Elective Repairs Research Articles

BHSeP48 A review of outcomes following the establishment of a Complex Abdominal Wall Reconstruction (CAWR) Multi-Disciplinary Team (MDT) at Medway NHS Foundation Trust

Abstract Background Medway ventral hernia patients have a high prevalence of co-morbidities, high Body Mass Index (BMI), recurrent hernias, multiple defects, mesh-explantation and stomas. Before CAWR MDT establishment, these patients were booked without standardized pre-operative pathways, experiencing delays and sub-optimal outcomes. Methods Prospective data of 55 patients were reviewed from February 2021 to February 2024 after the CAWR MDT was established. Median follow-up of 14 months. Outcome measures included compliance with Delphi consensus, MDT to surgery wait times, length of stay (LOS), complications, recurrences and EuraHS-Quality of Life (QoL) scores. Results MDT pre-operative planning achieved 99% guideline compliance. Key gaps were expert radiology, prehabilitation, and dietician input. 11 patients were unsuitable for surgery, another 6 referred to specialist centres.16 patients underwent surgery at Medway; 3 as emergencies. 42% had BMI ≥ 35, 60% required prehabilitation and median CeDAR (Carolina’s Equation for Determining Associated Risk) scores were 35% (IQR 22–43). Median time from MDT to elective repair was 6 months versus 2 months for emergencies. 38% of electives received ultrasound-guided Botulinum toxin injection into lateral abdominal wall musculature pre-operatively, median 47 days before surgery (IQR 40-61). LOS was 5.5 days for electives versus 14 days after emergency repairs (P = 0.002). Recurrence odds were 10 times higher for emergencies (95% CI 2.5, 153), with 100% complication rates (Clavien-Dindo ≥3) versus 8% for electives. QoL scores were best for elective patients (36/90) compared to those awaiting repair (60/90) and emergency patients (54/90). Elective repairs utilized mesh (retromuscular) in 82% of cases (62% biological), versus 66% and 33% in emergencies respectively. Conclusions CAWR MDT enables structured decision-making, optimizes resources and improves patient outcomes. Findings advocated for radiologist and prehabilitation input and expedited elective repairs to prevent significant morbidity in emergencies.

Laparoscopic Type IV Hiatal Hernia Repair in the Elective and Emergency Settings, Clinical Presentation, Outcomes, and Same-Day Surgery in Elective Repairs

Objective: We aimed to compare the outcomes of laparoscopic type IV hiatal hernia repairs in elective and emergent settings and assess the feasibility of same-day surgery (SDS) in elective repairs. Methods: SDS was defined as discharge on the day of the procedure. The feasibility of SDS in elective repairs was assessed. Results: There were 265 primary type IV hernia repairs: 208/265 (78.5%) elective versus 57/265 (21.5%) in emergent settings, age:70.0 (64.0-75.0) versus 73.0 (60.8-82.0), P = .059, BMI: 30.1 (26.6-33.8) versus 27.5 (24.4-32.4), P = .025, ASA IV: 5/208 (2.4%) versus 11/57 (19.3%), P < .001, LOS:1 (0-2) versus 2 (1-4), P < .001, 30-day mortality: 0/208 (0.0%) versus 2/57 (3.5%), P = .046. SDS was planned in 83/208 (39.9%) elective procedures and performed in 65/83 (78.3%); 18/83 (21.7%) were transitioned from SDS to observation/inpatient. NGT was attempted in 18/57 (31.6%) in emergent setting and was successful in 5/5 at the bedside and 11/13 (84.6%) endoscopically. Ischemia was seen in 4/57 (7.0%) in emergent settings and perforation in 1/4. Time from surgical consultation to arrival to the OR in patients without ischemia/perforation/obstructive gastric volvulus (n = 50) was 57.9 hours (44.0-79.7) versus 5.5 hours (4.1-8.9) in those with, (n = 7). Conclusion: Type IV hiatal hernia can be repaired laparoscopically with good outcomes in elective and emergent settings and as SDS in elective repairs. Emergent presentations can occur in about 20% of type IV hernias in older patients with lower BMI and higher ASA. Ischemia/perforation are rare. Emergent presentations without ischemia/perforation can be treated with gastric decompression and urgent repair during the same admission.

