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Clinical Trial: Study looks at GI tract recovery after hernia repair
A randomized, multi-center, double-blinded trial is underway to study or placebo.
One group will be given a 12-mg dose of alvimopan 30-90 minutes before the scheduled start of surgery on Day 0, and twice daily beginning on postoperative Day 1 after nasogastric tube (NGT) removal until hospital discharge or for a maximum of 7 days (up to 15 doses). The other group will be given a similarly colored 12-mg placebo capsule 30-90 minutes on the same schedule.
Primary outcomes will include the length of time (hrs/days) for recovery of the GI tract, measured by time to first flatus and time to first bowel movement, both measured twice daily. In addition, toleration of diet and oral pain medication will be measured. Variables such as NGT insertion, diet restriction or reductions, episodes of emesis, bloating, and pain will be recorded twice daily.
Secondary outcomes include length of hospital stay, 30-day morbidity and hospital readmission. Postoperative pain scores will be obtained during the hospital stay, and 2 weeks and 30 days postoperatively and the Hernia-Related Quality-of-Life Survey (HerQLes) will also be administered postoperatively.
The study is sponsored by the Medical College of Wisconsin in collaboration with Merck Sharp and Dohme Corp.
Find more information on the “Gastrointestinal Tract Recovery in Patients Undergoing Open Ventral Hernia Repair (NCT02379858),” at www.clincaltrials.gov.
A randomized, multi-center, double-blinded trial is underway to study or placebo.
One group will be given a 12-mg dose of alvimopan 30-90 minutes before the scheduled start of surgery on Day 0, and twice daily beginning on postoperative Day 1 after nasogastric tube (NGT) removal until hospital discharge or for a maximum of 7 days (up to 15 doses). The other group will be given a similarly colored 12-mg placebo capsule 30-90 minutes on the same schedule.
Primary outcomes will include the length of time (hrs/days) for recovery of the GI tract, measured by time to first flatus and time to first bowel movement, both measured twice daily. In addition, toleration of diet and oral pain medication will be measured. Variables such as NGT insertion, diet restriction or reductions, episodes of emesis, bloating, and pain will be recorded twice daily.
Secondary outcomes include length of hospital stay, 30-day morbidity and hospital readmission. Postoperative pain scores will be obtained during the hospital stay, and 2 weeks and 30 days postoperatively and the Hernia-Related Quality-of-Life Survey (HerQLes) will also be administered postoperatively.
The study is sponsored by the Medical College of Wisconsin in collaboration with Merck Sharp and Dohme Corp.
Find more information on the “Gastrointestinal Tract Recovery in Patients Undergoing Open Ventral Hernia Repair (NCT02379858),” at www.clincaltrials.gov.
A randomized, multi-center, double-blinded trial is underway to study or placebo.
One group will be given a 12-mg dose of alvimopan 30-90 minutes before the scheduled start of surgery on Day 0, and twice daily beginning on postoperative Day 1 after nasogastric tube (NGT) removal until hospital discharge or for a maximum of 7 days (up to 15 doses). The other group will be given a similarly colored 12-mg placebo capsule 30-90 minutes on the same schedule.
Primary outcomes will include the length of time (hrs/days) for recovery of the GI tract, measured by time to first flatus and time to first bowel movement, both measured twice daily. In addition, toleration of diet and oral pain medication will be measured. Variables such as NGT insertion, diet restriction or reductions, episodes of emesis, bloating, and pain will be recorded twice daily.
Secondary outcomes include length of hospital stay, 30-day morbidity and hospital readmission. Postoperative pain scores will be obtained during the hospital stay, and 2 weeks and 30 days postoperatively and the Hernia-Related Quality-of-Life Survey (HerQLes) will also be administered postoperatively.
The study is sponsored by the Medical College of Wisconsin in collaboration with Merck Sharp and Dohme Corp.
Find more information on the “Gastrointestinal Tract Recovery in Patients Undergoing Open Ventral Hernia Repair (NCT02379858),” at www.clincaltrials.gov.
FROM CLINICALTRIALS.COM
Dexamethasone lowered risk of urinary retention in laparoscopic hernia repair
SEATTLE – Intraoperative in 955 men at the NorthShore University HealthSystem, Chicago.
Urinary retention occurs in up to a third of hernia repair patients. Men are at far higher risk than women; benign prostatic hypertrophy (BPH) and older age also increase the risk.
Intraoperative dexamethasone is a common antiemetic. The investigators had a hunch that it also reduces urinary retention by calming overstimulation of the bladder neck and prostate during the operation. “We believe this overstimulation” causes urinary retention, lead investigator Merritt Denham, BS, said at the World Congress of Endoscopic Surgery hosted by SAGES & CAGS.
She and her team went back in the records about 8 years to compare 617 laparoscopic inguinal hernia repair patients who received intraoperative dexamethasone with 338 who did not. They were all men: women were excluded from the review. The men voided before surgery. Those who received dexamethasone received more fluids during the operation than those who did not, a mean of 973 mL versus 878 mL (P = .0019).
Even so, urinary retention was far less likely in the dexamethasone group (3.7% vs. 9.8%; P = .0001). Controlling for age and BPH, the corticosteroid was highly protective (odds ratio, 0.48; 95% confidence interval, 0.26-0.87; P = .0147). The benefit was the same regardless of the intraoperative dexamethasone dosage, which ranged from 4 mg to 8 mg.
Dexamethasone patients had a shorter length of stay, and, counterintuitively, fewer surgical site infections (0.2% vs. 1.7%; P = .0109). They were also less likely to have BPH (16.7% vs. 22.5%; P = 0.026). The urinary retention odds ratio controlled for the difference in BPH.
The results are “interesting, but I don’t think the conclusion is there yet; there are a lot of variables to consider. We need more data,” said moderator Eduardo Parra-Davila, MD, FACS, director of minimally invasive and colorectal surgery at Florida Hospital Celebration Health in Celebration, Fla.
In both groups, mean body mass index was about 26 kg/m2, mean age about 57 years, and mean operative time about 40 minutes. Four general surgeons performed the repairs.
There was no external funding for the work, and the investigators had no disclosures.
SOURCE: Denham M. et al. SAGES 2018, Abstract S006.
SEATTLE – Intraoperative in 955 men at the NorthShore University HealthSystem, Chicago.
Urinary retention occurs in up to a third of hernia repair patients. Men are at far higher risk than women; benign prostatic hypertrophy (BPH) and older age also increase the risk.
Intraoperative dexamethasone is a common antiemetic. The investigators had a hunch that it also reduces urinary retention by calming overstimulation of the bladder neck and prostate during the operation. “We believe this overstimulation” causes urinary retention, lead investigator Merritt Denham, BS, said at the World Congress of Endoscopic Surgery hosted by SAGES & CAGS.
She and her team went back in the records about 8 years to compare 617 laparoscopic inguinal hernia repair patients who received intraoperative dexamethasone with 338 who did not. They were all men: women were excluded from the review. The men voided before surgery. Those who received dexamethasone received more fluids during the operation than those who did not, a mean of 973 mL versus 878 mL (P = .0019).
Even so, urinary retention was far less likely in the dexamethasone group (3.7% vs. 9.8%; P = .0001). Controlling for age and BPH, the corticosteroid was highly protective (odds ratio, 0.48; 95% confidence interval, 0.26-0.87; P = .0147). The benefit was the same regardless of the intraoperative dexamethasone dosage, which ranged from 4 mg to 8 mg.
Dexamethasone patients had a shorter length of stay, and, counterintuitively, fewer surgical site infections (0.2% vs. 1.7%; P = .0109). They were also less likely to have BPH (16.7% vs. 22.5%; P = 0.026). The urinary retention odds ratio controlled for the difference in BPH.
The results are “interesting, but I don’t think the conclusion is there yet; there are a lot of variables to consider. We need more data,” said moderator Eduardo Parra-Davila, MD, FACS, director of minimally invasive and colorectal surgery at Florida Hospital Celebration Health in Celebration, Fla.
In both groups, mean body mass index was about 26 kg/m2, mean age about 57 years, and mean operative time about 40 minutes. Four general surgeons performed the repairs.
There was no external funding for the work, and the investigators had no disclosures.
SOURCE: Denham M. et al. SAGES 2018, Abstract S006.
SEATTLE – Intraoperative in 955 men at the NorthShore University HealthSystem, Chicago.
