Victor B. Tsirline

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.

Prospective, comparative study of postoperative quality of life in TEP, TAPP, and modified Lichtenstein repairs.

Introduction:The purpose of this study was to compare postoperative quality of life (QOL) in patients undergoing laparoscopic totally extraperitoneal (TEP), transabdominal preperitoneal (TAPP), or modified Lichtenstein (ML) hernia repairs. Methods:The International Hernia Mesh Registry (2007–2010) was interrogated. 2086 patients who underwent 2499 inguinal hernia repairs were identified. A Carolinas Comfort Score was self-reported at 1-, 6-, 12-months and results were compared. Subgroups analysis and logistic regression were used to identify confounders and to control for significant variables. Results:One hundred seventy-two patients met the exclusion criteria. The distribution of unilateral procedures was TEP (n = 217), TAPP (n = 331), and ML (n = 953). Average follow-up was 12 months. Use of >10 tacks, lack of prostate pathology, recurrent hernia repairs, and bilateral hernia repairs were significant predictors of postoperative pain. One month after surgery 8.9%, 16.6%, and 16.5% were symptomatic for TEP (P = 0.038 vs. ML), TAPP and ML, respectively. At 6 months and 1 year no differences were observed. The number of tacks used varied significantly, with 18.1% of TAPP and 2.3% of TEP with >10 tacks (P = 0.005). The incidence of hernia recurrences were equivalent: TEP (0.42%), TAPP (1.34%), and ML (1.27%). The number or type of tacks utilized did not impact recurrence rates. Conclusion:Use of >10 tacks doubles the incidence of early postoperative pain while having no effect on rates of recurrence. There was no difference in chronic postoperative pain comparing ML, TEP, and TAPP including when controlled for tack use.

The Addition of Lysostaphin Dramatically Improves Survival, Protects Porcine Biomesh from Infection, and Improves Graft Tensile Shear Strength

BACKGROUND Lysostaphin (LS), a naturally occurring Staphylococcal endopeptidase, has the ability to penetrate biofilm, and has been identified as a potential antimicrobial to prevent mesh infection. The goals of this study were to determine if LS adhered to porcine mesh (PM) can impact host survival, reduce the risk of long-term PM infection, and to analyze lysostaphin bound PM (LS-PM) mesh-fascial interface in an infected field. METHODS Abdominal onlay PMs measuring 3×3 cm were implanted in select groups of rats (n=75). Group assignments were based on bacterial inoculum and presence of LS on mesh. Explantation occurred at 60 d. Bacterial growth and mesh-fascial interface tensile strength were analyzed. Standard statistical analysis was performed. RESULTS Only one out of 30 rats with bacterial inoculum not treated with LS survived. All 30 LS treated rats survived and had normal appearing mesh, including 20 rats with a bacterial inoculum (10(6) and 10(8) CFU). Mean tensile strength for controls and LS and no inoculum samples was 3.47±0.86 N versus 5.0±1.0 N (P=0.008). LS groups inoculated with 10(6) and 10(8) CFU exhibited mean tensile strengths of 4.9±1.5 N and 6.7±1.6 N, respectively (P=0.019 and P<0.001 compared with controls). CONCLUSION Rats inoculated with S. aureus and not treated with LS had a mortality of 97%. By comparison, LS treated animals completely cleared S. aureus when challenged with bacterial concentrations of 1×10(6) and 1×10(8) with maintenance of mesh integrity at 60 d. These findings strongly suggest the clinical use of LS-treated porcine mesh in contaminated fields may translate into more durable hernia repair.

Poor resident-attending intraoperative communication may compromise patient safety.

