Marten N. Basta

Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation.

Background: The purpose of this study was to quantify the efficacy and safety of microsurgery for lymphedema through a systematic meta-analysis, which has not been described before. Methods: A literature search was conducted to identify all articles involving microsurgical treatment of lymphedema. Studies meeting criteria for inclusion were rated on methodologic quality based on the American Society of Plastic Surgeons levels of evidence. Demographic information, cause of lymphedema, and surgical technique were recorded. Quantitative change in lymphedema and perioperative complications were noted. Results: Twenty-seven studies were included, with 24 offering level IV evidence and three offering level III evidence. Lymphovenous shunt procedures were performed in 22 studies and lymph node transplantation was performed in five. Excess circumference was reduced by 48.8 ± 6.0 percent, and absolute circumference was reduced by 3.31 ± 0.73 cm. Studies reporting change in volume demonstrated reduction in excess volume by 56.6 ± 9.1 percent, and absolute volume was reduced by 23.6 ± 2.1 percent. The incidence of no improvement in lymphedema postoperatively was 11.8 percent, and 91.2 percent of patients reported subjective improvement. Approximately 64.8 percent of patients discontinued compression garments at follow-up. Complications included operative-site infection (4.7 percent), lymphorrhea (7.7 percent), reexploration for flap congestion (2.7 percent), and additional procedures (22.6 percent). Conclusions: Operative interventions for peripheral lymphedema appear to provide consistent quantitative improvements postoperatively, with a relatively wide safety margin. Lymph node transplantation may provide better outcomes compared with lymphovenous shunt, but well-designed head-to-head comparisons are needed to evaluate this further. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Children's Hospital of Philadelphia modification of the Furlow double-opposing Z-palatoplasty: 30-year experience and long-term speech outcomes.

Background: The purpose of this study was to evaluate the long-term outcomes following modified Furlow palatoplasty over a 30-year experience at a single institution. Methods: A retrospective review was performed of all nonsyndromic patients undergoing primary modified Furlow palatoplasty at The Children’s Hospital of Philadelphia between 1980 and 2011. Surgical success was evaluated by the rate of postoperative oronasal fistula, speech outcomes assessed at a minimum of age 5 years, and the need for secondary surgery for velopharyngeal dysfunction. Results were analyzed by surgeon, Veau cleft type, age at repair, and over time. Results: Eight hundred sixty-nine patients who underwent modified Furlow repair were included in this study. The mean age at palatoplasty was 1.1 years, and the mean length of follow-up was 6.7 years. Repairs were performed by 11 surgeons, with 44.3 percent performed by a single surgeon. The overall oronasal fistula rate was 5.2 percent, and this improved significantly over the 30-year period (p = 0.003). Speech results at age 5 or older were available for 559 patients. Of these 559 patients, 72.4 percent had a competent velopharyngeal mechanism, and 21.5 percent had a borderline mechanism consistent with socially acceptable speech. Secondary pharyngeal surgery was indicated in 8.1 percent of patients. Speech results were stable (p = 0.10), and rates of secondary surgery for velopharyngeal dysfunction declined significantly over the study period (p = 0.005). Conclusions: The authors’ 30-year experience with the modified Furlow palatoplasty shows stable speech results, decreasing rates of secondary surgery, and an acceptable rate of postoperative oronasal fistula. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention

Objectives:Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in todays health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed. Methods:All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. Results:A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2 ± 26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded

Cost-utility analysis of the use of prophylactic mesh augmentation compared with primary fascial suture repair in patients at high risk for incisional hernia

17.5 million. Notable independent risk factors for IH were ostomy reversal (HR = 2.76), recent chemotherapy (HR = 2.04), bariatric surgery (HR = 1.78), smoking history (HR = 1.74), liver disease (HR = 1.60), and obesity (HR = 1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statistic = 0.78). Conclusions:This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.