Risk Factors for Development of Incisional Hernia after Aortic Aneurysm Repair: Secondary Analysis of the OVER Randomized Controlled Trial

Since the risk of mortality from rupture is elevated, elective repair of abdominal aortic aneurysms (AAAs) is often recommended. Currently, over 80% of elective repairs are carried out using an endovascular approach. While open repair has similar late survival and fewer reintervention outcomes when compared to endovascular repair, incisional hernia is a frequent complication with morbidity and cost implications. The Open versus Endovascular Repair (OVER) trial was the largest randomized trial of endovascular versus open repair of AAA in the United States. The purpose of this study was to determine risk factors associated with incisional hernia development following AAA repair via secondary analysis of the OVER data. This was a multisite trial conducted within the Veterans Affairs health-care system. Study participants (N=881) were enrolled from 2002 to 2008 and followed until 2011 with additional administrative data collection until 2016. Eligible patients had AAA for which elective repair was planned and randomized 1:1 to either open or endovascular repair. Incisional hernia was a prespecified end point in the OVER protocol, specifically assessed at each protocol follow-up visit. Technical details were extracted from each operative report, repair case report form(s), and adverse event form(s). Patient demographics, comorbid conditions, reported preoperative activity level, and operative details including initial approach, blood loss, and closure methods were analyzed using Bayesian hierarchical Weibull survival regression modeling. Incisional hernias were recorded among 46 participants (5.2%). The average time to hernia diagnosis was 3.5years. Of the 437 participants randomized to open treatment, 427 received an open repair including crossovers from endovascular treatment assignment. Transperitoneal repair was performed in 81%, running suture in 96%, and absorbable suture in 71% of cases. Randomization to endovascular repair was associated with reduced risk of hernia (hazard ratio [HR] 0.70, 95% credible interval [CI] 0.49-0.94). Higher activity level was associated with increased hernia risk (HR 1.39, 95% CI 1.06-1.84). Approach, suture closure techniques, body mass index, diabetes, and smoking status were not associated with increased risk of hernia development. Incisional hernia is a frequent complication associated with open repair of abdominal aortic aneurysm and commonly required reintervention. Endovascular repair was associated with reduced risk of hernia. Patients with increased activity experienced a higher incidence of hernia. However, no other modifiable patient, operative, or technical factors were found to be associated with hernia development.

EVALUATION OF POSTOPERATIVE COMPLICATIONS AND REOPERATIONS IN PATIENTS UNDERGOING OPEN UMBILICAL HERNIA REPAIR

Abstract Background Umbilical hernia repair is a common surgical procedure. Open repair is recommended for small to medium size hernias, and use of mesh reduces recurrence. The primary aim was to evaluate the risk of postoperative complications and reoperations after emergency and elective open umbilical hernia repair, and secondly to evaluate whether complications and reoperations were associated to type of repair. Methods A single center retrospective cohort study of patients undergoing open umbilical hernia repair from October 2022 to September 2023. Data was extracted from the patient charts. Results A total of 151 had an umbilical hernia repair, 103 (68%) elective surgeries and 48 (32%) emergency surgeries. For the elective repairs, 37 (36%) got a suture- and 66 (64%) a mesh repair. There was no difference in complications, 5.4% versus 7.6%, p = 0.675. A higher percentage of emergency surgeries had the mesh placed in the onlay position 45.8% (22/48) compared to elective surgeries 30.1% (31/103), which more often received a preperitoneal mesh 34% (35/103). The overall complication rate tended to be higher for emergency repair compared with elective surgery, 6.8% and 14.6%, p = 0.124, with a tendency towards more complications with the use of mesh 12.1% (12/99) compared with suture repair 3.8% (2/52), p = 0.096. The most frequent complications were wound related (seroma, hematoma, wound infection). There were three (3%) reoperations in the elective group due to infection, and correspondingly two (4%) in the emergency group. Conclusion There is no difference in postoperative complication regarding suture or mesh repair of umbilical hernias.

