Background
Despite advances in diagnostic imaging capabilities, little information exists concerning the impact of physical dimensions of a paraesophageal hernia (PEH) on intraoperative decision ...making. The authors hypothesized that computerized volumetric analysis and multidimensional visualization to measure hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) would correlate to operative findings and required surgical techniques performed.
Methods
Using volumetric analysis software (
Aquarius iNtuition, TeraRecon, Inc
), HDA and HSV were measured in PEH patients with preoperative computerized tomography (CT) scans, and used to predict the likelihood of intraoperative variables. Multidimensional rotation of images enabled visualization of the entire hiatal defect in a plane mimicking the surgeon’s view during repair. The intrathoracic hernia sac was outlined producing volume measurements based on a summation of exact dimensions.
Results
A total of 213 PEHR patients had preoperative CT imaging, with 14.1% performed emergently. Primary cruroplasty was performed in 89.2%, salvage gastropexy in 10.3%, and diaphragmatic relaxing incisions in 4.2%. Median HDA was 25.7 cm
2
(IQR17.8–35.6 cm
2
); median HSV was 365.0 cm
3
(IQR150.0–611.0 cm
3
). Incremental 5 cm
2
increase in HDA was associated with greater likelihood of presenting emergently (OR 1.27; 95%CI 1.124–1.428,
p
= 0.0001), incarceration (OR 1.27; 1.074–1.499,
p
= 0.005), gastric volvulus (OR 1.13; 1.021–1.248,
p
= 0.02), and requiring either relaxing incision (OR 1.43; 1.203–1.709,
p
< 0.0001) or salvage gastropexy (OR 1.13; 1.001–1.274,
p
= 0.04). Similarly, HSV increases of 100 cm
3
were associated with 23% greater likelihood of emergent repair (CI 1.121–1.353,
p
< 0.0001), and were more likely to require a relaxing incision (OR 1.18; 1.043–1.339,
p
= 0.009) or salvage gastropexy (1.19; 1.083–1.312,
p
= 0.0003).
Conclusions
Utilization of CT volumetric measurements is a valuable adjunct in preoperative planning, allowing the surgeon to anticipate complexity of repair and operative approach, as incremental increases in HSV by 100 cm
3
and HDA by 5 cm
2
are more likely to require complex techniques or bailout procedures and/or present emergently.
Introduction
Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines ...the impact of abdominal volumes on postoperative RI in OVHR.
Methods
OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables.
Results
There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7 kg/m
2
, age of 58.5 ± 12.4 years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24 h respiratory support with ezPAP, CPAP, or biPAP (RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1 kg/m
2
,
p
< 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4 years,
p
= 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9 cm
2
,
p
< 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7 cm
3
,
p
< 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58,
p
< 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82–8.96), hernia PC (OR 1.47, CI 1.48–1.98), EAV PC (OR 1.24, CI 1.04–1.48), increased age (OR 1.04, CI 1.01–1.06), and diabetes (OR 1.8, CI 1.11–2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI.
Conclusion
The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.
Graphic abstract
Introduction
BMI and hernia defect size are strongly associated with outcomes after open ventral hernia repair (OVHR). The impact of abdominal subcutaneous fat (SQV), intra-abdominal volume (IAV), ...hernia volume (HV), and ratio of HV to intra-abdominal volume (HV:IAV, representing visceral eventration) is less clearly elucidated. This study examines the interaction of multiple markers of adiposity and hernia size in OVHR.
Methods
OVHR with preoperative CT scans were identified. 3D volumetric software measured HV, SQV, IAV, and HV:IAV was calculated. A principal component analysis was performed to create new component variables for collinear variables. Hernia PC was composed primarily of hernia dimensions, EAV (extra-abdominal volume PC) included SQV and BMI, and IAV PC included IAV.
