Robyn B. Broach

Impact of BMI on postoperative outcomes in patients undergoing proctectomy for rectal cancer: a national surgical quality improvement program analysis.

BACKGROUND: There is a mounting body of evidence that suggests worsened postoperative outcomes at the extremes of BMI, yet few studies investigate this relationship in patients undergoing proctectomy for rectal cancer. OBJECTIVE: We aimed to examine the relationship between BMI and short-term outcomes after proctectomy for cancer. DESIGN: This was a retrospective study comparing the outcomes of patients undergoing proctectomy for rectal cancer as they relate to BMI. SETTINGS: The American College of Surgeons-National Surgical Quality Improvement Program database was queried for this study. PATIENTS: Patients included were those who underwent proctectomy for rectal neoplasm between 2005 and 2011. MAIN OUTCOME MEASURES: Study end points included 30-day mortality and overall morbidity, including the receipt of blood transfusion, venous thromboembolic disease, wound dehiscence, renal failure, reintubation, cardiac complications, readmission, reoperation, and infectious complications (surgical site infection, intra-abdominal abscess, pneumonia, and urinary tract infection). Univariate logistic regression was used to analyze differences among patients of varying BMI ranges (kg/m2; ⩽20, 20-24, 25-29, 30-34, and ≥35). When significant differences were found, multivariable logistic regression, adjusting for preoperative demographic and clinical variables, was performed. RESULTS: A total of 11,995 patients were analyzed in this study. The incidences of overall morbidity, wound infection, urinary tract infection, venous thromboembolic event, and sepsis were highest in those patients with a BMI of ≥35 kg/m2 (OR, 1.63, 3.42, 1.47, 1.64, and 1.50). Wound dehiscence was also significantly more common in heavier patients. Patients with a BMI <20 kg/m2 had significantly increased rates of mortality (OR, 1.72) and sepsis (OR, 1.30). LIMITATIONS: This study was limited by its retrospective design. Furthermore, it only includes patients from the American College of Surgeons-National Surgical Quality Improvement Program database, limiting its generalizability to nonparticipating hospitals. CONCLUSIONS: Obese and underweight patients undergoing proctectomy for neoplasm are at a higher risk for postoperative complications and death.

Randomized Controlled Trial of Two Alcohol-based Preparations for Surgical Site Antisepsis in Colorectal Surgery

Objective: To compare 2 alcohol-based, dual-action skin preparations for surgical site infection (SSI) prevention in elective colorectal surgery. Background: Colorectal surgery is associated with the highest SSI rate among elective surgical procedures. Although evidence indicates that alcohol-based skin preparations are superior in SSI prevention, it is not clear if different alcohol-based preparations are equivalent in clean-contaminated colorectal procedures. Methods: We performed a blinded, randomized, noninferiority trial comparing iodine povacrylex-alcohol (IPA) and chlorhexidine-alcohol for elective, clean-contaminated colorectal surgery. The primary outcome was the presence or absence of SSI, defined as superficial or deep SSI, within 30 days postdischarge. A 6.6% noninferiority margin was chosen. Results: Between January 2011 and January 2015, 802 patients were randomized with 788 patients included in the intent to treat analysis (396 IPA and 392 chlorhexidine-alcohol). The difference in overall SSI rate between IPA (18.7%) and chlorhexidine-alcohol (15.9%) was 2.8% (P = 0.30). The upper bound of the 2.5% confidence interval of this difference was 8.9%, which is greater than the prespecified noninferiority margin of 6.6%. Other endpoints, including individual SSI types, time to SSI diagnosis, and length of stay were not different between the 2 arms. Conclusions: In patients undergoing elective, clean contaminated colorectal surgery, the use of IPA failed to meet criterion for noninferiority for overall SSI prevention compared with chlorhexidine-alcohol. Photodocumentation of wounds and rigorous tracking of outcomes up to 30 days postdischarge contributed to high fidelity to current standard SSI descriptions and wound classifications.

Patient-Reported Outcomes Following Ventral Hernia Repair: Designing a Qualitative Assessment Tool.

BackgroundCurrent hernia patient-reported outcome (PRO) measures were developed without patient input, greatly impairing their content validity.ObjectiveThe purpose of this study was to develop a conceptual model for PRO measures for ventral hernia (VH) patients.MethodsFifteen semi-structured, concept elicitation interviews and two focus groups employing nominal group technique were conducted with VH patients. Patients were recruited between November 2015 and July 2016 over the telephone from a five-surgeon patient cohort at our institution. Iterative thematic analysis identified domains. Reliability and validation were achieved using inter-rater reliability checks and triangulation.ResultsSeven framework domains were established: (1) expectations; (2) self and others; (3) surgeon and surgical team; (4) sensation; (5) function; (6) appearance; and (7) overall satisfaction. Overall patient satisfaction was associated with two themes: (1) provider–patient relationship; and (2) patient assessment of post-repair improvement.ConclusionsVH patients experience a profoundly broad range of reactions to VH repair. A patient-informed PRO instrument that addresses the spectrum of patient-identified outcomes can guide practice, optimizing care targeting VH patients’ needs.

Abstract: Institutional Experience with Ultrasonic Debridement for the Treatment of Complex Wounds

BACKGROUND: Regret after gender-affirming surgery is considered a rare outcome. There is a paucity of literature examining the incidence and/or etiology of surgical deand re-transition. Coupled with the current issues in access and barriers for those seeking gender-affirming surgery, research in this field is extremely controversial. There are currently no professional guidelines or resources for providers who encounter patients who experience regret and/or seek detransition. In this paper the authors try to answer the question of how frequently gender surgeons are confronted with patients seeking the above care and what the current controversies are surrounding this very important topic.

Prophylactic mesh augmentation: Patient selection, techniques, and early outcomes

BACKGROUND Incisional hernias (IH) following abdominal surgery are frequent and morbid. Prophylactic mesh augmentation (PMA) has emerged as a technique to reduce IH formation. We aim to report patient selection, techniques and early outcomes after PMA. METHODS Retrospective chart review identified descriptive characteristics, risk factors, operative technique, and early post-operative outcomes for PMA patients and matched non-PMA patients between January 1, 2016 and October 31, 2017. RESULTS 18 consecutive PMA cases were performed (55.6% female, mean age 54.3 years and mean BMI = 29.5 kg/m2). 88.9% of patients had at least two high-risk features for IH. Zero PMA patients developed IH compared to 5.3% non-PMA patients (p = 0.314) (6-months mean follow-up). No difference in surgical site occurrences (SSO) were identified between the two groups. CONCLUSIONS Early results are encouraging, demonstrating PMA is safe with equivocal SSO. Further studies are needed to assess if the reduction in IH formation is statistically significant with longer follow-up.