Presentation and Outcomes of Elective and Nonelective Complex Endovascular Repair for Thoracoabdominal and Juxtarenal Aortic Aneurysms

Endovascular repair of thoracoabdominal aortic aneurysms (TAAA) and juxtarenal aortic aneurysms (JAA) with fenestrated and/or branched endografts (B/FEVAR) has become common. Physician modified endografts for patients presenting with symptomatic or contained ruptures has made B/FEVAR a feasible option in nonelective settings. The purpose of this study was to describe our 10-year institutional experience with endovascular interventions for TAAA in elective and nonelective cases to evaluate differences in outcomes and the clinical risk factors associated with nonelective presentation. A prospectively maintained database was retrospectively queried for patients undergoing B/FEVAR for TAAA and JAA at a single tertiary care academic institution between 1/2011 and 12/2020. Data collected included demographics, comorbidities, presenting symptoms, aneurysm characteristics, and clinical outcomes. Nonelective repair was defined as any patient that presented through the Emergency Department, as a hospital transfer, or as a direct admission from clinic and had aortic repair performed during the same admission. Univariate analyses were used to compare patients. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included perioperative complications and nonhome discharge. Between 1/201 and 12/2020, a total of 208 patients underwent B/FEVAR for TAAA (173) and JAA (35). Nonelective repair was performed in 44 (21%) patients with 39 for TAAA (23%) and 5 for JAA (14%). Nonelective patients were younger (71±11 vs. 74±7years, P=0.03), more likely to be self-pay or have Medicaid (11% vs. 2%, P=0.02) and had a different race distribution compared to the elective cohort (P<0.01). Thirty-day mortality was 4% (n=6) in elective repairs and 7% (n=3) in nonelective repairs. One-year mortality was 13% (n=22) in elective repairs and 18% (n=8) in nonelective repairs. There were no differences between patients receiving elective versus nonelective repair in 30-day (P=0.40) or1-year mortality (P=0.47). Nonelective patients had longer median duration of stay (11 interquartile range (IQR) 6-15 vs. 5 IQR 4-8, P<0.01), postoperative length of stay (7 IQR 5-12 vs. 4 IQR 3-7, P<0.01), and more intensive care unit days (6 IQR 3-8 vs. 3 IQR 2-5, P<0.01). There were no differences in other secondary outcomes between elective and nonelective patients including inpatient and access-related complications, re-interventions, and nonhome discharge (P>0.05 for all comparisons). A composite "any complication" occurred more frequently in patients with nonelective repair (50% vs. 35%, P=0.03). Endovascular repair for TAAA or JAA is a good option in patients undergoing nonelective surgical intervention, with comparable 30-day mortality, 1-year mortality, and perioperative morbidity to that of patients undergoing elective B/FEVAR.

Women with large intact abdominal aortic aneurysms remain untreated

ObjectiveA lower elective repair rate among women with abdominal aortic aneurysms (AAAs) has been a consistent finding. Reasons behind this gender gap have not been thoroughly outlined. MethodsThis was a retrospective multicenter cohort study (ClinicalTrials.gov: NCT05346289) at three European vascular centers in Sweden, Austria and Norway. Patients in surveillance with AAAs were consecutively identified starting from January 1, 2014, until reaching a total sample size of 200 women and 200 men. All individuals were followed for 7 years through medical records. Final treatment distributions and the proportion of “truly untreated” (surgically untreated despite reaching guideline-directed thresholds: 50 mm for women and 55 mm for men) were determined. In a complementary analysis, a universal 55-mm threshold was used. Gender-specific primary reasons behind untreated statuses were clarified. Eligibility for endovascular repair among the truly untreated was assessed in a structured computed tomography analysis. ResultsWomen and men had similar median diameters at inclusion (46 mm; P = .54) and at treatment decisions (55 mm; P = .36). After 7 years, the repair rate was lower among women (47% vs 57%). More women were truly untreated (26% vs 8%; P < .001) despite similar mean ages as for male counterparts (79.3 years; P = .16). With the 55-mm threshold, 16% women still classified as truly untreated. Similar reasons for nonintervention were captured for women and men (50% due to comorbidities alone, 36% morphology and comorbidity). The endovascular repair imaging analysis revealed no gender differences. Among truly untreated women, ruptures were common (18%), and mortality was high (86%). ConclusionsSurgical AAA management differed between women and men. Women could be underserved in terms of elective repairs: one in every four women was untreated with over-the-threshold AAAs. The lack of obvious gender differences in eligibility analyses could imply unmeasured discrepancies (eg, in disease extent or patient frailty).