Results
A total of 1178 OVHR patients had a preoperative CT scan. Their demographics included a mean age of 58.5 ± 12.4 years, BMI of 34.2 ± 7.7 kg/m
2
, and 57.8% were female. The mean defect area was 150.8 ± 136.7 cm
2
, and 66.0% were recurrent, Patients had mean SQV of 6719.4 ± 3563.9 cm
3
, HV of 966.9 ± 1303.5 cm
3
, IAV of 4250.2 ± 2118.1 cm
3
, and a HV:IAV of 0.29 ± 0.46. In multivariate analysis, Hernia PC was associated with panniculectomy (OR 1.52, CI 1.37–1.69) and component separation (OR 1.34, CI 1.21–1.49) and was negatively associated with fascial closure (OR 0.78, CI 0.69–0.88). Hernia PC was also associated with reoperation, readmission, and development of wound complications (OR 1.18, CI 1.08–1.30; OR 1.15, CI 1.04–1.27; OR 1.28, CI 1.16–1.41, respectively). EAV PC was associated with performance of a panniculectomy (OR 1.33, CI 1.20–1.48), readmission (OR 1.18, CI 1.06–1.32), and wound complications (OR 1.41, CI 1.27–1.57). IAV PC was not associated with adverse outcomes.
Conclusion
Values of hernia area, volume, IAV, HV:IAV, BMI, and SQV are collinear markers of patient obesity and hernia proportions. They are distinct enough to be represented by three principal component variables, indicating more nuanced discrete influences on variability of surgical outcomes other than BMI.
Introduction
Anterior component separation (ACS) is a well-established, highly functional technique to achieve fascial closure in complex abdominal wall reconstruction (AWR). Unfortunately, ACS is ...also associated with an increased risk of wound complications. Perforator sparing ACS (PS-ACS) has more recently been introduced to maintain the subcutaneous perforators derived from the deep epigastric vessels. The aim of this study is to evaluate wound-related outcomes in patients undergoing open AWR after implementation of a PS-ACS technique.
Methods
A prospectively collected database were queried for patients who underwent open AWR and an ACS from 2006 to 2018. Patients who underwent PS-ACS were compared to patients undergoing ACS using standard statistical methods. Patients undergoing concomitant panniculectomy were included in the standard ACS group.
Results
In total, 252 patients underwent ACS, with 24 (9.5%) undergoing PS-ACS. Age and specific comorbidities were similar between groups (all
p
> 0.05) except for the PS-ACS groups having a higher rate of prior tobacco use (45.8% vs 19.6%,
p
= 0.003). Mean hernia defect area was 381.6 ± 267.0 cm
2
with 64.3% recurrent hernias, and both were similar between groups (all
p
> 0.05). The PS-ACS group did have more complex wounds with more Ventral Hernia Working Group Grade 3 and 4 hernias (
p
= 0.04). OR time and length of stay were similar between groups (all
p
> 0.05). Despite increased complexity, wound complication rates were much lower in the PS-ACS group (20.8% vs 46.1%,
p
= 0.02), and all specific wound complications were lower but not statistically different. Hernia recurrence rate was similar between PS-ACS and ACS groups (4.2% vs 7.0%,
p
> 0.99) with mean follow-up of 27.7 ± 26.9 months.
Conclusions
In complex AWR, preservation of the deep epigastric perforating vessels during ACS significantly lowers the rates of wound complications, despite its performance in more complex patients with an increased risk of infection. PS-ACS should be performed preferentially over a standard ACS whenever possible.
Background
Male patients undergoing bariatric surgery have (historically) been considered higher risk than females. The aim of this study was to examine the disparity between genders undergoing ...laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) procedures and assess gender as an independent risk factor.
Methods
The MBSAQIP® Data Registry Participant User Files for 2015–2017 was reviewed for patients having primary SG and RYGB. Patients were divided into groups based on gender and procedure. Variables for major complications were grouped together, including but not limited to PE, stroke, and MI. Univariate and propensity matching analyses were performed.
