Luciano Tastaldi

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.

A call for standardization of wound events reporting following ventral hernia repair

IntroductionPostoperative wound events following ventral hernia repair are an important outcome measure. While efforts have been made by hernia surgeons to identify and address risk factors for postoperative wound events following VHR, the definition of these events lacks standardization. Therefore, the purpose of our study was to detail the variability of wound event definitions in recent ventral hernia literature and to propose standardized definitions for postoperative wound events following VHR.MethodsThe top 50 cited ventral hernia, peer-reviewed publications from 1995 through 2015 were identified using the search engine Google Scholar. The definition of wound event used and the incidence of postoperative wound events was recorded for each article. The number of articles that used a standardized definition for surgical site infection (SSI), surgical site occurrence (SSO), or surgical site occurrence requiring procedural intervention (SSOPI) was also identified.ResultsOf the 50 papers evaluated, only nine (18%) used a standardized definition for SSI, SSO, or SSOPI. The papers that used standardized definitions had a smaller variability in the incidence of wound events when compared to one another and their reported rates were more consistent with recently published ventral hernia repair literature.ConclusionPostoperative wound events following VHR are intimately associated with patient quality of life and long-term hernia repair durability. Standardization of the definition of postoperative wound events to include SSI, SSO, and SSOPI following VHR will improve the ability of hernia surgeons to make evidence-based decisions regarding the management of ventral hernias.

Single center experience with the modified retromuscular Sugarbaker technique for parastomal hernia repair

PurposeParastomal hernias are challenging to manage, and an optimal repair has yet to be defined. An open, modified, retromuscular Sugarbaker technique has recently been described in the literature as a technically feasible approach to parastomal hernia repair. This study evaluates our initial institutional experience with parastomal hernia repair with the aforementioned technique with respect to safety and durability.MethodsAll patients who underwent an open, modified retromuscular Sugarbaker parastomal hernia repair from 2014 through 2016 at our institution were identified. Patient characteristics, hernia variables, operative details, and 30-day and medium-term outcomes were abstracted from the Americas Hernia Society Quality Collaborative database. Outcomes of interest included 30-day wound morbidity, mesh-related complications, and hernia recurrence.ResultsThirty-eight patients met inclusion criteria. 20 (53%) patients presented to our institution for management of a recurrent parastomal hernia. 35 (92%) patients had a concurrent midline incisional hernia with a mean total hernia width of 15.1xa0cm and mean defect size of 353xa0cm2. Thirty-day wound morbidity rate was 13%. At a mean of follow-up of 13xa0months (range 4–30), the hernia recurrence rate was 11%. Three patients (8%) experienced mesh erosion into the stoma bowel, leading to stoma necrosis, bowel obstruction, and/or perforation which required reoperation at day 8, 12, and 120xa0days, respectively.ConclusionsThe outcomes of the retromuscular Sugarbaker technique for the management of parastomal hernias have been disappointing at our institution, with a concerning rate of serious mesh-related complications. This operation, as originally described, needs further study before widespread adoption with a particular focus on the technique of mesh placement, the most appropriate mesh selection, and the long-term rate of mesh erosion.

Online Surgeon Ratings and Outcomes in Hernia Surgery: An Americas Hernia Society Quality Collaborative Analysis

BACKGROUNDnOnline surgeon ratings are viewed as a measure of physician quality by some consumers. Nevertheless, the correlation between online surgeon ratings and surgeon quality metrics remains unknown. The purpose of this study was to investigate the association between online surgeon ratings and hernia-specific quality metrics.nnnSTUDY DESIGNnThe Americas Hernia Society Quality Collaborative (AHSQC) is recognized by the Centers for Medicaid and Medicare as a Quality Clinical Data Registry (QCDR) that reports risk-adjusted quality metrics for hernia surgeons. All surgeons who input at least 10 patients into the AHSQC and had both a HealthGrades.com and Vitals.com rating were included in the analysis. The association of surgeons average, risk-adjusted QCDR quality score with their online ratings was investigated using a linear regression model.nnnRESULTSnA total of 70 surgeons met inclusion criteria. The median number of evaluations each surgeonxa0received on HealthGrades.com was 7; the median number of evaluations each surgeon received on Vitals.com was 3. There was a statistically significant correlation betweenxa0the ratings surgeons received on HealthGrades.com and those that they received on Vitals.com (pxa0<xa00.0001). However, there was no correlation between surgeon ratings on either HealthGrades.com or Vitals.com and surgeon QCDR quality scores (pxa0= 0.37 and pxa0= 0.18, respectively).nnnCONCLUSIONSnOnline physician rating systems correlate with one another, but they do not accurately reflect physician quality. The development of specialty-specific, risk-adjusted quality measures and appropriate public dissemination of this information may help patients make more informed decisions about their health care.