Urinary retention occurs in up to a third of hernia repair patients. Men are at far higher risk than women; benign prostatic hypertrophy (BPH) and older age also increase the risk.
Intraoperative dexamethasone is a common antiemetic. The investigators had a hunch that it also reduces urinary retention by calming overstimulation of the bladder neck and prostate during the operation. “We believe this overstimulation” causes urinary retention, lead investigator Merritt Denham, BS, said at the World Congress of Endoscopic Surgery hosted by SAGES & CAGS.
She and her team went back in the records about 8 years to compare 617 laparoscopic inguinal hernia repair patients who received intraoperative dexamethasone with 338 who did not. They were all men: women were excluded from the review. The men voided before surgery. Those who received dexamethasone received more fluids during the operation than those who did not, a mean of 973 mL versus 878 mL (P = .0019).
Even so, urinary retention was far less likely in the dexamethasone group (3.7% vs. 9.8%; P = .0001). Controlling for age and BPH, the corticosteroid was highly protective (odds ratio, 0.48; 95% confidence interval, 0.26-0.87; P = .0147). The benefit was the same regardless of the intraoperative dexamethasone dosage, which ranged from 4 mg to 8 mg.
Dexamethasone patients had a shorter length of stay, and, counterintuitively, fewer surgical site infections (0.2% vs. 1.7%; P = .0109). They were also less likely to have BPH (16.7% vs. 22.5%; P = 0.026). The urinary retention odds ratio controlled for the difference in BPH.
The results are “interesting, but I don’t think the conclusion is there yet; there are a lot of variables to consider. We need more data,” said moderator Eduardo Parra-Davila, MD, FACS, director of minimally invasive and colorectal surgery at Florida Hospital Celebration Health in Celebration, Fla.
In both groups, mean body mass index was about 26 kg/m2, mean age about 57 years, and mean operative time about 40 minutes. Four general surgeons performed the repairs.
There was no external funding for the work, and the investigators had no disclosures.
SOURCE: Denham M. et al. SAGES 2018, Abstract S006.
REPORTING FROM SAGES 2018
Key clinical point: Patients given dexamethasone intraoperatively were less likely to have urinary retention.
Major finding: The dexamethasone group was less likely to have urinary retention, 3.7% versus 9.8% (P = 0.0001).
Study details: A review of 955 laparoscopic inguinal hernia repairs.
Disclosures: There was no external funding for the work, and the investigators had no disclosures.
Source: Denham M et al. SAGES 2018, Abstract S006.
Can adhesive small bowel obstructions be addressed laparoscopically?
LAS VEGAS – whether they are open or laparoscopic. Small bowel obstructions can result, and management decisions can be complex. What if the patient resolves? Should you offer elective adhesiolysis? If it doesn’t resolve, can the surgery be done laparoscopically or should the procedure be open?
Bradley R. Davis, MD, FACS, discussed some of these options, and the case circumstances that inform the surgeon’s choices at the Annual Minimally Invasive Surgery Symposium by -Global Academy for Medical Education. Dr. Davis is chief of general surgery and of rectal surgery at Carolinas Medical Center, Charlotte, N.C.
Laparoscopic surgeries are associated with significantly lower rates of small bowel obstruction, but it can still happen. More often, patients will have had a previous open surgery, and this should be a selling point for doing first-time surgeries using minimally invasive techniques. “That’s one thing I tell my patients when I see them in the office. There’s a real reduction in adhesive small bowel obstruction and certainly in hernia formation, so there are long-term benefits that I don’t think we talk enough about,” said Dr. Davis.
Although the majority of obstructions are caused by adhesions, some are the result of malignancies or hernias, and Dr. Davis encourages his residents to do exams to determine if a hernia is to blame. “That’s harder and harder to do now that everyone does a CT scan, but that’s always an interesting question to ask a resident,” he said. Inflammatory bowel disease is sometimes also a cause, but that’s rare.
CT scans are the diagnostic mode of choice for small bowel obstructions. Some believe that oral contrast agents may help resolve obstructions, but Dr. Davis mentioned evidence from a study showing that contrast agents don’t change the course of obstructions or reduce laparotomy rates. However, contrast agents can help predict the clinical course of an obstruction. If the contrast agent is present in the colon at 24 hours, then that predicts that the patient will resolve with conservative treatment. “You have a pretty good idea that the patient is going to get better,” said Dr. Davis.
The American Association for the Surgery of Trauma severity grade is helpful for adhesive small bowel obstructions. Grade 2 cases involve intestinal distension and possibly a transition zone, some passage of contrast on follow-up films, and no evidence of intestinal compromise. Grade 3 cases have no distal contrast flow and evidence of complete obstruction or impending bowel compromise. In the latter cases, “we’re scratching our heads wondering whether to take the patient to the operating room. Certainly most of these cases we’ll manage initially nonoperatively, but those patients will end up getting an earlier operation,” said Dr. Davis.
The majority of surgeries are adhesiolysis, sometimes with a bowel resection. Whether or not the surgery can be performed laparoscopically or as an open surgery depends on several factors. If the index operation was done laparoscopically, chances are good that the adhesiolysis can be performed the same way. On the other hand, “if a patient has a known hostile abdomen, I wouldn’t even try. I would basically go straight to an open procedure,” said Dr. Davis.
Generally speaking, though, reoperative surgeries can be attempted laparoscopically and then converted to open procedures if needed, he added. The most common reasons for conversion are dense adhesions and ischemia-related resection.
However, iatrogenic injuries can also occur as a result of trocar access. “Just keep in mind that if you put the trocar into the bowel, the worst thing you can do is take it out because you won’t always find that hole. Just leave the trocar in the bowel, convert to an open procedure, and find the hole and fix it,” said Dr. Davis.
Cases are particularly challenging when the transition zone is in the pelvis. Those procedures are difficult to do laparoscopically because of a difficult angle, and they are more likely to convert to open surgery. “To be honest, that’s not an easy operation to open either, so beware that transition zone in the pelvis can be a difficult case.
“I don’t try to do anything heroic laparoscopically. If you put a camera in and you find it’s going to be a massive adhesiolysis laparoscopically, you might just be better off to open,” said Dr. Davis. In cases like that it can be hard to find the transition zone, which must be identified in order to ensure that the underlying problem is fixed.
An aggressive option in difficult cases is to use a PEEK Port, which starts with a 6-8 cm incision. The surgeon can open up a minimum of disposables and put a hand in to assist the laparoscopic view and determine if the procedure can be completed laparoscopically. “If you encounter extensive adhesions, you just convert to a laparotomy and you haven’t lost any time or spent any money in terms of disposables,” he said.
Dr. Davis had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – whether they are open or laparoscopic. Small bowel obstructions can result, and management decisions can be complex. What if the patient resolves? Should you offer elective adhesiolysis? If it doesn’t resolve, can the surgery be done laparoscopically or should the procedure be open?
Bradley R. Davis, MD, FACS, discussed some of these options, and the case circumstances that inform the surgeon’s choices at the Annual Minimally Invasive Surgery Symposium by -Global Academy for Medical Education. Dr. Davis is chief of general surgery and of rectal surgery at Carolinas Medical Center, Charlotte, N.C.
Laparoscopic surgeries are associated with significantly lower rates of small bowel obstruction, but it can still happen. More often, patients will have had a previous open surgery, and this should be a selling point for doing first-time surgeries using minimally invasive techniques. “That’s one thing I tell my patients when I see them in the office. There’s a real reduction in adhesive small bowel obstruction and certainly in hernia formation, so there are long-term benefits that I don’t think we talk enough about,” said Dr. Davis.
Although the majority of obstructions are caused by adhesions, some are the result of malignancies or hernias, and Dr. Davis encourages his residents to do exams to determine if a hernia is to blame. “That’s harder and harder to do now that everyone does a CT scan, but that’s always an interesting question to ask a resident,” he said. Inflammatory bowel disease is sometimes also a cause, but that’s rare.
CT scans are the diagnostic mode of choice for small bowel obstructions. Some believe that oral contrast agents may help resolve obstructions, but Dr. Davis mentioned evidence from a study showing that contrast agents don’t change the course of obstructions or reduce laparotomy rates. However, contrast agents can help predict the clinical course of an obstruction. If the contrast agent is present in the colon at 24 hours, then that predicts that the patient will resolve with conservative treatment. “You have a pretty good idea that the patient is going to get better,” said Dr. Davis.
