larger hernias, VHWG grades of 3 or 4, and incision class 3 or 4 with longer operative durations and more ASA class 4 cases. The patients were well matched. Comparing PADM with synthetic mesh, there was no difference in SSI (20% vs. 35%; p=0.29), seromas (32.5% vs. 15%; p=0.17), mesh explantations (5% vs. 15%, p=0.28), readmissions within 90 d (37.5% vs. 45%; p=1.00), or recurrence (8.5% vs. 22.5%; p=0.15). Compared with suture repair, patients with PADM had fewer recurrences (11.9% vs. 33.9%; p<0.01) and more seromas (32.2% vs. 10.2%; p=0.02), but a similar number of SSIs (23.7% vs. 39.0%; p=0.19) and 90-d readmissions (35.6% vs. 39.0%; p=0.88). Propensity score-adjusted multi-variable logistic regression of the entire cohort corroborated the results of the case-matched patients. CONCLUSIONS The PADM repair of complicated OVHR resulted in fewer recurrences, more seromas, and no difference in SSI compared with suture repair. Although no reduction in SSI was identified with the use of PADM rather than synthetic mesh or suture for OVHR, the meaning of this finding is unclear, as this case-controlled study was underpowered and limited by selection bias. According to our data, 280 patients would have been needed to identify a clinically significant difference in the primary outcome of SSI as well as secondary outcomes of mesh explantation and recurrence (α=0.05; β=0.20). A randomized trial is warranted to compare PADM with synthetic mesh in complicated OVHR.

Postoperative transitional care needs in the elderly: an outcome of recovery associated with worse long-term survival.

OBJECTIVE To characterize transitional care needs (TCNs) after colorectal cancer (CRC) surgery and examine their association with age and impact on overall survival (OS). BACKGROUND TCNs after cancer surgery represent additional burden for patients and are associated with higher short-term mortality. They are not well-characterized in CRC patients, particularly in the context of a growing elderly population, and their effect on long-term survival is unknown. METHODS A retrospective cohort study of CRC patients (N = 486) having curative surgery at a tertiary referral center (2002-2011) was conducted. Outcomes included TCNs (home health or nonhome destination at discharge) and OS. Patients were compared on the basis of age: young (<65 years), old (65-74 years), and oldest (≥75 years). Multivariate logistic regression models were used to examine the association of age with TCNs, and OS was compared on the basis of TCNs and stage, using the Kaplan-Meier method. RESULTS TCNs were required by 130 patients (27%). The oldest patients had highest TCNs (49%) compared with the other age groups (P < 0.01), with rehabilitation services as their primary TCNs (80%). After multivariate analysis, patients 75 years or older had significantly increased TCN risk (odds ratio, 4.7; 95% confidence interval, 2.6-8.5). TCN was associated with worse OS for patients with early- and advanced stage CRC (P < 0.001). CONCLUSIONS TCNs after CRC surgery are common and significantly increased in patients 75 years or older, represent an outcome of postoperative recovery, and are associated with worse long-term survival. Preoperative identification of higher risk populations should be used for patient counseling, advanced preoperative planning, and to implement strategies targeted at minimizing TCNs.

Circular closure is associated with the lowest rate of surgical site infection following stoma reversal: a systematic review and multiple treatment meta-analysis.

Stoma reversal is frequently complicated by surgical site infection (SSI). To reduce SSI, several techniques for skin closure have been studied, with no agreement on which is best. The aim of this study was to identify the skin closure technique associated with the lowest rate of SSI following stoma reversal.

Readmission following open ventral hernia repair: incidence, indications, and predictors

BACKGROUND The aim of this study was to evaluate the incidence, indications, and predictive factors of hospital readmission after open ventral hernia repair. METHODS A retrospective review of all open ventral hernia repairs at a single institution from 2000 to 2010 was performed to assess readmissions between 1 to 30, 1 to 90, and 91 to 365 days. Multivariate analysis was performed to identify independent predictors of 30-day readmission. RESULTS Of the 888 patients, 75 (8%) were readmitted between 1 and 30 days, 97 (11%) between 1 and 90 days, and 78 (9%) between 91 and 365 days. Unplanned readmissions related to the surgery constituted the majority of 1-day to 30-day and 1-day to 90-day readmissions (82% and 74%, respectively) but not between 91 and 365 days (32%). Prior superficial or deep surgical-site infection (odds ratio, 2.39; 95% confidence interval, 1.32 to 4.32) and duration of surgery (odds ratio, 1.35; 95% confidence interval, 1.05 to 1.73) were associated with 30-day readmission. CONCLUSIONS Efforts to reduce readmissions should be directed at modifiable risk factors for surgical-site infection and other surgical complications, particularly among those with prior skin infections and longer durations of surgery.

Outcomes of acute versus elective primary ventral hernia repair.

BACKGROUND The morbidity and mortality associated with acute primary ventral hernia repair have not been well described. We examined the rate of surgical site infection (SSI), hernia recurrence, and mortality in acute versus elective primary ventral hernia repair and identified predictors of morbidity and mortality after primary ventral hernia repair. METHODS A retrospective study on all patients undergoing open primary ventral hernia repair at a single institution (2000–2010) was performed. Primary outcomes were mortality at any time, SSI, and recurrence. Survival analysis for the entire, unmatched sample was conducted. We performed a risk-adjusted analysis of outcomes using two methods as follows: (1) case matching and (2) propensity score–adjusted regression model. RESULTS We identified 497 patients; 57 (11%) underwent acute primary ventral hernia repair. For the entire cohort, survival was worse for patients undergoing acute repair (log rank, 0.03). Following case matching on age, body mass index, American Society of Anesthesiologists score, and hernia size, there was no difference in mortality, SSI, or recurrence. After propensity score adjustment, acute surgery was not a predictor for mortality or SSI; however, incarcerated hernias predicted recurrence. CONCLUSION After risk adjustment, acute primary ventral hernia repair was not associated with higher mortality, infection, or recurrence compared with elective repair. LEVEL OF EVIDENCE Therapeutic study, level IV.