Paul D. Colavita

Prospective, Long-Term Comparison of Quality of Life in Laparoscopic Versus Open Ventral Hernia Repair

Objectives:To compare laparoscopic ventral hernia repair (LVHR) versus open ventral hernia repair (OVHR) for quality of life (QOL), complications, and recurrence in a large, prospective, multinational study. Introduction:As recurrence rates have decreased for LVHR and OVHR, QOL has become an extremely important differentiating outcomes measure. Methods:A prospective, international database was queried from September 2007 to July 2011 for LVHR and OVHR. Carolinas Comfort Scale (CCS) was utilized to quantify QOL (pain, movement limitation, and mesh sensation) preoperatively and at 1, 6, and 12 months postoperatively. Results:A total of 710 repairs included 402 OVHR and 308 LVHR. Demographics were mean age 57.1 ± 13.3 years, 49.6% male, 21.7% recurrent hernias, mean body mass index of 30.3 ± 6.6, and mean defect size of 89.4 ± 130.8. Preoperatively, 56.9% had pain, and 53.2% experienced movement limitation. At 1-month follow-up, 587 (82.7%) patients were provided CCS scores; more LVHR patients experienced pain (P < 0.001) and movement limitations (P < 0.001). At 6 and 12 months, there were no differences in QOL with 466 (65.6%) and 478 (67.3%) patients responding, respectively. After controlling for confounding variables, LVHR was independently associated with more frequent discomfort [odds ratio (OR) = 1.9, confidence interval (CI): 1.2–3.1], movement limitation (OR = 1.6, CI: 1.0–2.7), and overall symptoms (OR = 1.6, CI: 1.0–2.6) at 1 month. LVHR resulted in a shorter length of stay (LOS) (P < 0.001) and fewer infections (P = 0.004), but overall complication rates were equal. Recurrence rates were also equal (P = 0.66). Conclusion:In the largest, prospective QOL study comparing LVHR and OVHR, LVHR is associated with a decrease in QOL in the short term. LOS and infection rates are decreased in LVHR, but overall complication and recurrence rates are equal.

Colonoscopy is superior to neostigmine in the treatment of Ogilvie's syndrome

BACKGROUND Colonic pseudo-obstruction in critically ill patients may lead to devastating colonic perforation. Neostigmine is often the first-line intervention, because colonoscopy is more invasive and labor intensive. METHODS A retrospective 10-year review at a tertiary medical center identified 100 patients with Ogilvies syndrome, in whom treatment course and clinical and radiographic response were evaluated. RESULTS Colonoscopy was significantly more successful than neostigmine (defined as no further therapy) after 1 or 2 interventions (75.0% vs 35.5%, P = .0002, and 84.6% vs 55.6%, P = .0031, respectively). One colonoscopy was more effective than 2 neostigmine administrations (75.0% vs 55.6%, P = .044). Clinical response (poor, fair, or good) was significantly better after colonoscopy than neostigmine after 1 or 2 interventions (P = .0028 and P = .00079). Cecal diameters decreased significantly more after colonoscopy than neostigmine (from 10.2 ± .5 cm to 7.1 ± .4 cm vs from 10.5 ± .5 cm to 8.8 ± .5 cm, P = .026). Neostigmine administration before colonoscopy did not affect outcomes. There were 3 perforations (3.7%): 1 each after colonoscopy, neostigmine, and no intervention. Neostigmine dose or repetition did not affect radiographic (P = .41) or clinical (P = .31) response. CONCLUSIONS Colonoscopy is superior to neostigmine for Ogilvies syndrome and should be considered first-line therapy, although neostigmine is useful in select patients and repeat interventions.

Nationwide inpatient sample: have antireflux procedures undergone regionalization?

