Richard A. Pierce

Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery

BACKGROUND Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations. STUDY DESIGN A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times. RESULTS Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01). CONCLUSIONS In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.

Cost-Utility Analysis of Biologic and Biosynthetic Meshes in Ventral Hernia Repair: When Are They Worth It?

BACKGROUND Biologic and biosynthetic meshes typically cost more than synthetic meshes for use in ventral hernia repair (VHR), with unknown comparative effectiveness. STUDY DESIGN Cost-utility analysis was performed from a limited societal perspective assessing direct medical costs and outcomes for open, elective, retromuscular VHR. Short-term and 5-year major complications and costs were modeled using best available evidence from published studies, Healthcare Cost and Utilization Project data, and Americas Hernia Society Quality Collaborative data. Costs were analyzed in 2017 US dollars, and utilities were assessed using quality adjusted life years (QALYs). Sensitivity analyses were performed to determine threshold probabilities of long-term complications favoring particular mesh types. RESULTS Synthetic mesh was the preferred strategy, with a cost of

Preoperative Imaging in Hernia Surgery

15,620 and QALYs of 18.85, assuming a baseline 5.6% rate of long-term complications for all meshes. One-way sensitivity analysis demonstrated that biosynthetic and biologic mesh became the better choice as long-term complication rates for synthetic mesh increased to 15.5% and 26.2%, respectively. Two-way sensitivity analysis demonstrated that biologic and biosynthetic meshes became favorable as the cost of biologic mesh decreased and long-term synthetic mesh complication rates increased. Biologic and biosynthetic meshes also became more cost-effective when their relative long-term complication rates decreased and long-term synthetic mesh complication rates increased. CONCLUSIONS Using modeling techniques, synthetic mesh is the best option for retromuscular VHR given currently available evidence. We established long-term complication thresholds, possibly justifying the higher up-front costs for biologic or biosynthetic meshes. This emphasizes the critical need to obtain long-term complication surveillance data to help individualize mesh choice in VHR.

Patient reported outcomes after incisional hernia repair—establishing the ventral hernia recurrence inventory

Hernia diseases continue to be one of the main problems managed by General Surgeons with increasing incidence over time (Poulose et al., Hernia 16:179–83, 2012). Increasingly complex patients, combined with a multitude of different repair techniques make detection and characterization of new hernia defects challenging. Even small defects can cause significant pain and lead to incarceration, yet they can be very difficult to detect on physical exam alone. Likewise, large defects may be easily detectable, yet can represent extremely complex deviations from normal anatomy, especially in the setting of the multiply recurrent hernia. The time-honored evaluation of physical exam has a reported sensitivity of only 77 % in detecting incisional hernias; this further emphasizes that rapid, accurate, and cost-effective imaging is of critical importance to today’s hernia surgeon (Baucom et al., J Am Coll Surg 218:363–6, 2014).