Results
Of 429,664 cases, 20.58% were male. Univariate analysis demonstrated males were older (46.48 ± 11.96 vs. 43.71 ± 11.89 years,
p
< 0.0001), had higher BMI (46.58 ± 8.46 vs. 45.05 ± 7.75 kg/m
2
,
p
< 0.0001), and had higher incidence of comorbidities. Males had higher rates of major complications (1.72 vs. 1.05%;
p
< 0.0001) and 30-day mortality (0.18 vs. 0.07%,
p
< 0.0001). Significance was maintained after subgroup analysis of SG and RYGB. Propensity matched analysis demonstrated male gender was an independent risk factor for RYGB and SG, major complications 2.21 vs. 1.7%,
p
< 0.0001 (RYGB), 1.12 vs. 0.89%,
p
< 0.0001 (SG), and mortality 0.23 vs. 0.12%,
p
< 0.0001 (RYGB), 0.10 vs. 0.05%;
p
< 0.0001 (SG).
Conclusion
Males continue to represent a disproportionately small percentage of bariatric surgery patients despite having no difference in obesity rates compared to females. Male gender is an independent risk factor for major post-operative complications and 30-day mortality, even after controlling for comorbidities.
While childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after ...elective colorectal procedures.
Children ages 2–18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts.
858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p=0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p=0.04). Incremental increase in BMI by 1.0kg/m2 was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS.
Increasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications.
III
Introduction
In complex abdominal wall reconstruction (AWR), the role of concomitant panniculectomy has been debated due to concern for increased wound complications that impact outcomes; however, ...long-term outcomes and quality of life (QOL) have not been well described. The aim of our study was to evaluate the outcomes and QOL in patients undergoing AWR with panniculectomy utilizing 3D volumetric-based propensity match.
Methods
A prospective database from a tertiary referral hernia center was queried for patients undergoing open AWR. 3D CT volumetrics were analyzed and a propensity match comparing AWR patients with and without panniculectomy was created including subcutaneous fat volume (SFV). QOL was analyzed using the Carolinas Comfort Scale.
Results
Propensity match yielded 312 pairs, all with adequate CT imaging for volumetric analysis. The panniculectomy group had a higher BMI (
p
= 0.03) and were more likely female (
p
< 0.0001), but all other demographics and comorbidities were similar. The panniculectomy group was more likely to have undergone prior hernia repair (77% vs 64%,
p
< 0.001), but hernia area, SFV, and CDC wound class were similar (all
p
> 0.05). Requirement of component separation (61% vs 50%,
p
= 0.01) and mesh excision (44% vs 35%,
p
= 0.02) were higher in the panniculectomy group, but operative time were similar (all
p
≥ 0.05). Panniculectomy patients had a higher overall wound occurrence rate (45% vs 32%,
p
= 0.002) which was differentiated only by a higher rate of wound breakdown (24% vs 14%,
p
= 0.003); all other specific wound complications were equal (all
p
≥ 0.05). Hernia recurrence rates were similar (8% vs 9%,
p
= 0.65) with an average follow-up of 28 months. Overall QOL was equal at 2 weeks, and 1, 6, and 12 months (all
p
≥ 0.05).
Conclusions
Despite panniculectomy patients and their hernias being more complex, concomitant panniculectomy increased wound complications but did not negatively impact infection rates or long-term outcomes. Concomitant panniculectomy should be considered in appropriate patients to avoid two procedures.
Background
Component Separation (CST) typically involves incision of one or more fascial planes to generate myofascial advancement flaps to assist with fascial closure in ventral hernia repair (VHR). ...The aim of this study was to compare peri-operative outcomes and quality of life (QOL) after CST versus patients without CST (No-CST) in large, preperitoneal VHR (PPVHR).
Methods
A prospective, single institution hernia study examined all patients undergoing PPVHR with synthetic mesh. Emergency and contaminated operations were excluded. A case–control cohort was identified using propensity score matching for CST and No-CST. QOL was assessed using the Carolinas Comfort Scale.