25, 50 and 75 years ago

25, 50 and 75 years ago

The Epidemiology of Surgically Managed Hiatal Hernia: A Nine Year Review of National Trends

Background: National-level data on the burden of disease related to surgically managed hiatal hernia (HH) is not available. This study intends to define this burden of disease in the United States with attention to patient demographics, surgical approach, readmissions, mortality, and charges. Methods: Data from national Healthcare Utilization Project (HCUP) databases for 2010-2018 were retrospectively reviewed. Adult patients undergoing elective or emergent non-congenital diaphragmatic hernia repair were included. Spearman’s rank correlation was utilized to determine significance of trends over time. Results: In 2018, an estimated 62 528 HH repairs were performed, an incidence of 19.14/100 000 persons per year. The non-ambulatory procedure incidence was 7.52/100 000 persons in 2010 compared to 12.76/100 000 persons in 2018. Between the first and final years of analysis, patients undergoing non-elective repairs increased in age (2010: 62 years vs 2018: 69 years, P &lt; .01) and frailty (4.9% vs 16.3%, P &lt; .01). Rates of 30-day readmission remained similar for elective (6.5% vs 5.7%, P = .06) and non-elective operations (9.9% vs 9.5%, P = .71). In-hospital mortality increased for elective repairs (0.3% vs 0.6%, P &lt; .01). In the final year of analysis, median charges were: Ambulatory: $37 864 versus Elective laparoscopic: $54 377 versus Elective Open: $73 436 versus Non-elective Laparoscopic: $85 906, versus Non-elective Open: $117 845, and total annual healthcare charges were $4.28 billion. Conclusions: Incidence of HH repair and charges increased over the study period. The proportion of frail patients undergoing elective and non-elective repairs increased. Changes in the incidence of underlying disease, patient perceptions and symptom tolerance, or surgeon decision-making may have contributed to these trends.

Outcomes of parastomal hernia repair after national centralization.

In 2010, it was decided to centralize parastomal hernia repairs to five specialized hernia centres in Denmark to improve outcomes. The aim of this nationwide cohort study was to evaluate whether centralization of parastomal hernia repairs has had an impact on outcomes. Specifically, readmission, reoperation for complication, and operation for recurrence were analysed before and after centralization. By merging clinical and administrative outcome data from the Danish Hernia Database with those from the Danish National Patient Registry, all patients undergoing parastomal hernia repair in Denmark from 1 January 2007 to 31 December 2018 were included. Centralization was defined as having at least 70 per cent of procedures were performed at one of the five national centres. Readmission, reoperation, and recurrence rates for emergency and elective repairs were evaluated before and after centralization. In total, 1062 patients were included. Median follow-up was 992 days. Overall, the centralization process took 7 years. For elective repairs, the readmission, reoperation, mortality, and recurrence rates were comparable before and after centralization, but more patients overall and more patients with co-morbidity were offered surgery after centralization. For emergency repairs, there was a significant reduction in rates of reoperation (from 44.9 per cent (48 of 107) to 23 per cent (14 of 62); P = 0.004) and mortality (from 10.3 per cent (11 of 107) to 2 per cent (1 of 62); P = 0.034) after centralization. Centralization led to more elective operations and better outcomes when emergency repair was needed. Centralization of parastomal hernia repair led to more patients receiving elective repair and significantly improved outcomes after emergency repair.

Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs

SPINAL CORD ISCHEMIA (SCI) after thoracoabdominal aortic repair is a well-known complication of both open and endovascular surgery, with reported rates as high as 5%-to-21% after open repair. 1 Gravereaux EC Faries PL Burks JA et al. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysm. Jour of Vasc Surg. 2001; 34: 997-1003 Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar Resultant morbidity, including paraparesis and paraplegia, are devastating, and a fair amount of research has gone into developing strategies for mitigating SCI-related complications. Cerebrospinal fluid drainage (CSFD) with the placement of lumbar drains (LDs) is considered the current recommendation for both prevention and treatment of SCI in high-risk patients. 2 Coselli JS LeMaire SA Koksoy C et al. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002; 35: 631-639 Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar ,3 Hiratzka LF Bakris GL Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121: e266-e369 Crossref PubMed Scopus (1914) Google Scholar While there is some controversy over the utility of CSFD for endovascular repairs, it is still a widely accepted practice that is performed frequently for patients at high risk of developing SCI postrepair. 4 Isaak RS Furman W. Con: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should not receive prophylactic cerebrospinal fluid drainage. J Cardiothorac Vasc Anesth. 2015; 29: 1381-1383 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Protocols regarding the placement of LDs can vary by institution, whereby some centers may routinely use imaging guidance for the procedure. In this review, the authors examine the specifics of using fluoroscopic guidance for the preoperative placement of LDs in patients who are at a high risk of developing SCI after thoracoabdominal aortic repair. It is the authors’ belief that the universal use of fluoroscopic guidance is unnecessary, potentially harmful, confers additional expense, and is unsupported by the current body of evidence.

1061 Is There Potential for Prevention of Emergency Open Hernia Repairs?

Abstract Aim Emergency hernia repairs are associated with increased post-operative complications. We aim to compare symptoms and healthcare contacts prior to surgery in patients undergoing emergency hernia repair to those who underwent elective hernia repair. Method Retrospective study of all patients with acutely strangulated/obstructed hernias between October 2019 and October 2021. Emergency repairs were compared with cohort of elective repairs carried out over the same study period. Results 41 patients required emergency open hernia repairs. The median age was 79(range 44–91) years. 25 were inguinal hernias, 7 para-umbilical, 4 incisional, and 4 femoral. 14/41(35.4%) patients had healthcare consultation for hernia prior to acute presentation. Of these, 11(27.1%) were already awaiting elective surgery. 25/41(60.4%) patients were asymptomatic prior to acute presentation. 28/48(68.7%) patients were not aware of hernia diagnosis prior to emergency surgery. There was significantly higher presence of hernia symptoms, healthcare contact, and awareness of diagnosis, in the elective patients compared to the emergency group (P&amp;lt;0.05). There was significantly higher rate of in-patient stay and need for small bowel resection in emergency patients (P&amp;lt;0.001). We found significantly higher rates of wound infection, haematoma/seroma, and urinary retention in emergency repair patients compared to the elective group (P&amp;lt;0.01). Conclusion Early diagnosis and hernia repair is required to prevent need for emergency surgery and reduce risks of post-operative complications. Improved patient education regarding early presentation would allow earlier detection and intervention. Lack of symptoms prior to incarceration, however, would hinder early presentation, and therefore potential for emergency surgery prevention remains limited.

The Hyperattenuating Crescent Sign Is Not Necessarily a Sign of Impending Aortic Aneurysm Rupture

The "crescent sign" is a hyperattenuating crescent-shaped region on CT within the mural thrombus or wall of an aortic aneurysm. Although it has previously been associated with aneurysm instability or impending rupture, the literature is largely based on retrospective analyses of urgently repaired aneurysms. We strove to more rigorously assess the association between an isolated "crescent sign" and risk of impending aortic rupture. Patients were identified by querying a single health system PACS database for radiology reports noting a crescent sign. Adult patients with a CT demonstrating a descending thoracic, thoracoabdominal, or abdominal aortic aneurysm and "crescent sign" between 2004 and 2019 were included, with exclusion of those showing definitive signs of aortic rupture on imaging. A total of 82 patients were identified. Aneurysm size was 7.1 ± 2.0 cm. Thirty patients had emergent or urgent repairs during their index admission (37%), 19 had elective repairs at a later date (23%), and 33 patients had no intervention due to either patient choice or prohibitive medical comorbidities (40%). Patients without intervention had a median follow up of 275 days before death or loss to follow up. In patients undergoing elective intervention, 6,968 patient-days elapsed between presentation and repair, with zero episodes of acute rupture (median 105 days). Patients undergoing elective repair had smaller aneurysms compared to those who underwent emergent/urgent repair (6.2 ± 1.3 vs. 7.7 ± 2.1 cm, P=0.008). No surgical candidate with an aneurysm smaller than 8 cm ruptured. There were 31 patients with previous axial imaging within 2 years prior to presentation with a "crescent sign," with mean aneurysm growth rate of 0.85 ± 0.62 cm per 6 months [median 0.65, range 0-2.6]. Those with aneurysms sized below 5.5 cm displayed decreased aneurysm growth compared to patients with aneurysm's sized 5.5-6.5 cm or patients with aneurysms greater than 6.5 cm (0.12 vs. 0.64 vs. 1.16 cm per 6 months, P= 0.002). The finding of an isolated radiographic "crescent sign" without other signs of definitive aortic rupture (i.e., hemothorax, aortic wall disruption, retroperitoneal bleeding) is not necessarily an indicator of impending aortic rupture, but may be found in the setting of rapid aneurysm growth. Many factors, including other associated radiographic findings, aneurysm size and growth rate, and patient symptomatology, should guide aneurysm management in these patients. We found that patients with minimal symptoms, aneurysm sizes below 6.5 cm, and no further imaging findings of aneurysm instability, such as periaortic fat stranding, can be successfully managed with elective intervention after optimization of comorbid factors with no evidence of adverse outcomes.