BACKGROUND Prior research suggests that hierarchy in medicine may impact communication and patient safety. This study examined the factors that influence surgical trainees in expressing their opinion in the operating room and the consequences this might have on patient safety. METHODS An anonymous survey of general surgery, gynecology, and orthopedic surgery residents and attendings was conducted at a teaching institution in 2010. Separate surveys were used for attendings and for trainees consisting of 26 and 27 questions, respectively, with 17 questions in common. The surveys assessed whether the surgical hierarchy interfered with the residents voicing concerns about patient safety. Survey data was compiled, and χ2, Fisher exact tests, and the Wilcoxon rank sum test were used depending on the normality of the data. RESULTS Thirty-eight trainees and 23 attendings participated in the survey; 74%-78% of trainees and attendings recalled an incident where the trainee spoke up and prevented an adverse event. While all attendings reported that they encourage residents to question their intraoperative decision making, only 55% of residents agreed (P<0.01). Residents indicated that they were more likely to voice their opinion with some attendings than with others based on their personality. Both groups agreed that the hierarchical structure of general surgical residency is necessary. CONCLUSION Our findings indicate that resident attending intraoperative communication can prevent adverse patient events. Trainees often feel impaired in voicing their concerns to their attendings. Strategies that improve resident attending communication intraoperatively are needed as they are likely to enhance patient safety.

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.

Microwave ablation using 915-MHz and 2.45-GHz systems: what are the differences?

OBJECTIVES This study was conducted to evaluate differences between 915-MHz and 2.45-GHz microwave ablation (MWA) systems in the ablation of hepatic tumours. METHODS A retrospective analysis of patients undergoing hepatic tumour MWA utilizing two different systems over a 10-month period was carried out. RESULTS Data for a total of 48 patients with a mean age of 58 ± 1.24 years were analysed. A total of 124 tumours were ablated; 72 tumours were ablated with a 915-MHz system and 52 with a 2.45-GHz system. Mean tumour diameters were 1.7 ± 0.1 cm in the 915-MHz group and 2.5 ± 0.2 cm in the 2.45-GHz group (P < 0.01). Mean ablation time per burn was 8.1 ± 0.3 min in the 915-MHz group and 4.0 ± 0.1 min in the 2.45-GHz group (P < 0.01). The mean number of burns per lesion was 2.0 ± 0.1 in the 915-MHz group and 1.7 ± 0.1 in the 2.45-GHz group (P < 0.05). The mean ablation time per lesion was 9.7 ± 0.7 min in the 915-MHz group, and 6.6 ± 0.6 min in the 2.45-GHz group (P < 0.01). The 2.45-GHz system demonstrated a better correlation between ablation time and tumour size (r(2) = 0.6222) than the 915-MHz system; (r(2) = 0.0696). Mean total energy applied per lesion, and energy applied per cm, were greater with the 915-MHz system (P < 0.05 and P < 0.01, respectively). Total energy applied per lesion was similarly correlated for the 2.45-GHz (r(2) = 0.6263) and 915-MHz (r(2) = 0.7012) systems. Mean total energy applied per cm/min was greater with the 2.45-GHz system (P < 0.05). CONCLUSIONS Both 915-MHz and 2.45-GHz MWA systems achieve reproducible hepatic tumour ablation. The 2.45-GHz system achieves equivalent, but more predictable and faster ablations using a single antenna system.

Quality of Life Following Component Separation Versus Standard Open Ventral Hernia Repair for Large Hernias

Introduction. Component separation (CS) has become a viable alternative to repair large ventral defects when the fascia cannot be reapproximated. However, the impact of transecting the external oblique to facilitate closure of the abdomen on quality of life (QOL) has yet to be investigated. The study goal was to investigate QOL and outcomes after standard open ventral hernia repair (OVHR) versus CS for large ventral hernias. Study design. Prospective data for all CSs were reviewed and compared with matched OVHR controls. All defects were 100 to 1000 cm2 in size and repaired with mesh. Comorbidities, complications, outcomes, and Carolinas Comfort Scale (CCS) scores, were reviewed. Results. Seventy-four CS patients were compared with 154 patients undergoing standard OVHR with similar defect sizes. Age (56.7±13.0 vs 54.7 ± 12.3 years, P = .26), defect sizes (299 ± 160 vs 304 ± 210cm2, P = .87), and BMI (32.7 ± 6.9 vs 34.2 ± 9.0 kg/m2, P = .26) were similar in both groups, respectively. There were no differences in major postoperative complications (P = .22), mesh infections (P = 1.00), wound infections (P = .07), or hernia recurrence (P = .09), but wound breakdown increased after CS (10% vs 1%, P < .001) as did seroma interventions (15% vs 4%, P = .005). Postoperative CCS scores were similar at 1 month (P = .82) and 1 year (P = .14). Conclusions. In the first comparative study of its kind, it is found that patient undergoing CS with mesh reinforcement had equal short- and long-term QOL outcomes compared with similar patients who underwent standard OVHR. Whereas wound breakdown and seroma formation are higher, the overall complication, mesh infection, and recurrence rates are similar.