The Nissen fundoplication was introduced in 1956 by Rudolph Nissen and is a proven, effective treatment for gastroesophageal reflux disease (GERD). The laparoscopic technique was first described in 1991 by Bernard Dallemagne and has also been shown to be safe and effective in treatment of GERD. From 1990 to 1997, antireflux surgery rates almost tripled and peaked in 1999, which was followed by a steady decline through 2006. The decline in surgical volume has been partially attributed to a question of the longterm effectiveness of antireflux surgery, where re-operation can often become required, and many patients require acid suppression medications post-operatively. –11 The decline of operative intervention has also been attributed to the availability of over-the-counter proton pump inhibitors, new endoscopic therapies for treating GERD, and the rise of bariatric surgery. 7 Increasing outpatient antireflux procedures has also been examined as a potential cause for the decrease of inpatient cases. However, analysis of outpatient data in several states has revealed that the decrease in inpatient procedures in not nearly matched by the volume of outpatient procedures. The effect of hospital volume on mortality has been demonstrated since the 1970s, but the literature describing this effect rapidly increased in the late 1990s. –17 This lead to a call for regionalization of many procedures on a national level by the year 2000. Regionalization has been demonstrated for many complex procedures, oncologic and otherwise. 20 The timing of the national call for regionalization coincided closely with the peak of antireflux surgery. The purpose of this study is to examine trends in antireflux surgery to determine the extent of regionalization, if any at all, in the decade following the zenith of antireflux surgery.

Carolinas Comfort Scale as a Measure of Hernia Repair Quality of Life: A Reappraisal Utilizing 3788 International Patients.

Objective: The goal of the present study was to reaffirm the psychometric properties of the CCS using an expansive, multinational cohort. Background: The Carolinas Comfort Scale (CCS) is a validated, disease-specific, quality of life (QOL) questionnaire developed for patients undergoing hernia repair. Methods: The data were obtained from the International Hernia Mesh Registry, an American, European, and Australian prospective, hernia repair database designed to capture information delineating patient demographics, surgical findings, and QOL using the CCS at 1, 6, 12, and 24 months postoperatively. Results: A total of 3788 patients performed 11,060 postoperative surveys. Patient response rates exceeded 80% at 1 year postoperatively. Acceptability was demonstrated by an average of less than 2 missing items per survey. The formal test of reliability revealed a global Cronbachs alpha exceeding 0.95 for all hernia types. Test-retest validity was supported by the correlation found between 2 different administrations of the CCS using the kappa coefficient. Principal component analysis identified 2 components with a good distribution of variance, with the first component explaining approximately 60% of the variance, regardless of hernia type. Discriminant validity was assessed by comparing survey responses and use of pain medication at 1 month postoperatively and analysis revealed that symptomatic patients demonstrated significantly higher odds of requiring pain medication in all activity domains and for all hernia types. Conclusions: The present study confirms that the CCS questionnaire is a validated, sensitive, and robust instrument for assessing QOL after hernia repair, which has become a predominant outcome measure in this discipline of surgery.

Simulation in General Surgery

Simulation in general surgery has had many advances in recent years. From the development of a variety of simulators to the creation of national skills curricula, the establishment of the accredited education institute network, and the refinement of assessment tools and metrics, the progress achieved signals a very bright future for the field. Surgical simulation will continue bringing the education and assessment of surgical trainees and practicing surgeons to new levels and is destined to improve patient care and outcomes.

A nationwide evaluation of robotic ventral hernia surgery

BACKGROUND The purpose of this study was to examine outcomes of robotic ventral hernia repair(RVHR) versus laparoscopic ventral hernia repair(LVHR). METHODS The Nationwide Inpatient Sample was queried from October 2008 to December 2013 for ventral hernia repairs. Demographics, morbidity, mortality, and charges were compared between RVHR and LVHR. RESULTS From 2008-2013, 149,622 ventral hernia surgeries were identified; 117,028 open, 32,243 laparoscopic, and 351 robotic. Open repairs were excluded. RVHR rose annually with 2013 containing 47.9% of all RVHRs. RVHR patients were more likely to be older and have more chronic conditions. There was no difference between length of stay. Pneumonia rates were higher with RVHR; however, after controlling for confounding variables, there was no difference in pneumonia rates. Mortality and other major complications were similar. Total charges were increased for RVHR in univariate and multivariate analysis. RVHR was more common in teaching hospitals and wealthier zip codes. CONCLUSION RVHR demonstrates comparable safety to the laparoscopic technique, with increased charges and increased volume in urban teaching hospitals and patients from areas of higher median income.