Predicting Ileus in Elective Open Ventral Hernia Repairs with Retromuscular Mesh: a Post Hoc Analysis of 2 Randomized Controlled Trials

Predicting Ileus in Elective Open Ventral Hernia Repairs with Retromuscular Mesh: a Post Hoc Analysis of 2 Randomized Controlled Trials

Costs of abdominal aortic aneurysm care at a regional Veterans Affairs medical center with the implementation of an abdominal aortic aneurysm screening program

BackgroundAbdominal aortic aneurysm (AAA) screening has demonstrated to be cost-effective in reducing AAA-related morbidity and all-cause mortality. However, the downstream care costs of an implemented AAA screening in clinical practice have not been reported. The purpose of this study is to determine direct regional Department of Veterans Affairs (VA) costs in implementing and sustaining an AAA screening program over a 10-year period. MethodsA cost data analysis (adjusted to 2021 U.S. dollars) of an AAA screening program was conducted from 2007 to 2016, where 19,649 veteran patients aged 65-75 with a smoking history were screened at a regional VA medical center. A decision support system tracked direct and indirect encounter costs from Medicare billing codes associated with AAA care. Costs from a patient’s initial screening, follow-up imaging, to AAA repair or at the end of the analysis period, March 31, 2021, were recorded. Costs for AAA repairs outside the VA system were also tracked. ResultsA total of 1,183 patients screened were identified with an AAA ≥3.0 cm without history of repair. Estimated screening costs were $2.8 million or $280,000 annually ($143/screening) in the care of 19,649 screened patients. There were 221 patients who required repair (143 repairs in VA, 78 repairs outside VA). The average cost of elective endovascular repair was $43,021 and that of open repair was $49,871. The total costs for all elective repairs were $9,692,591. Screening, implementation, maintenance, and surgical repair cost involved in the management of patients with AAA disease was $13.7 million, with $10,686 per life-year lived after repair (5.8 ± 3.5 mean life-years) and $490 per life-year lived after screening (6.9 ± 3.5 mean life-years) for all patients screened. There were 13 deaths of unknown causes and one patient with a ruptured AAA that required emergency repair at a cost of $124,392. CONCLUSIONSDespite known limitations, the implementation of an AAA ultrasound screening program is feasible, cost-effective, and a worthwhile endeavor.

AB183. SOH21AS215. A 2019 nationwide review of emergency vs. elective umbilical hernia repair Ireland: is there a role for non-operative management?

Background: Asymptomatic umbilical hernias are often repaired electively, however there are no high-quality studies defining benefits of elective repair compared to watchful waiting. Low evidence studies suggest that elective repairs are safer than emergencies, with 30-day readmission rates of 5.9% compared to 18.8% in emergency surgery. 16% of those managed conservatively require surgery within 5 years, 3.9% as emergencies.