The American Association for the Surgery of Trauma severity grade is helpful for adhesive small bowel obstructions. Grade 2 cases involve intestinal distension and possibly a transition zone, some passage of contrast on follow-up films, and no evidence of intestinal compromise. Grade 3 cases have no distal contrast flow and evidence of complete obstruction or impending bowel compromise. In the latter cases, “we’re scratching our heads wondering whether to take the patient to the operating room. Certainly most of these cases we’ll manage initially nonoperatively, but those patients will end up getting an earlier operation,” said Dr. Davis.
The majority of surgeries are adhesiolysis, sometimes with a bowel resection. Whether or not the surgery can be performed laparoscopically or as an open surgery depends on several factors. If the index operation was done laparoscopically, chances are good that the adhesiolysis can be performed the same way. On the other hand, “if a patient has a known hostile abdomen, I wouldn’t even try. I would basically go straight to an open procedure,” said Dr. Davis.
Generally speaking, though, reoperative surgeries can be attempted laparoscopically and then converted to open procedures if needed, he added. The most common reasons for conversion are dense adhesions and ischemia-related resection.
However, iatrogenic injuries can also occur as a result of trocar access. “Just keep in mind that if you put the trocar into the bowel, the worst thing you can do is take it out because you won’t always find that hole. Just leave the trocar in the bowel, convert to an open procedure, and find the hole and fix it,” said Dr. Davis.
Cases are particularly challenging when the transition zone is in the pelvis. Those procedures are difficult to do laparoscopically because of a difficult angle, and they are more likely to convert to open surgery. “To be honest, that’s not an easy operation to open either, so beware that transition zone in the pelvis can be a difficult case.
“I don’t try to do anything heroic laparoscopically. If you put a camera in and you find it’s going to be a massive adhesiolysis laparoscopically, you might just be better off to open,” said Dr. Davis. In cases like that it can be hard to find the transition zone, which must be identified in order to ensure that the underlying problem is fixed.
An aggressive option in difficult cases is to use a PEEK Port, which starts with a 6-8 cm incision. The surgeon can open up a minimum of disposables and put a hand in to assist the laparoscopic view and determine if the procedure can be completed laparoscopically. “If you encounter extensive adhesions, you just convert to a laparotomy and you haven’t lost any time or spent any money in terms of disposables,” he said.
Dr. Davis had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – whether they are open or laparoscopic. Small bowel obstructions can result, and management decisions can be complex. What if the patient resolves? Should you offer elective adhesiolysis? If it doesn’t resolve, can the surgery be done laparoscopically or should the procedure be open?
Bradley R. Davis, MD, FACS, discussed some of these options, and the case circumstances that inform the surgeon’s choices at the Annual Minimally Invasive Surgery Symposium by -Global Academy for Medical Education. Dr. Davis is chief of general surgery and of rectal surgery at Carolinas Medical Center, Charlotte, N.C.
Laparoscopic surgeries are associated with significantly lower rates of small bowel obstruction, but it can still happen. More often, patients will have had a previous open surgery, and this should be a selling point for doing first-time surgeries using minimally invasive techniques. “That’s one thing I tell my patients when I see them in the office. There’s a real reduction in adhesive small bowel obstruction and certainly in hernia formation, so there are long-term benefits that I don’t think we talk enough about,” said Dr. Davis.
Although the majority of obstructions are caused by adhesions, some are the result of malignancies or hernias, and Dr. Davis encourages his residents to do exams to determine if a hernia is to blame. “That’s harder and harder to do now that everyone does a CT scan, but that’s always an interesting question to ask a resident,” he said. Inflammatory bowel disease is sometimes also a cause, but that’s rare.
CT scans are the diagnostic mode of choice for small bowel obstructions. Some believe that oral contrast agents may help resolve obstructions, but Dr. Davis mentioned evidence from a study showing that contrast agents don’t change the course of obstructions or reduce laparotomy rates. However, contrast agents can help predict the clinical course of an obstruction. If the contrast agent is present in the colon at 24 hours, then that predicts that the patient will resolve with conservative treatment. “You have a pretty good idea that the patient is going to get better,” said Dr. Davis.
The American Association for the Surgery of Trauma severity grade is helpful for adhesive small bowel obstructions. Grade 2 cases involve intestinal distension and possibly a transition zone, some passage of contrast on follow-up films, and no evidence of intestinal compromise. Grade 3 cases have no distal contrast flow and evidence of complete obstruction or impending bowel compromise. In the latter cases, “we’re scratching our heads wondering whether to take the patient to the operating room. Certainly most of these cases we’ll manage initially nonoperatively, but those patients will end up getting an earlier operation,” said Dr. Davis.
The majority of surgeries are adhesiolysis, sometimes with a bowel resection. Whether or not the surgery can be performed laparoscopically or as an open surgery depends on several factors. If the index operation was done laparoscopically, chances are good that the adhesiolysis can be performed the same way. On the other hand, “if a patient has a known hostile abdomen, I wouldn’t even try. I would basically go straight to an open procedure,” said Dr. Davis.
Generally speaking, though, reoperative surgeries can be attempted laparoscopically and then converted to open procedures if needed, he added. The most common reasons for conversion are dense adhesions and ischemia-related resection.
However, iatrogenic injuries can also occur as a result of trocar access. “Just keep in mind that if you put the trocar into the bowel, the worst thing you can do is take it out because you won’t always find that hole. Just leave the trocar in the bowel, convert to an open procedure, and find the hole and fix it,” said Dr. Davis.
Cases are particularly challenging when the transition zone is in the pelvis. Those procedures are difficult to do laparoscopically because of a difficult angle, and they are more likely to convert to open surgery. “To be honest, that’s not an easy operation to open either, so beware that transition zone in the pelvis can be a difficult case.
“I don’t try to do anything heroic laparoscopically. If you put a camera in and you find it’s going to be a massive adhesiolysis laparoscopically, you might just be better off to open,” said Dr. Davis. In cases like that it can be hard to find the transition zone, which must be identified in order to ensure that the underlying problem is fixed.
An aggressive option in difficult cases is to use a PEEK Port, which starts with a 6-8 cm incision. The surgeon can open up a minimum of disposables and put a hand in to assist the laparoscopic view and determine if the procedure can be completed laparoscopically. “If you encounter extensive adhesions, you just convert to a laparotomy and you haven’t lost any time or spent any money in terms of disposables,” he said.
Dr. Davis had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM MISS
Smokers face higher infection risk after hernia operations
Jonah Stulberg, MD, FACS, is stickler about requiring patients to stop smoking at least 3 months before hernia surgery. He even uses urine tests to confirm whether they actually quit. A study by Dr. Stulberg and his colleagues supports this approach: .
The finding held up even after the researchers controlled for various factors. “Our findings are in agreement with other findings in higher risk surgeries, and they provide evidence that low-risk surgeries are not exempt from the risks associated with smoking,” said Dr. Stulberg in an interview. “Our data would suggest that there is significant clinical benefit to encouraging smoking cessation before elective hernia repair.”
The researchers launched the study to better understand how smoking affects complication rates in light of the fact that “surgeons in the U.S. tend to offer low-risk elective surgical procedures to patients who are actively smoking despite overwhelming evidence that smoking increases surgical risks,” Dr. Stulberg said.
The researchers tracked 220,629 patients in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database who underwent several types of elective hernia repair from 2011 to 2014.
Just over 18% of the patients said they’d smoked over the past year; they were more likely to be younger (median age, 50 for smokers vs. 57 for nonsmokers). Smokers also were more likely to be black, to be underweight, and to consume two or more alcoholic beverages per day (P less than .05).
The researchers tracked serious complications in the 30 days after surgery such as death, sepsis, and readmission.
Complications developed in 6.34% of smokers and 4.72% of nonsmokers (P less than .001). Numerous kinds of complications were more common in the smokers prior to adjustment: death, return to the operating room, readmission, and transfusion plus wound, pulmonary, thromboembolic and cardiac complications.
The researchers adjusted their statistics to account for factors such as ethnicity, sex, body mass index, preexisting comorbidities, and type of hernia operation. They found that risk of all complications was higher in smokers, compared with nonsmokers (odds ratio, 1.30) as were several other complications: death (OR, 1.53), return to operating room (OR, 1.23), readmission (OR, 1.24), wound complication (OR, 1.36), sepsis/septic shock (OR, 1.31), pulmonary complication (OR 1.77-2.30) and cardiac complication (OR, 1.27-1.43).