Results
The algorithm matched 113 CST cases to 113 No-CST cases. The groups (CST vs No-CST) were similar regarding age, BMI, diabetes, smoking, defect size, mesh size, and follow-up. In univariate analysis, there was no difference in recurrence between the CST and no-CST groups (0.9% vs 0.9%,
p
= 1.0) or mesh infection (0.9% vs 0.0%,
p
= 1.0). CST did have more wound complications (29.2% vs 16.1%,
p
= 0.019). When controlling for panniculectomy and diabetes with multivariate logistic regression, CST continued to have had an increased risk for wound complications (OR 2.27, CI 1.16–4.47). QOL was routinely assessed. The groups were similar pre-operatively with 76.3% of CST patients and 77.8% of No-CST patients having pain (
p
= 1.0). At 1, 6, 12, 24, and 36 months post-operatively, the groups had equal QOL.
Conclusion
The use of CST versus No-CST in the repair of large VHs results in an increased risk of wound complications but does not increase the hernia recurrence rate. In the largest QOL comparative study to date, CST’s generation of myofascial advancement flaps does not negatively impact patient QOL in the repair of large ventral hernias in the short or long term.
Abstract Background Patients with complex ventral hernias may benefit from preoperative optimization. This study evaluates the financial impact of preventable comorbidities (PCM) in elective open ...ventral hernia repair. Methods In this single institution prospectively collected data from 2007-2011, hospital charges (included all hernia-related visits, interventions, or readmissions) and wound-related complications in patients with PCM—diabetes, tobacco use, and obesity—were compared to patients without such risks using standard statistical methods. Results Within the study period, there were 118 patients with no PCM; of those, 33 had complications, and 85 did not. In the 131 patients with two or more PCM, 81 had complications; 89 of 251 patients had complications in the group with only 1 PCM; groups with PCM were significantly more likely to have complications compared to the no PCM group (62% versus 35.4% versus 28%, P < 0.05). The majority of the patient population was female (57.2%) with a mean age of 57.8 y (range, 22-84 ys), and median defect size was 150 cm2 (interquartile range, 50-283 cm2 ). Body mass index was higher in PCM group with complications than in PCM without complications (40 versus 36 kg/m2 , P < 0.05). For patients with complications, the average hospital charges were $80,660 in the PCM group compared to $55,444 in the no PCM group ( P = 0.038). Hospital charges in those with PCM without complications compared to no PCM with complications were equivalent ($65,453 versus $55,444, P = 0.55). Even when no complications occurred, patients with PCM incurred higher charges than No PCM for inpatient ($61,269 versus $31,236, P < 0.02), outpatient ($4,185 versus $552, P < 0.04), and total hospital charges ($65,453 versus $31,788, P ≤ 0.001). Those patients without complications but with a single PCM incurred larger charges than those with no PCM during follow-up ($3578 versus $552, P = 0.04), but there was no difference in hospital or overall total charges ( P > 0.05). Interestingly, patients without complications, both hospital ($38,333 versus $61,269, P = 0.02) and total charges ($41,911 versus $65,453, P = 0.01) were increased for patients with 2+ PCM compared to those with only a single PCM. If complications occurred, no difference between the single PCM group compared to the two or more PCM groups existed for hospital, follow-up, or overall charges ( P > 0.05). Conclusions Patients with PCM undergoing open ventral hernia repair are more likely to have complications than patients without comorbidities. Patients with PCM generate higher hospital charges than those without PCM even when no complications occur; furthermore, the more PCM, the patient has the more significant the impact. Interestingly, patients with multiple PCM and no complications had equivalent hospital costs compared to patients with no PCM and with complications. Aggressive risk reduction may translate into significant savings. Preoperative preparation of patients before elective surgery is indicated.
Introduction
Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for ...emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair.
Methods
A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software.
Results
Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%,
p
= 0.016) and regurgitation (21.9%vs40.2%,
p
= 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%,
p
< 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm
3
,
p
< 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm
2
,
p
< 0.001). In multivariate analysis, HSV increase of 100cm
3
(OR 1.17 CI 1.02–1.35,
p
= 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all
p
< 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (
p
> 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence.
Conclusions
Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.
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