809 Nationwide Inpatient Sample: Have Antireflux Procedures Undergone Regionalization?

Introduction: With improved outcomes demonstrated at high volume centers, many complex surgical procedures have migrated to large, specialized hospitals. The purpose of this study is to examine the extent of regionalization and outcomes in anti-reflux surgery. Methods: The Nationwide Inpatient Sample (NIS) data were analyzed from 1998-99 (T1) and 200809 (T2) for all antireflux operations in patients with gastroesophageal reflux symptoms using ICD-9-CM codes. Hospitals were stratified into high-, mid-, and low-volume centers (HVC, MVC, LVC) based on annual antireflux surgery volume. Complications and outcomes were also compared. Socio-demographic factors were examined as effectors of surgery location. Results: A total of 11804 cases were performed in T1 and 8856 in T2. In T1, 41.0% of procedures were performed in a HVC vs 35.4% in T2. LVC rates increased with time: 20.53% vs. 26.87% (p<0.0001). Rural hospitals had decreased surgical volume (19.10% vs. 10.33%, p<0.0001), while all urban hospitals increased volumes: teaching (48.23% vs. 51.03%, p<0.0001) and non-teaching (32.67% vs. 38.64%, p<0.0001). Using multivariate regression, the following were predictors of surgery at a LVC in T1: non-caucasian race (OR 1.42, p<0.0001), emergent admission (OR 2.24, p<0.0001), living in a zip code with low median income (OR 1.52 lowest vs. highest, p=0.0039), increasing age (p=0.0002), and increasing concurrent diagnosis number (p=0.0029). In T2, emergent admission (OR 1.34, p=0.038), low median income (OR 1.69 highest vs lowest, p<0.0001), and number of concurrent diagnoses (p=0.034) were independent predictors of antireflux surgery at a LVC. In T2, mean LOS at a LVC was 4.0 days vs 3.3days at a HVC (p<0.0001), but this was not significant in multivariate analysis. Total charges were lower at a LVC (

Prospective, International Comparison of Quality of Life Outcomes After Laparoscopic vs Open Ventral Hernia Repair

38000 vs

Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open

41000, p=0.0032) in multivariate analysis. Complication rates increased at all centers with time, but were twice as common in LVCs (6.39% vs. 3.16% at HVCs, p<0.0001) in T2. Controlling for confounding variables, complications remained more likely in LVCs (T1: OR 1.71, p<0.0001, T2: OR 1.49, p<0.0001). In hospital mortality decreased in all centers with time and did not differ significantly in either era. Patients at all centers have increased their mean number of concurrent diagnoses over time(3.92 vs 6.70, p<0.0001). Conclusion: Despite improved results at HVCs, LVCs have increased their percentage of antireflux operations over time. The urban non-teaching hospitals have experienced the largest gains in caseload. Overall complication rates have increased with time, possibly due to noted increased incidence of comorbidities in the patients seeking antireflux surgery. After controlling for confounding variables, complications remain more likely in LVCs. Regionalization has not occurred over time, but may improve outcomes if supported.

Laparoscopic versus open hernia repair: outcomes and sociodemographic utilization results from the nationwide inpatient sample

RESULTS: A total of 1,221 repairs were performed, 578 LVHR and 643 OVHR, with a mean age of 56.9 years. Laparoscopic VHR was more frequently associated with females (57.2% vs 48.1%; p 1⁄4 0.002) and higher BMI (32.6 kg/m vs 31.0 kg/m; p < 0.0001), but other comorbidities were similar. Laparoscopic VHR had shorter length of stay (LOS, 2.8 2.4 days vs 4.3 5.1 days; p < 0.0001). Recurrences did not differ (5.7% vs 7.2%; p 1⁄4 0.3056). Wound complications were higher in OVHR (4.1% vs 0.4%; p < 0.0001), however, abdominal wall seromas and hematomas were increased in LVHR (16.6% vs 10.6%; p 1⁄4 0.002). The QOL at 1 month was worse for LVHR with regard to pain (odds ratio [OR], 1.98; 95% CI, 1.336-2.936), movement limitation (OR, 1.61; 95% CI, 1.076-2.402), and overall QOL (OR, 1.69; 95% CI, 1.1402.497). At 1 year, LVHR remained independently associated with increased pain (OR, 1.64; 95% CI, 1.025-2.624). No differences in QOL outcomes were noted at 2 years. Increased defect size was independently associated with worse overall postoperative QOL.