Only transfusion (OR, 0.90) and thromboembolic (OR, 0.87) complications were less likely in smokers.
The researchers noted that the statistics don’t allow them to analyze whether it makes any difference if smokers quit shortly before their procedures. Still, Dr. Stulberg stands by his you-must-quit-smoking-before-surgery edict. “I believe that their active smoking habit is a bigger health threat than their asymptomatic hernia, and therefore feel the right thing to do as their physician is support them through their smoking cessation,” he said. “I offer counseling and nicotine replacement if needed. I have very good quit rates and would encourage other surgeons to do the same.”
Dr. Stulberg noted that he can’t point to evidence supporting his requirement that patients quit at least 3 months before surgery. “Most data out there says the farther away from your last cigarette, the better,” he said. “But there isn’t any magic to 3 months, other than I believe it will lead to a higher likelihood of permanent cessation.”
Northwestern Memorial Hospital and Northwestern University funded the study. Four of the nine authors, including Dr. Stulberg, report various disclosures that are not directly related to the study, including funding from government agencies, physician organizations, Health Care Services Corporation and Blue Cross Blue Shield of Illinois, Mallinckrodt, and Northwestern University. The other authors report no disclosures.
SOURCE: DeLancey JO et al. Am J Surg. 2018 Mar 6. doi: 10.1016/j.amjsurg.2018.03.004.
Jonah Stulberg, MD, FACS, is stickler about requiring patients to stop smoking at least 3 months before hernia surgery. He even uses urine tests to confirm whether they actually quit. A study by Dr. Stulberg and his colleagues supports this approach: .
The finding held up even after the researchers controlled for various factors. “Our findings are in agreement with other findings in higher risk surgeries, and they provide evidence that low-risk surgeries are not exempt from the risks associated with smoking,” said Dr. Stulberg in an interview. “Our data would suggest that there is significant clinical benefit to encouraging smoking cessation before elective hernia repair.”
The researchers launched the study to better understand how smoking affects complication rates in light of the fact that “surgeons in the U.S. tend to offer low-risk elective surgical procedures to patients who are actively smoking despite overwhelming evidence that smoking increases surgical risks,” Dr. Stulberg said.
The researchers tracked 220,629 patients in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database who underwent several types of elective hernia repair from 2011 to 2014.
Just over 18% of the patients said they’d smoked over the past year; they were more likely to be younger (median age, 50 for smokers vs. 57 for nonsmokers). Smokers also were more likely to be black, to be underweight, and to consume two or more alcoholic beverages per day (P less than .05).
The researchers tracked serious complications in the 30 days after surgery such as death, sepsis, and readmission.
Complications developed in 6.34% of smokers and 4.72% of nonsmokers (P less than .001). Numerous kinds of complications were more common in the smokers prior to adjustment: death, return to the operating room, readmission, and transfusion plus wound, pulmonary, thromboembolic and cardiac complications.
The researchers adjusted their statistics to account for factors such as ethnicity, sex, body mass index, preexisting comorbidities, and type of hernia operation. They found that risk of all complications was higher in smokers, compared with nonsmokers (odds ratio, 1.30) as were several other complications: death (OR, 1.53), return to operating room (OR, 1.23), readmission (OR, 1.24), wound complication (OR, 1.36), sepsis/septic shock (OR, 1.31), pulmonary complication (OR 1.77-2.30) and cardiac complication (OR, 1.27-1.43).
Only transfusion (OR, 0.90) and thromboembolic (OR, 0.87) complications were less likely in smokers.
The researchers noted that the statistics don’t allow them to analyze whether it makes any difference if smokers quit shortly before their procedures. Still, Dr. Stulberg stands by his you-must-quit-smoking-before-surgery edict. “I believe that their active smoking habit is a bigger health threat than their asymptomatic hernia, and therefore feel the right thing to do as their physician is support them through their smoking cessation,” he said. “I offer counseling and nicotine replacement if needed. I have very good quit rates and would encourage other surgeons to do the same.”
Dr. Stulberg noted that he can’t point to evidence supporting his requirement that patients quit at least 3 months before surgery. “Most data out there says the farther away from your last cigarette, the better,” he said. “But there isn’t any magic to 3 months, other than I believe it will lead to a higher likelihood of permanent cessation.”
Northwestern Memorial Hospital and Northwestern University funded the study. Four of the nine authors, including Dr. Stulberg, report various disclosures that are not directly related to the study, including funding from government agencies, physician organizations, Health Care Services Corporation and Blue Cross Blue Shield of Illinois, Mallinckrodt, and Northwestern University. The other authors report no disclosures.
SOURCE: DeLancey JO et al. Am J Surg. 2018 Mar 6. doi: 10.1016/j.amjsurg.2018.03.004.
Jonah Stulberg, MD, FACS, is stickler about requiring patients to stop smoking at least 3 months before hernia surgery. He even uses urine tests to confirm whether they actually quit. A study by Dr. Stulberg and his colleagues supports this approach: .
The finding held up even after the researchers controlled for various factors. “Our findings are in agreement with other findings in higher risk surgeries, and they provide evidence that low-risk surgeries are not exempt from the risks associated with smoking,” said Dr. Stulberg in an interview. “Our data would suggest that there is significant clinical benefit to encouraging smoking cessation before elective hernia repair.”
The researchers launched the study to better understand how smoking affects complication rates in light of the fact that “surgeons in the U.S. tend to offer low-risk elective surgical procedures to patients who are actively smoking despite overwhelming evidence that smoking increases surgical risks,” Dr. Stulberg said.
The researchers tracked 220,629 patients in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database who underwent several types of elective hernia repair from 2011 to 2014.
Just over 18% of the patients said they’d smoked over the past year; they were more likely to be younger (median age, 50 for smokers vs. 57 for nonsmokers). Smokers also were more likely to be black, to be underweight, and to consume two or more alcoholic beverages per day (P less than .05).
The researchers tracked serious complications in the 30 days after surgery such as death, sepsis, and readmission.
Complications developed in 6.34% of smokers and 4.72% of nonsmokers (P less than .001). Numerous kinds of complications were more common in the smokers prior to adjustment: death, return to the operating room, readmission, and transfusion plus wound, pulmonary, thromboembolic and cardiac complications.
The researchers adjusted their statistics to account for factors such as ethnicity, sex, body mass index, preexisting comorbidities, and type of hernia operation. They found that risk of all complications was higher in smokers, compared with nonsmokers (odds ratio, 1.30) as were several other complications: death (OR, 1.53), return to operating room (OR, 1.23), readmission (OR, 1.24), wound complication (OR, 1.36), sepsis/septic shock (OR, 1.31), pulmonary complication (OR 1.77-2.30) and cardiac complication (OR, 1.27-1.43).
Only transfusion (OR, 0.90) and thromboembolic (OR, 0.87) complications were less likely in smokers.
The researchers noted that the statistics don’t allow them to analyze whether it makes any difference if smokers quit shortly before their procedures. Still, Dr. Stulberg stands by his you-must-quit-smoking-before-surgery edict. “I believe that their active smoking habit is a bigger health threat than their asymptomatic hernia, and therefore feel the right thing to do as their physician is support them through their smoking cessation,” he said. “I offer counseling and nicotine replacement if needed. I have very good quit rates and would encourage other surgeons to do the same.”
Dr. Stulberg noted that he can’t point to evidence supporting his requirement that patients quit at least 3 months before surgery. “Most data out there says the farther away from your last cigarette, the better,” he said. “But there isn’t any magic to 3 months, other than I believe it will lead to a higher likelihood of permanent cessation.”
Northwestern Memorial Hospital and Northwestern University funded the study. Four of the nine authors, including Dr. Stulberg, report various disclosures that are not directly related to the study, including funding from government agencies, physician organizations, Health Care Services Corporation and Blue Cross Blue Shield of Illinois, Mallinckrodt, and Northwestern University. The other authors report no disclosures.
SOURCE: DeLancey JO et al. Am J Surg. 2018 Mar 6. doi: 10.1016/j.amjsurg.2018.03.004.
FROM AMERICAN JOURNAL OF SURGERY
Key clinical point: Smokers are more likely than are nonsmokers to develop serious complications after elective hernia surgery.
Major finding: The adjusted risk of serious complications after elective hernia surgery is higher (odds ratio, 1.30) in smokers than nonsmokers.