Epidemiology of abdominal wall and groin hernia repairs in children

We sought to estimate the prevalence, incidence, and timing of surgery for elective and non-elective hernia repairs. We performed a retrospective cohort study, abstracting data on children < 18 years from the 2005-2014 DoD Military Health System Data Repository, which includes > 3 million dependents of U.S. Armed Services members. Our primary outcome was initial hernia repair (inguinal, umbilical, ventral, or femoral), stratified by elective versus non-elective repair and by age. We calculated prevalence, incidence rate, and time from diagnosis to repair. 19,398 children underwent hernia repair (12,220 inguinal, 5761 umbilical, 1373 ventral, 44 femoral). Prevalence of non-elective repairs ranged from 6% (umbilical) to 22% (ventral). Incidence rates of elective repairs ranged from 0.03 [95% CI: 0.02-0.04] (femoral) to 8.92 [95% CI: 8.76-9.09] (inguinal) per 10,000 person-years, while incidence rates of non-elective repairs ranged from 0.005 [95% CI: 0.002-0.01] (femoral) to 0.68 [95% CI: 0.64-0.73] (inguinal) per 10,000 person-years. Inguinal (median = 20, interquartile range [IQR] = 0-46days), ventral (median = 23, IQR = 5-62days), and femoral hernias (median = 0, IQR = 0-12days) were repaired more promptly and with less variation than umbilical hernias (median = 66, IQR = 23-422days). These data describe the burden of hernia repair in the U.S. The large variation in time between diagnosis and repair by hernia type identifies an important area of research to understand mechanisms underlying such heterogeneity and determine the ideal timing for repair. Prognosis study II.

Early outcomes of emergency ventral hernia repair in a cohort of poorly optimized patients.

Strangulated and obstructed ventral hernias require emergent repair to mitigate the risk of life-threatening complications. Emergency ventral hernia repairs are associated with a higher rate of surgical complications and recurrence compared to elective repairs. The purpose of this study was to explore the impact of patient factors, hernia and operative characteristics on post-operative outcomes in patients requiring emergency ventral hernia repairs. Data were collected from a prospectively held database on 86 consecutive patients undergoing emergency ventral hernia repairs between January 2016 and January 2019 at Logan Hospital. Patient, hernia and operative characteristics were collected for reporting and analysis. Of the 86 patients, 29 (34%) developed a surgical complication, of which 17 patients (59%) had surgical site infections. We identified obesity (P = 0.017), history of smoking (P = 0.008), American Society of Anesthesiologists class of III-IV (P = 0.008), hernia defect size ≥3 cm (P = 0.048) and concomitant small bowel resection (P = 0.028) to be associated with post-operative surgical complication. Multivariate analysis identified smoking (P = 0.005) and concomitant small bowel resection (P = 0.026) as independent predictors for developing surgical complications. Seven patients (8%) recurred at a median of 221 days. Incisional hernias (P = 0.001), recurrent hernias (P < 0.001), greater than one defect (P < 0.001) and bowel involvement (P = 0.049) were associated with higher rates of hernia recurrence. Patient factors significantly influence outcomes in the emergency setting. Given that this is not modifiable at the time of surgery, greater emphasis needs to be placed on optimizing the physical and behavioural factors of patients with early symptomatic hernias for an elective repair.

Outcome of laparoscopic paraesophageal hernia repair in octogenarians: a registry-based, propensity score-matched comparison of 360 patients

BackgroundParaesophageal hernias (PEH) tend to occur in elderly patients and the assumed higher morbidity of PEH repair may dissuade clinicians from seeking a surgical solution. On the other hand, the mortality rate for emergency repairs shows a sevenfold increase compared to elective repairs. This analysis evaluates the complication rates after elective PEH repair in patients 80 years and older in comparison with younger patients.MethodsIn total, 3209 patients with PEH were recorded in the Herniamed Registry between September 1, 2009 and January 5, 2018. Using propensity score matching, 360 matched pairs were formed for comparative analysis of general, intraoperative, and postoperative complication rates in both groups.ResultsOur analysis revealed a disadvantage in general complications (6.7% vs. 14.2%; p = 0.002) for patients ≥ 80 years old. No significant differences were found between the two groups for intraoperative (4.7% vs. 5.8%, p = 0.627) and postoperative complications (2.2% vs. 2.8%, p = 0.815) or for complication-related reoperations (1.7% vs. 2.2%, p = 0.791).ConclusionsDespite a higher risk of general complications, PEH repair in octogenarians is not in itself associated with increased rates of intraoperative and postoperative complications or associated reoperations. Therefore, PEH repair can be safely offered to elderly patients with symptomatic PEH, if general medical risk factors are controlled.

Repair of Chronic Achilles Ruptures Has a High Incidence of Venous Thromboembolism.