A Systematic Review and Head-to-Head Meta-Analysis of Outcomes following Direct-to-Implant versus Conventional Two-Stage Implant Reconstruction.

BACKGROUND Although hernia repair with mesh can be successful, prophylactic mesh augmentation (PMA) represents a potentially useful preventative technique to mitigate incisional hernia risk in select high-risk patients. The efficacy, cost-benefit, and societal value of such an intervention are not known. The aim of this study was to determine the cost-utility of using prophylactic mesh to augment fascial incisions. METHODS A decision tree model was employed to evaluate the cost-utility of using PMA relative to primary suture closure (PSC) after elective laparotomy. The authors adopted the societal perspective for cost and utility estimates. A systematic review of the literature on PMA was performed. The costs in this study included direct hospital costs and indirect costs to society, and utilities were obtained through a survey of 300 English-speaking members of the general public evaluating 14 health state scenarios relating to ventral hernia. RESULTS PSC without mesh demonstrated an expected average cost of

Optimizing patient selection in ventral hernia repair with concurrent panniculectomy: An analysis of 1974 patients from the ACS-NSQIP datasets

17,182 (average quality-adjusted life-year [QALY] of 21.17) compared with

Propensity-Matched, Longitudinal Outcomes Analysis of Complications and Cost: Comparing Abdominal Free Flaps and Implant-Based Breast Reconstruction

15,450 (expected QALY was 21.21) for PMA. PSC was associated with an incremental cost-efficacy ratio (ICER) of -

A 35-year experience with syndromic cleft palate repair: operative outcomes and long-term speech function.

42,444/QALY compared with PMA such that PMA was more effective and less costly. Monte Carlo sensitivity analysis was performed demonstrating more simulations resulting in ICERs for PSC above the willingness-to-pay threshold of

A Cost-Utility Assessment of Mesh Selection in Clean-Contaminated Ventral Hernia Repair.

50,000/QALY, supporting the finding that PMA is superior. CONCLUSION Cost-utility analysis of PSC compared to PMA for abdominal laparotomy closure demonstrates PMA to be more effective, less costly, and overall more cost-effective than PSC.

Complicated breast cancer–related lymphedema: evaluating health care resource utilization and associated costs of management

Background: Innovative approaches to reconstruction have ushered in an era of breast reconstruction in which direct-to-implant procedures can provide an immediately reconstructed breast. Balancing the benefits against its technical challenges is vital. The authors evaluated the safety and efficacy of using direct-to-implant versus conventional two-stage reconstruction through a systematic meta-analysis. Methods: A literature search identified all articles published after 1999 involving prosthetic-based breast reconstruction as a two-stage tissue expander/implant or direct-to-implant technique. The primary outcomes of interest, including implant loss, capsular contracture, reoperation, and infection, were analyzed by means of head-to-head meta-analysis. Results: Thirteen studies involving 5216 breast reconstructions were included. The average patient age was 47.2 ± 1.0 years, the average body mass index was 24.9 ± 0.8 mg/k2, and the average follow-up was 40.8 months. Wound infection, seroma, and capsular contracture risk were similar between groups. However, direct-to-implant reconstruction was associated with a higher risk for skin flap necrosis (OR, 1.43; p = 0.01; I2 = 51 percent) and reoperation (OR, 1.25; p = 0.04; I2 = 43 percent). Ultimately, the risk for implant loss was nearly two-fold higher with direct-to-implant reconstruction compared with tissue expander/implant reconstruction (OR, 1.87; p = 0.04; I2 = 33 percent). Conclusions: Although direct-to-implant and two-stage tissue expander/implant reconstruction are successful approaches, this meta-analysis demonstrates significantly greater risk of flap necrosis and implant failure with direct-to-implant reconstruction. The authors’ findings suggest that the critical component of patient selection is judgment of mastectomy flap tissue quality. These findings can enhance the risk counseling process and highlight the need for additional investigations to optimize outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.