Study details: Retrospective study of ACS NSQIP data on 220,629 patients in the United States (18% smokers) who underwent elective hernia operations during 2011-2014.
Disclosures: Northwestern Memorial Hospital and Northwestern University funded the study. Four of the nine authors reported various disclosures. The other authors report no disclosures.
Source: DeLancey JO et al. Am J Surg. 2018 Mar 6. doi: 10.1016/j.amjsurg.2018.03.004.
Defining incisional hernia risk in IBD surgery
Open surgery for inflammatory bowel disease (IBD) has been known to carry a high risk of incisional hernia, but the risk factors have not been well understood.
A review of 1,000 operations performed over nearly 40 years at a high-volume, nationally recognized center has identified five patient factors that can raise the risk of incisional hernia in these operations by 50% or more, according to a study published in the Annals of Surgery.
The study followed the patients for an average of 8 years after their operations, which were performed between January 1976 and December 2014 at Mount Sinai Medical Center in New York. The overall incidence of incisional hernia was 20%-21% for patients with ulcerative colitis and 20% for those with Crohn’s disease.
Half of these patients developed an incisional hernia less than 2 years after the index surgery and 75% in less than 4 years.
The researchers identified the following statistically significant risk factors for incisional hernia: wound infection (hazard ratio, 3.66; P less than .001); hypoalbuminemia (HR, 2.02; P = .002); previous bowel resection (HR, 1.6; P = .003); ileostomy created at time of procedure (HR, 1.53; P = .01); and a history of smoking (HR, 1.52; P less than .013). Other risk factors to lesser degrees are body mass index at time of surgery (HR, 1.036; P = .009); age at time of surgery (HR, 1.021; P less than .001), and age at disease onset (HR, 1.018; P less than .001).
Lead author Tomas Heimann, MD, and his coauthors pointed out that this study population had severe levels of disease. Almost half of the patients had severe intractable disease that had resisted medical treatment. More than a quarter of these patients had received preoperative steroid therapy within 6 weeks, and 15% had received recent immunosuppressive therapy. Almost 80% were either anemic or had hypoalbuminemia or both. The average duration of disease was 12 years. More than half had undergone previous bowel surgery – “often lengthy and difficult” – with many patients suffering from fistulae, abscesses, and dense adhesions. “These factors were more likely to predispose patients to develop wound infections and delayed healing resulting in incisional hernia in one-fifth of our patients,” Dr. Heimann and his coauthors noted.
A somewhat unexpected finding was that immunosuppressive therapy and steroids were not linked to incisional hernia in these patients.
Prophylactic mesh placement in patients with IBD is impractical because of the risk of infection it carries, Dr. Heimann and his coauthors said.
Dr. Heimann and his coauthors reported having no financial disclosures.
SOURCE: Heimann T et al. Ann Surg. 2018 Mar;267(3):532-6.
Open surgery for inflammatory bowel disease (IBD) has been known to carry a high risk of incisional hernia, but the risk factors have not been well understood.
A review of 1,000 operations performed over nearly 40 years at a high-volume, nationally recognized center has identified five patient factors that can raise the risk of incisional hernia in these operations by 50% or more, according to a study published in the Annals of Surgery.
The study followed the patients for an average of 8 years after their operations, which were performed between January 1976 and December 2014 at Mount Sinai Medical Center in New York. The overall incidence of incisional hernia was 20%-21% for patients with ulcerative colitis and 20% for those with Crohn’s disease.
Half of these patients developed an incisional hernia less than 2 years after the index surgery and 75% in less than 4 years.
The researchers identified the following statistically significant risk factors for incisional hernia: wound infection (hazard ratio, 3.66; P less than .001); hypoalbuminemia (HR, 2.02; P = .002); previous bowel resection (HR, 1.6; P = .003); ileostomy created at time of procedure (HR, 1.53; P = .01); and a history of smoking (HR, 1.52; P less than .013). Other risk factors to lesser degrees are body mass index at time of surgery (HR, 1.036; P = .009); age at time of surgery (HR, 1.021; P less than .001), and age at disease onset (HR, 1.018; P less than .001).
Lead author Tomas Heimann, MD, and his coauthors pointed out that this study population had severe levels of disease. Almost half of the patients had severe intractable disease that had resisted medical treatment. More than a quarter of these patients had received preoperative steroid therapy within 6 weeks, and 15% had received recent immunosuppressive therapy. Almost 80% were either anemic or had hypoalbuminemia or both. The average duration of disease was 12 years. More than half had undergone previous bowel surgery – “often lengthy and difficult” – with many patients suffering from fistulae, abscesses, and dense adhesions. “These factors were more likely to predispose patients to develop wound infections and delayed healing resulting in incisional hernia in one-fifth of our patients,” Dr. Heimann and his coauthors noted.
A somewhat unexpected finding was that immunosuppressive therapy and steroids were not linked to incisional hernia in these patients.
Prophylactic mesh placement in patients with IBD is impractical because of the risk of infection it carries, Dr. Heimann and his coauthors said.
Dr. Heimann and his coauthors reported having no financial disclosures.
SOURCE: Heimann T et al. Ann Surg. 2018 Mar;267(3):532-6.
Open surgery for inflammatory bowel disease (IBD) has been known to carry a high risk of incisional hernia, but the risk factors have not been well understood.
A review of 1,000 operations performed over nearly 40 years at a high-volume, nationally recognized center has identified five patient factors that can raise the risk of incisional hernia in these operations by 50% or more, according to a study published in the Annals of Surgery.
The study followed the patients for an average of 8 years after their operations, which were performed between January 1976 and December 2014 at Mount Sinai Medical Center in New York. The overall incidence of incisional hernia was 20%-21% for patients with ulcerative colitis and 20% for those with Crohn’s disease.
Half of these patients developed an incisional hernia less than 2 years after the index surgery and 75% in less than 4 years.
The researchers identified the following statistically significant risk factors for incisional hernia: wound infection (hazard ratio, 3.66; P less than .001); hypoalbuminemia (HR, 2.02; P = .002); previous bowel resection (HR, 1.6; P = .003); ileostomy created at time of procedure (HR, 1.53; P = .01); and a history of smoking (HR, 1.52; P less than .013). Other risk factors to lesser degrees are body mass index at time of surgery (HR, 1.036; P = .009); age at time of surgery (HR, 1.021; P less than .001), and age at disease onset (HR, 1.018; P less than .001).
Lead author Tomas Heimann, MD, and his coauthors pointed out that this study population had severe levels of disease. Almost half of the patients had severe intractable disease that had resisted medical treatment. More than a quarter of these patients had received preoperative steroid therapy within 6 weeks, and 15% had received recent immunosuppressive therapy. Almost 80% were either anemic or had hypoalbuminemia or both. The average duration of disease was 12 years. More than half had undergone previous bowel surgery – “often lengthy and difficult” – with many patients suffering from fistulae, abscesses, and dense adhesions. “These factors were more likely to predispose patients to develop wound infections and delayed healing resulting in incisional hernia in one-fifth of our patients,” Dr. Heimann and his coauthors noted.
A somewhat unexpected finding was that immunosuppressive therapy and steroids were not linked to incisional hernia in these patients.
Prophylactic mesh placement in patients with IBD is impractical because of the risk of infection it carries, Dr. Heimann and his coauthors said.
Dr. Heimann and his coauthors reported having no financial disclosures.
SOURCE: Heimann T et al. Ann Surg. 2018 Mar;267(3):532-6.
FROM ANNALS OF SURGERY
Key clinical point: Patients with IBD have a high incidence of incisional hernia after open bowel resection.
Major finding: The overall incidence of incisional hernia after open bowel resection was 20%.
Data source: One thousand patients who had undergone open bowel surgery for IBD at Mount Sinai Medical Center, New York, between January 1976 and December 2014.
Disclosures: Dr. Heimann and his coauthors reported having no financial disclosures.
Source: Heimann T et al. Ann Surg. 2018 Mar;267(3):532-6.
Morbid, super obesity raises laparoscopic VHR risk
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
REPORTING FROM THE ANNUAL ACADEMIC SURGICAL CONGRESS
Key clinical point: Laparoscopic ventral hernia repair is associated with a significantly increased risk of complications in the morbidly and super obese.
Major finding: Individuals with a body mass index in the overweight range (BMI 25 to 29.99 kg/m2) had a complication rate of 3% vs. 6.9% for those with BMI greater than or equal to 50 kg/m2.