Despite the low incidence of deep vein thrombosis (DVT) in foot and ankle surgery, some authors report a high incidence of symptomatic DVT following Achilles tendon rupture. The purpose of this study was to identify DVT risk factors inherent to Achilles tendon repair to determine which patients may benefit from prophylaxis. One hundred and thirteen patient charts were reviewed following elective and nonelective Achilles tendon repair. For elective repair of insertional or noninsertional Achilles tendinopathy, parameters examined included lateral versus prone positioning and the presence versus absence of a flexor hallucis longus transfer. For nonelective repair, acute Achilles tendon ruptures were compared to chronic Achilles tendon ruptures. Of 113 Achilles tendon repairs, 3 venous thromboembolism (VTE) events (2.65%) occurred including 2 pulmonary emboli (1.77%). Seventeen of these repairs were chronic Achilles tendon ruptures, and all 3 VTE events (17.6%) occurred within this subgroup. Elevated body mass index was associated with VTE in patients with chronic Achilles ruptures although this did not reach significance ( P = .064). No VTE events were reported after repair of 28 acute tendon ruptures or after 68 elective repairs of tendinopathy. Two patients with misdiagnosed partial Achilles tendon tears were excluded because they experienced a VTE event 3 weeks and 5 weeks after injury, prior to surgery. In our retrospective review, chronic Achilles ruptures had a statistically significant higher incidence of VTE compared with acute Achilles ruptures ( P = .048) or elective repair ( P = .0069). Pharmaceutical anticoagulation may be considered for repair of chronic ruptures. Repair of acute ruptures and elective repair may not warrant routine prophylaxis due to a lower incidence of VTE. Prognostic, Level III: Case Control Study.

Regional variation exists in patient selection and treatment of abdominal aortic aneurysms

Significant regional variation in surgical rates has been identified following multiple surgical procedures. However, limited data have examined the regional variability in patient selection and treatment of abdominal aortic aneurysms (AAAs). This study aimed to evaluate regional variation in patient selection, perioperative management, and operative approach for the repair of AAAs. All patients undergoing open repair or endovascular aneurysm repair (EVAR) of an AAA in the Vascular Quality Initiative from 2009 to 2014 were identified. All regional groups were deidentified, and those with fewer than 100 open repairs were combined into a single region. We identified 17,269 elective repairs (EVAR, 13,759; open, 3510) and 1462 ruptured AAAs (EVAR, 749; open, 713). There was significant regional variation in the use of EVAR for elective repair (range, 66%-88%; P< .01) andruptured AAA repair (40%-80%; P< .01). The median diameter for elective repair was similar among regions (EVAR,5.4cm; open, 5.7cm). There was wide variation in the treatment of small aneurysms in male patients (<5.5cm) for EVAR (34%-49%; P< .01) and open repair (17%-38%; P< .01) and variation in the treatment of small aneurysms in female patients (<5cm) for EVAR (14%-32%; P< .01) but not significant for open repair (6%-24%). For elective cases, preoperative aspirin (EVAR, 50%-75% [P< .01]; open, 49%-78% [P< .01]) and statin use (EVAR, 61%-75% [P< .01]; open, 56%-80% [P< .01]) varied widely. Among elective cardiac patients, preoperative management varied significantly, including beta-blocker use (EVAR, 66%-78% [P< .01]; open, 69%-88% [P= .01]) and the frequency of stress tests (EVAR, 33%-64% [P< .01]; open, 31%-73% [P< .01]). Among open repairs for aneurysms extending at or beyond the juxtarenal segment, there was wide variation in the use of retroperitoneal exposures (7%-70%; P< .01) and adjunctive renal protective measures (cold renal perfusion, 2%-43% [P< .01]; mannitol, 47%-92% [P< .01]). Significant regional variation exists in patient selection, perioperative management, and operative approach for the repair of AAA. Definitive evidence is lacking in many aspects of operative care, including the use of the retroperitoneal approach and renal protective strategies. However, this variation emphasizes the importance of research to determine best practice in the areas of greatest variation. Furthermore, where current clinical process measures exist and data are clear, such as the use of statin and antiplatelet agents, the high degree of variation should serve as an impetus for regional quality improvement projects.