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.

Incisional Hernia Repair: Open Retromuscular Approaches

In this article, we discuss concepts, surgical techniques and published literature about the most common abdominal wall reconstructive techniques performed with retromuscular mesh placement through an open approach.

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.

Impact of inadvertent enterotomy on short-term outcomes after ventral hernia repair: An AHSQC analysis

Background: Patients undergoing ventral hernia repair (VHR) are at risk of an inadvertent enterotomy during surgery. Inadvertent enterotomies potentially contaminate the surgical field presenting a management dilemma for the surgeon. The aim of our study was to define the incidence and risk factors for a recognized inadvertent enterotomy and determine its impact on short‐term outcomes after ventral hernia repair. Methods: Using a nationwide hernia registry, the Americas Hernia Society Quality Collaborative, we reviewed all ventral hernia repair performed between 2013 and 2017. Patients were assessed for full‐thickness inadvertent enterotomies at the time of surgery. Patients with inadvertent enterotomies and without enterotomies were compared to assess differences in 30‐day outcomes, using regression modeling. Results: A total of 5,916 patients were included. The incidence of inadvertent enterotomy was 1.9%, with no difference between open and laparoscopic approaches. Inadvertent enterotomies did not increase surgical site occurrences but there were more surgical site infections (OR: 2.20 [95% CI: 1.24–3.90], P=.007). Patients were less likely to receive mesh if there was an enterotomy. Inadvertent enterotomies led to higher rates of reoperations, readmission, enterocutaneous fistulas, and mortality. Conclusion: Inadvertent enterotomies are more common in complex cases of ventral hernia repair and have an overall incidence of 1.9%. These patients are at increased risk of surgical site infections, reoperations, readmission, and mortality. Although definitive hernia repair with mesh can be safely performed, surgeons should consider multiple factors, including type of mesh and location of mesh in the abdominal wall, before proceeding with definitive repair in any case of an enterotomy.

Does active smoking really matter before ventral hernia repair? An AHSQC analysis

Background: Many studies implicate active smoking as a risk factor for postoperative wound complications and all 30‐day morbidity, but the definitions of inclusion and exclusion criteria as well as outcome parameters are inconsistent. Critically, the ability of large databases and meta‐analyses to generate statistically significant associations of active smoking with morbidity do not address whether those relationships are actually clinically meaningful. We investigated this relationship after open ventral hernia repair. Study Design: Patients undergoing elective open ventral hernia repair in clean wounds with 30‐day follow‐up were extracted from the Americas Hernia Society Quality Collaborative. Current smokers (within 30 days of surgery) were 1:1 propensity matched to patients who had never smoked based on demographics, comorbidities, and operative characteristics. Wound complications and all 30‐day morbidity were assessed. Results: After matching 418 current smokers to 418 patients who had never smoked, the groups were similar with the exception of minor differences in body mass index (31.4 vs 33.3, P < .001) and incidence of chronic obstructive pulmonary disease (18% vs 6%, P < .001). Rates of surgical site occurrence were greater in active smokers (12.0% vs 7.4%, P = .03) driven by increased rates of wound cellulitis (2.4% vs 1.2%) and seroma (5.5% vs 1.2%); however, rates of surgical site infection (4.1 vs 4.1, P = .98), surgical site occurrences requiring a procedural intervention (6.2% vs 5.0%, P = .43), reoperation (1.9% vs 1.2%, P = .39), and all 30‐day morbidity (7.5 vs 6.6, P = .60) were not significantly increased in active smokers. There were no instances of mesh excision. Conclusion: Active smoking prior to elective clean OVHR is associated with clinically insignificant differences in wound morbidity. Surgeons allowing perioperative smoking should monitor their outcomes to assure these findings are replicable in their own practice.