Story details: A retrospective analysis of 57,957 patients in the NSQIP database who had laparoscopic ventral hernia repair between 2005 and 2015.
Disclosures: Dr. Swendiman and coauthors reported having no financial disclosures.
Source: Academic Surgical Congress. Abstract 50.02.
Unscheduled visits for pain after hernia surgery common, costly
And although these calls and visits are costly in health care resources, many patients do not receive an actionable diagnosis, according to a study published in The American Journal of Surgery.
Colin G. DeLong, MD, and his colleagues reviewed health records of patients who underwent an open procedure for complex ventral hernia repair (cVHR) at Penn State Milton S. Hershey Medical Center in Hershey, Penn., between January 2013 and August 2015 using the American College of Surgeons National Surgery Quality Improvement Project (NSQIP) data available at the institution. They identified a cohort of 177 patients, 79% of whom were reviewed for pain issues at 1 year.
The study focused on postoperative pain during the first year following open cVHR. The investigators looked at how patients registered postoperative discomfort, risk factors that predicted greater utilization of the health system for pain-related complaints, and how often complaints of chronic pain resulted in an actionable diagnosis.
All postop encounters in the year after surgery were documented, including the sequence of events in response to pain complaints. In addition, the investigators recorded “instances in which a diagnosis resulted from such actions and whether the diagnosis was actionable, meaning it led to a specific intervention that was expected to alleviate the pain.”
Of the 177 patients, 91 patients made an unsolicited call, clinic visit, or ED visit for pain issues. For 38 patients in this group, action was taken (additional prescription, imaging ordered, ED workup recommended or undertaken). For the other 53, no action was taken. From each group, some cases resolved because of further intervention, and some cases resolved without further action. Mesh use and preoperative pain scores were predictors of postop pain, but not age, ethnicity, sex, or other comorbidities. But 38 (21%) patients continued to have pain that was not resolved at 1 year, 32 of which had no actionable diagnosis.
The study was retrospective and limited by inclusion of visits and calls only to the surgical services and not to other medical services or physicians. Pain complaints were subjective and levels of severity were not recorded.
The investigators concluded that estimates of the number of patients who have chronic pain after cVHR do not capture the level of health care resource utilization for this problem. Patients experiencing postop pain make unscheduled calls or visits to the clinic or ED, and many do so repeatedly without receiving an actionable diagnosis. “A cost analysis specific to treating postoperative pain for 1 year would provide a better understanding of the magnitude of the problem. Subjective complaints of pain in the year following cVHR are frequent and represent a hidden driver of resource utilization which must be better understood to achieve optimal, cost effective care.”
The authors declared no conflicts of interest.
SOURCE: DeLong CG et al. Am J Surg. 2018. doi: 10.1016/j.amjsurg.2018.01.030.
And although these calls and visits are costly in health care resources, many patients do not receive an actionable diagnosis, according to a study published in The American Journal of Surgery.
Colin G. DeLong, MD, and his colleagues reviewed health records of patients who underwent an open procedure for complex ventral hernia repair (cVHR) at Penn State Milton S. Hershey Medical Center in Hershey, Penn., between January 2013 and August 2015 using the American College of Surgeons National Surgery Quality Improvement Project (NSQIP) data available at the institution. They identified a cohort of 177 patients, 79% of whom were reviewed for pain issues at 1 year.
The study focused on postoperative pain during the first year following open cVHR. The investigators looked at how patients registered postoperative discomfort, risk factors that predicted greater utilization of the health system for pain-related complaints, and how often complaints of chronic pain resulted in an actionable diagnosis.
All postop encounters in the year after surgery were documented, including the sequence of events in response to pain complaints. In addition, the investigators recorded “instances in which a diagnosis resulted from such actions and whether the diagnosis was actionable, meaning it led to a specific intervention that was expected to alleviate the pain.”
Of the 177 patients, 91 patients made an unsolicited call, clinic visit, or ED visit for pain issues. For 38 patients in this group, action was taken (additional prescription, imaging ordered, ED workup recommended or undertaken). For the other 53, no action was taken. From each group, some cases resolved because of further intervention, and some cases resolved without further action. Mesh use and preoperative pain scores were predictors of postop pain, but not age, ethnicity, sex, or other comorbidities. But 38 (21%) patients continued to have pain that was not resolved at 1 year, 32 of which had no actionable diagnosis.
The study was retrospective and limited by inclusion of visits and calls only to the surgical services and not to other medical services or physicians. Pain complaints were subjective and levels of severity were not recorded.
The investigators concluded that estimates of the number of patients who have chronic pain after cVHR do not capture the level of health care resource utilization for this problem. Patients experiencing postop pain make unscheduled calls or visits to the clinic or ED, and many do so repeatedly without receiving an actionable diagnosis. “A cost analysis specific to treating postoperative pain for 1 year would provide a better understanding of the magnitude of the problem. Subjective complaints of pain in the year following cVHR are frequent and represent a hidden driver of resource utilization which must be better understood to achieve optimal, cost effective care.”
The authors declared no conflicts of interest.
SOURCE: DeLong CG et al. Am J Surg. 2018. doi: 10.1016/j.amjsurg.2018.01.030.
And although these calls and visits are costly in health care resources, many patients do not receive an actionable diagnosis, according to a study published in The American Journal of Surgery.
Colin G. DeLong, MD, and his colleagues reviewed health records of patients who underwent an open procedure for complex ventral hernia repair (cVHR) at Penn State Milton S. Hershey Medical Center in Hershey, Penn., between January 2013 and August 2015 using the American College of Surgeons National Surgery Quality Improvement Project (NSQIP) data available at the institution. They identified a cohort of 177 patients, 79% of whom were reviewed for pain issues at 1 year.
The study focused on postoperative pain during the first year following open cVHR. The investigators looked at how patients registered postoperative discomfort, risk factors that predicted greater utilization of the health system for pain-related complaints, and how often complaints of chronic pain resulted in an actionable diagnosis.
All postop encounters in the year after surgery were documented, including the sequence of events in response to pain complaints. In addition, the investigators recorded “instances in which a diagnosis resulted from such actions and whether the diagnosis was actionable, meaning it led to a specific intervention that was expected to alleviate the pain.”
Of the 177 patients, 91 patients made an unsolicited call, clinic visit, or ED visit for pain issues. For 38 patients in this group, action was taken (additional prescription, imaging ordered, ED workup recommended or undertaken). For the other 53, no action was taken. From each group, some cases resolved because of further intervention, and some cases resolved without further action. Mesh use and preoperative pain scores were predictors of postop pain, but not age, ethnicity, sex, or other comorbidities. But 38 (21%) patients continued to have pain that was not resolved at 1 year, 32 of which had no actionable diagnosis.
The study was retrospective and limited by inclusion of visits and calls only to the surgical services and not to other medical services or physicians. Pain complaints were subjective and levels of severity were not recorded.
The investigators concluded that estimates of the number of patients who have chronic pain after cVHR do not capture the level of health care resource utilization for this problem. Patients experiencing postop pain make unscheduled calls or visits to the clinic or ED, and many do so repeatedly without receiving an actionable diagnosis. “A cost analysis specific to treating postoperative pain for 1 year would provide a better understanding of the magnitude of the problem. Subjective complaints of pain in the year following cVHR are frequent and represent a hidden driver of resource utilization which must be better understood to achieve optimal, cost effective care.”
The authors declared no conflicts of interest.
SOURCE: DeLong CG et al. Am J Surg. 2018. doi: 10.1016/j.amjsurg.2018.01.030.
FROM THE AMERICAN JOURNAL OF SURGERY
Key clinical point: Chronic pain has a significant effect on resource utilization following complex ventral hernia repair.
Major finding: Of patients who made unscheduled calls or visits to the clinic or ED for postop pain, 21% did not receive an actionable diagnosis.
Study details: Records from the ACS NSQIP of 177 patients undergoing cVHR were reviewed for postop pain visits and follow-up.
Disclosures: The authors declared no conflicts of interest.
Source: DeLong CG et al. Am J Surg. 2018. doi: 10.1016/j.amjsurg.2018.01.030.