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.

Evaluation of an Innovative, Cordless Ultrasonic Dissector

Ultrasonic thermal energy is commonly used for dissection and vessel ligation. This study compared HARMONIC ACE and Sonicision Cordless Ultrasonic Dissector (SCUD). The devices were used in an in vivo porcine model to coagulate 189 arteries up to 5 mm. Seal times were similar: SCUD, 5.2 ± 1.7 s; ACE, 4.9 ± 1.5 s (P = .20). Burst pressures for SCUD and AVE were 578 ± 284 and 605 ± 288 mm Hg, respectively (P = .48). Stratification by vessel diameter yielded similar results. In all, 17 applications resulted in seal failure on either the proximal or distal side, with no difference between SCUD (4.4%) and ACE (6.6%; P = .37). Histological examination of 48 specimens showed similar thermal spreads: 1.06 ± 0.05 versus 1.08 ± 0.05 mm for SCUD and ACE, respectively (P = .82). In 41 timed mesenteric transections, SCUD required 24.8 ± 4.9 s, which was significantly less than the 33.8 ± 5.4 s for ACE (P < .0001), with no bleeding in either group. SCUD and ACE showed similar vessel seal times, burst pressures, thermal spreads, and seal failure rates. SCUD was more efficient than ACE in mesenteric transection.

Application of Subcutaneous Talc after Axillary Dissection in a Porcine Model Safely Reduces Drain Duration and Prevents Seromas

BACKGROUND Talc, the most common pleurodesis agent, has recently been shown to prevent seromas and decrease drain duration when placed subcutaneously after large subcutaneous dissection accompanying open ventral hernia repair. We hypothesized that talc would decrease drain duration and prevent seromas after axillary dissection without local or systemic side effects. STUDY DESIGN Six pigs underwent full, bilateral axillary dissection (n 12 dissections). Three animals each had aerosolized small particle (SP) talc and large particle (LP) talc sprayed unilaterally (TALC) before closure, with the contralateral axillary dissection serving as the control (NOTALC). Functional status, wound complications, and drain duration were recorded. Local neurovascular structures and systemic organs were harvested at 28 days, processed with hematoxylin and eosin, and examined under normal and polarized light microscopy by blinded physicians. RESULTS All pigs were back to baseline functional status by 72 hours. Two seromas (33%) were noted in the NOTALC dissections vs 0 in the TALC group (0%). Drain duration was significantly decreased in TALC vs NOTALC dissections (8.3 ± 2.7 vs 12.0 ± 3.2 days, p = 0.03), as was total drain volume (222.5 ± 127.1 mL vs 334.2 ± 137.9 mL, p = 0.02). Gross and histologic evaluation revealed neurovascular structures to be intact. Minimal splenic deposition of talc within macrophages without evidence of injury was identified in all specimens, with fewer deposits in the large particle talc group. Serum laboratory examination at time of harvest revealed all animals to have normal values. CONCLUSIONS Direct application of talc throughout the wound after axillary dissection in pigs decreased drain duration and drain volume and prevented seroma formation. Gross, histologic, and serum laboratory evaluation demonstrated no talc-related local or systemic complications. Aerosolized talc is an effective and safe pretreatment to prevent seromas and hasten drain removal after axillary dissection.