The case for closing robotic surgery port sites
JACKSONVILLE, FLA. – Findings from a retrospective chart review of robotic operations performed over 6 years has identified situations in which surgeons may consider closing 8-mm port sites after robotic surgery, according to a presentation at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Although the incidence of hernia through the 8-mm port sites was low, it’s still important because it’s a significant cause of morbidity in these patients,” Dr. Diez-Barroso said. Two of the three 8-mm port-site hernias required emergency surgery for small bowel incarceration.
“Both of the hernias occurred in the left lower quadrant in the lateral most port, near the anterior superior iliac spine,” he said. “The nearest site of muscle insertions was where the abdominal wall muscle layers have a limited ability to slide over one another during insufflation and desufflation and therefore have a lack of ability to seal off the port site correctly.”
These results have caused surgeons in his group to take a closer look at their own practices, Dr. Diez-Barroso said. “In our practice, now we’re considering closure of the ports in that location in the presence of known risk factors for hernia formation,” he said.
Dr. Diez-Barroso noted other scenarios when surgeons might consider closing 8-mm port sites, for example, after a prolonged operation, when significant torque has been placed on the port site, and in obese patients. The two cases of emergency surgery for port-site hernias involved obese patients: a female with a body mass index of 33 kg/m2 who had an abdominoperineal resection and a male with a BMI of 34 kg/m2 who had a right-sided ventral hernia repair.
The study had a number of limitations, Dr. Diez-Barroso said: its small sample size, retrospective nature, and short follow-up. “Moving forward, to understand better the true incidence of port-site hernias, we want further investigation with longer follow-up times and a larger sample size,” he said.
During questions, moderator Lesly Ann Dossett, MD, FACS, of the University of Michigan, Ann Arbor, asked whether there were other steps surgeons could take, such as where to place the ports or how much torque they apply, besides closing the ports.
“We’ve always placed ports with the standard approach: inserting them perpendicular to the abdominal wall,” Dr. Diez-Barroso said. “Others have theorized that the lateral sites undergo more torque, but I think that also needs further investigation.”
Dr. Diez-Barroso and coauthors reported having no financial disclosures.
Source: Diez-Barroso R. Academic Surgical Congress 2018.
JACKSONVILLE, FLA. – Findings from a retrospective chart review of robotic operations performed over 6 years has identified situations in which surgeons may consider closing 8-mm port sites after robotic surgery, according to a presentation at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Although the incidence of hernia through the 8-mm port sites was low, it’s still important because it’s a significant cause of morbidity in these patients,” Dr. Diez-Barroso said. Two of the three 8-mm port-site hernias required emergency surgery for small bowel incarceration.
“Both of the hernias occurred in the left lower quadrant in the lateral most port, near the anterior superior iliac spine,” he said. “The nearest site of muscle insertions was where the abdominal wall muscle layers have a limited ability to slide over one another during insufflation and desufflation and therefore have a lack of ability to seal off the port site correctly.”
These results have caused surgeons in his group to take a closer look at their own practices, Dr. Diez-Barroso said. “In our practice, now we’re considering closure of the ports in that location in the presence of known risk factors for hernia formation,” he said.
Dr. Diez-Barroso noted other scenarios when surgeons might consider closing 8-mm port sites, for example, after a prolonged operation, when significant torque has been placed on the port site, and in obese patients. The two cases of emergency surgery for port-site hernias involved obese patients: a female with a body mass index of 33 kg/m2 who had an abdominoperineal resection and a male with a BMI of 34 kg/m2 who had a right-sided ventral hernia repair.
The study had a number of limitations, Dr. Diez-Barroso said: its small sample size, retrospective nature, and short follow-up. “Moving forward, to understand better the true incidence of port-site hernias, we want further investigation with longer follow-up times and a larger sample size,” he said.
During questions, moderator Lesly Ann Dossett, MD, FACS, of the University of Michigan, Ann Arbor, asked whether there were other steps surgeons could take, such as where to place the ports or how much torque they apply, besides closing the ports.
“We’ve always placed ports with the standard approach: inserting them perpendicular to the abdominal wall,” Dr. Diez-Barroso said. “Others have theorized that the lateral sites undergo more torque, but I think that also needs further investigation.”
Dr. Diez-Barroso and coauthors reported having no financial disclosures.
Source: Diez-Barroso R. Academic Surgical Congress 2018.
JACKSONVILLE, FLA. – Findings from a retrospective chart review of robotic operations performed over 6 years has identified situations in which surgeons may consider closing 8-mm port sites after robotic surgery, according to a presentation at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Although the incidence of hernia through the 8-mm port sites was low, it’s still important because it’s a significant cause of morbidity in these patients,” Dr. Diez-Barroso said. Two of the three 8-mm port-site hernias required emergency surgery for small bowel incarceration.
“Both of the hernias occurred in the left lower quadrant in the lateral most port, near the anterior superior iliac spine,” he said. “The nearest site of muscle insertions was where the abdominal wall muscle layers have a limited ability to slide over one another during insufflation and desufflation and therefore have a lack of ability to seal off the port site correctly.”
These results have caused surgeons in his group to take a closer look at their own practices, Dr. Diez-Barroso said. “In our practice, now we’re considering closure of the ports in that location in the presence of known risk factors for hernia formation,” he said.
Dr. Diez-Barroso noted other scenarios when surgeons might consider closing 8-mm port sites, for example, after a prolonged operation, when significant torque has been placed on the port site, and in obese patients. The two cases of emergency surgery for port-site hernias involved obese patients: a female with a body mass index of 33 kg/m2 who had an abdominoperineal resection and a male with a BMI of 34 kg/m2 who had a right-sided ventral hernia repair.
The study had a number of limitations, Dr. Diez-Barroso said: its small sample size, retrospective nature, and short follow-up. “Moving forward, to understand better the true incidence of port-site hernias, we want further investigation with longer follow-up times and a larger sample size,” he said.
During questions, moderator Lesly Ann Dossett, MD, FACS, of the University of Michigan, Ann Arbor, asked whether there were other steps surgeons could take, such as where to place the ports or how much torque they apply, besides closing the ports.
“We’ve always placed ports with the standard approach: inserting them perpendicular to the abdominal wall,” Dr. Diez-Barroso said. “Others have theorized that the lateral sites undergo more torque, but I think that also needs further investigation.”
Dr. Diez-Barroso and coauthors reported having no financial disclosures.
Source: Diez-Barroso R. Academic Surgical Congress 2018.
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Some 8-mm robotic port sites may warrant closure under certain circumstances.
Major finding: Of 178 patients, 3 had complications caused by 8-mm robotic port sites that were not closed, 2 of which required emergency reoperation for small bowel incarceration.
Data source: Retrospective chart review of 178 patients who had robotic general and oncologic surgical procedures between July 2010 and December 2016.
Disclosures: Dr. Diez-Barroso and coauthors reported having no financial disclosures.
Source: Diez-Barroso R. Academic Surgical Congress 2018.
Hernia repair patients had less pain with lightweight mesh
and less discomfort at 1 year in a group of patients who had lightweight mesh, compared with patients who had heavyweight mesh, in a multicenter, randomized clinical trial.
Martin Rutegård, MD, of Umeå (Sweden) University, and his research associates reported that 3%-10% of all hernia surgeries “result in severe or moderately severe pain for more than a year after hernia surgery, which may have a significant impact on social activities, sex life, and quality of life. ... Interest in the use of lightweight meshes in groin hernia repair has increased in recent years, as it is assumed that this type of mesh may cause less discomfort and chronic pain.”
Patients were followed for 1-3 years and given questionnaires to report their outcomes. Patients were all male and were close in weight (mean body mass index, 25.2 kg/m2 in the lightweight-mesh group and 25.3 in the heavyweight-mesh group), age (59 and 58, respectively), and American Society of Anaesthesiologists classification of their hernia defect.
Of a total of 363 patients, 185 patients were randomized to the lightweight-mesh group and 178 patients to the heavyweight group. Investigators found that there were significant differences concerning awareness of a groin lump and groin discomfort, favoring the lightweight group 1 year after surgery. A total of 6% of the lightweight group reported the groin lump awareness at 1 year, vs. 18% of the heavyweight group. Groin discomfort was reported by 18% of the lightweight group and 28% of the heavyweight group.
After 1 year, that difference subsided. In terms of discomfort, the investigators found no statistically significant or clinically relevant differences between types of mesh, with 263/288 patients (91.3%) reporting improvement after 12 months, 19/288 patients (6.6%) experiencing no change, and 6/288 patients (2.1%) having worsened.
Additionally, there was no statistically significant difference in quality of life as measured by the EuroQol five dimensions (EQ-5D) between the different mesh groups. It was noted that all the patients had a statistically significantly better quality of life postoperatively from day 11 and onward, compared with before surgery. In addition, the investigators did not detect a significant difference between the mesh groups in their reported sexual life after surgery at 4 and 12 months subsequent to the operation.
The recurrence rate at the follow-up visit and clinical examination was 2.4% and equal between both groups.
The study was limited by possible bias of the expertise-based design and also some missing data, especially with regard to sexual life after surgery.
The study was funded by the Västerbotten County Council, VISARE NORR Fund, and Northern Country Councils Regional Federation. The investigators reported no conflicts of interest.
SOURCE: M. Rutegård et al. Hernia 2018 Jan 20. doi: 10.1007/s10029-018-1734-z.
and less discomfort at 1 year in a group of patients who had lightweight mesh, compared with patients who had heavyweight mesh, in a multicenter, randomized clinical trial.
Martin Rutegård, MD, of Umeå (Sweden) University, and his research associates reported that 3%-10% of all hernia surgeries “result in severe or moderately severe pain for more than a year after hernia surgery, which may have a significant impact on social activities, sex life, and quality of life. ... Interest in the use of lightweight meshes in groin hernia repair has increased in recent years, as it is assumed that this type of mesh may cause less discomfort and chronic pain.”
Patients were followed for 1-3 years and given questionnaires to report their outcomes. Patients were all male and were close in weight (mean body mass index, 25.2 kg/m2 in the lightweight-mesh group and 25.3 in the heavyweight-mesh group), age (59 and 58, respectively), and American Society of Anaesthesiologists classification of their hernia defect.
Of a total of 363 patients, 185 patients were randomized to the lightweight-mesh group and 178 patients to the heavyweight group. Investigators found that there were significant differences concerning awareness of a groin lump and groin discomfort, favoring the lightweight group 1 year after surgery. A total of 6% of the lightweight group reported the groin lump awareness at 1 year, vs. 18% of the heavyweight group. Groin discomfort was reported by 18% of the lightweight group and 28% of the heavyweight group.
After 1 year, that difference subsided. In terms of discomfort, the investigators found no statistically significant or clinically relevant differences between types of mesh, with 263/288 patients (91.3%) reporting improvement after 12 months, 19/288 patients (6.6%) experiencing no change, and 6/288 patients (2.1%) having worsened.
Additionally, there was no statistically significant difference in quality of life as measured by the EuroQol five dimensions (EQ-5D) between the different mesh groups. It was noted that all the patients had a statistically significantly better quality of life postoperatively from day 11 and onward, compared with before surgery. In addition, the investigators did not detect a significant difference between the mesh groups in their reported sexual life after surgery at 4 and 12 months subsequent to the operation.
The recurrence rate at the follow-up visit and clinical examination was 2.4% and equal between both groups.
The study was limited by possible bias of the expertise-based design and also some missing data, especially with regard to sexual life after surgery.
The study was funded by the Västerbotten County Council, VISARE NORR Fund, and Northern Country Councils Regional Federation. The investigators reported no conflicts of interest.
SOURCE: M. Rutegård et al. Hernia 2018 Jan 20. doi: 10.1007/s10029-018-1734-z.
and less discomfort at 1 year in a group of patients who had lightweight mesh, compared with patients who had heavyweight mesh, in a multicenter, randomized clinical trial.
Martin Rutegård, MD, of Umeå (Sweden) University, and his research associates reported that 3%-10% of all hernia surgeries “result in severe or moderately severe pain for more than a year after hernia surgery, which may have a significant impact on social activities, sex life, and quality of life. ... Interest in the use of lightweight meshes in groin hernia repair has increased in recent years, as it is assumed that this type of mesh may cause less discomfort and chronic pain.”
Patients were followed for 1-3 years and given questionnaires to report their outcomes. Patients were all male and were close in weight (mean body mass index, 25.2 kg/m2 in the lightweight-mesh group and 25.3 in the heavyweight-mesh group), age (59 and 58, respectively), and American Society of Anaesthesiologists classification of their hernia defect.
Of a total of 363 patients, 185 patients were randomized to the lightweight-mesh group and 178 patients to the heavyweight group. Investigators found that there were significant differences concerning awareness of a groin lump and groin discomfort, favoring the lightweight group 1 year after surgery. A total of 6% of the lightweight group reported the groin lump awareness at 1 year, vs. 18% of the heavyweight group. Groin discomfort was reported by 18% of the lightweight group and 28% of the heavyweight group.
After 1 year, that difference subsided. In terms of discomfort, the investigators found no statistically significant or clinically relevant differences between types of mesh, with 263/288 patients (91.3%) reporting improvement after 12 months, 19/288 patients (6.6%) experiencing no change, and 6/288 patients (2.1%) having worsened.
Additionally, there was no statistically significant difference in quality of life as measured by the EuroQol five dimensions (EQ-5D) between the different mesh groups. It was noted that all the patients had a statistically significantly better quality of life postoperatively from day 11 and onward, compared with before surgery. In addition, the investigators did not detect a significant difference between the mesh groups in their reported sexual life after surgery at 4 and 12 months subsequent to the operation.
The recurrence rate at the follow-up visit and clinical examination was 2.4% and equal between both groups.
The study was limited by possible bias of the expertise-based design and also some missing data, especially with regard to sexual life after surgery.
The study was funded by the Västerbotten County Council, VISARE NORR Fund, and Northern Country Councils Regional Federation. The investigators reported no conflicts of interest.
SOURCE: M. Rutegård et al. Hernia 2018 Jan 20. doi: 10.1007/s10029-018-1734-z.
FROM HERNIA
Key clinical point: The weight of mesh used for inguinal hernia repair did not impact outcomes.
Major finding: A total of 6% of the lightweight group reported groin lump awareness at 1 year, vs. 18% of the heavyweight group.
Study details: A randomized, multicenter study of 363 patients.
Disclosures: The study was funded by the Västerbotten County Council, VISARE NORR Fund, and Northern Country Councils Regional Federation. The investigators reported no conflicts of interest.
Source: Rutegård M et al. Hernia. 2018 Jan 20. doi: 10.1007/s10029-018-1734-z.
Clinical trial: Telescopic vs. balloon dissection for hernia
A randomized clinical trial will compare two techniques for achieving extraperitoneal space during hernia surgery.
The in operative times, early postoperative pain scores, surgical complications, and rate of hernia recurrence. The Spacemaker Balloon Dissector will be used for the trial.
The techniques will be timed and measured in minutes from incision to end of procedure. Pain outcomes will be measured using the Numeric Pain Rating Scale (NRS-11) at postoperative days 1, 7, and 30. Intraoperative complications, 30-day infections, and 1-year recurrence will be reported in numbers and percent as appropriate.
The study is sponsored by The Cleveland Clinic.
For more details about the trial, go to www.clinicaltrials.gov.
SOURCE: Clinical Trial NCT03276871.
A randomized clinical trial will compare two techniques for achieving extraperitoneal space during hernia surgery.
The in operative times, early postoperative pain scores, surgical complications, and rate of hernia recurrence. The Spacemaker Balloon Dissector will be used for the trial.
The techniques will be timed and measured in minutes from incision to end of procedure. Pain outcomes will be measured using the Numeric Pain Rating Scale (NRS-11) at postoperative days 1, 7, and 30. Intraoperative complications, 30-day infections, and 1-year recurrence will be reported in numbers and percent as appropriate.
The study is sponsored by The Cleveland Clinic.
For more details about the trial, go to www.clinicaltrials.gov.
SOURCE: Clinical Trial NCT03276871.
A randomized clinical trial will compare two techniques for achieving extraperitoneal space during hernia surgery.
The in operative times, early postoperative pain scores, surgical complications, and rate of hernia recurrence. The Spacemaker Balloon Dissector will be used for the trial.
The techniques will be timed and measured in minutes from incision to end of procedure. Pain outcomes will be measured using the Numeric Pain Rating Scale (NRS-11) at postoperative days 1, 7, and 30. Intraoperative complications, 30-day infections, and 1-year recurrence will be reported in numbers and percent as appropriate.
The study is sponsored by The Cleveland Clinic.
For more details about the trial, go to www.clinicaltrials.gov.
SOURCE: Clinical Trial NCT03276871.
FROM CLINICALTRIALS.GOV