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Local versus general anesthesia in open umbilical hernia repair (UHR): results from a prospective, international study
Vol. 217, No. 3S, September 2013
Surgical Forum Abstracts
(2.81 vs 0.93 days, p<0.001) and abscess formation (OR 14.8, p<0.001). CT to OR time
<3 <6 <9 >9
hours hours hours hours
% Perforation
Odds ratio
P-Value
10% 16% 27% 25%
2.38 1.88 1.92 1.15
0.059 0.011 0.38 0.71
CONCLUSIONS: Time from diagnosis to OR of less than 3 hours decreased risk of perforation. Patients without perforated appendicitis had 2 days less hospitalization and significantly fewer complications. Best outcomes require OR and surgical team availability 24 hours per day. A multicenter prospective observational cohort study of permanent synthetic mesh versus biologic mesh reinforcement for open ventral hernia repair in cleancontaminated and contaminated surgical sites Jaime Ann Cavallo, MD, MPH, Cory Criss, MD, Benjamin K Poulose, MD, MPH, FACS, Brent D Matthews, MD, FACS, William S Cobb IV, MD, FACS, Alfredo M Carbonell II, DO, FACS, Yuri W Novitsky, MD, Michael J Rosen, MD, FACS Washington University School of Medicine, Saint Louis, MO INTRODUCTION: The emergence of lightweight macroporous permanent synthetic meshes (PSM) with improved performance in clean-contaminated and contaminated fields challenges the previously-held belief that PSM use is contraindicated in contaminated fields. We hypothesized that PSM reinforcement would incur significantly reduced rates of hernia recurrence (HR), surgical site occurrences (SSO), and surgical site occurrences requiring procedural intervention (SSOPI) when compared to biologic mesh (BM) reinforcement of open ventral hernia repair (OVHR) in clean-contaminated and contaminated surgical sites.
S25
and contaminated surgical sites. These data constitute the first observational cohort study of the comparative effectiveness of PSM versus BM reinforcement in clean-contaminated and contaminated OVHR. The impact of mesh position on open umbilical hernia repair outcomes: a comparison of preperitoneal and intraperitoneal placement in a prospective multicenter study Blair A Wormer, MD, Dimitrios Stefanidis, MD, PhD, FACS, Kris B Williams, MD, Joel F Bradley III, MD, Vedra A Augenstein, MD, B Todd Heniford, MD, FACS Carolinas Medical Center, Charlotte, NC INTRODUCTION: Mesh is becoming more commonly utilized in umbilical hernia repairs (UHR) but little is known about technique-related outcomes. The goal of this study was to compare outcomes of preperitoneal (PP) versus intraperitoneal (IP) mesh placement after open UHR. METHODS: The International Hernia Mesh Registry, a prospective database from over 35 institutions in Europe, Australia, Canada, and the USA, was queried for open UHR (2007-2012). Carolinas Comfort Scale (CCS) was used to compare postoperative quality of life (QOL) at 1, 6, 12, and 24 months. Standard statistical methods were used. RESULTS: Of 288 open UHR, 161(55.9%) underwent PP and 127(44.1%) IP repair. Patient age was 5114 years. 97% were primary repairs. Patients undergoing PP repair were more often male (82.1% vs 71.7%; p¼0.04), had a higher BMI (30.25.5 vs 28.74.7; p¼0.03), and larger defect size (4.12.3cm vs 3.22.1cm; p<0.001). There were no differences in age, race, steroid use, smoking status, prior UHR, and preoperative pain scores. PP had longer OR duration (36.716.1min vs 28.612.2min; p<0.0001), and a lower rate of postoperative skin and soft tissue infection (0% vs 3.9%; p¼0.01) compared with IP repair. There was no difference in seroma, hematoma, recurrence, reoperation, postoperative pain, activity limitation, or mesh sensation between the two techniques at any follow-up time point.
METHODS: Data from consecutive patients presenting for cleancontaminated or contaminated OVHR with PSM or BM reinforcement to Greenville Hospital System or Case Medical Center (2008-2013) were prospectively recorded and analyzed for HR, SSO, and SSOPI rates. Observed rates of HR, SSO, and SSOPI were compared between PSM and BM cohorts using two-tailed z-tests with alpha¼0.05.
CONCLUSIONS: Preperitoneal and intraperitoneal mesh position in open UHR results in similar QOL outcomes. However, the infection rate was lower in preperitoneal repair despite heavier patients with larger defects and longer OR duration. Preperitoneal mesh placement, therefore, may be favored over IP for open UHR.
RESULTS: Data from 200 subjects (111 PSM:89 BM) were collected with a mean follow-up of 13.4512.70 months. Mean age at time of OVHR was 57.6713.83 years and 60.4913.19 years for the BM and PSM cohorts, respectively (p¼0.1441). HR rates were 29.21% versus 9.01% (p¼0.0003), SSO rates were 46.07% versus 31.53% (p¼0.0356), and SSOPI rates were 39.02% versus 9.01% (p<0.0001) for the BM and PSM cohorts, respectively.
Local versus general anesthesia in open umbilical hernia repair (UHR): results from a prospective, international study Blair A Wormer, MD, Joel F Bradley III, MD, Kristopher B Williams, MD, Vedra A Augenstein, MD, Amanda Walters, MS, Amy E Lincourt, PhD, B Todd Heniford, MD, FACS Carolinas Medical Center, Charlotte, NC
CONCLUSIONS: Short-term rates of HR, SSO, and SSOPI were significantly reduced for subjects following OVHR with PSM reinforcement compared to BM reinforcement in clean-contaminated
INTRODUCTION: The goal of this study was to evaluate outcomes in patients undergoing open UHR with local anesthesia (LA)
S26
Surgical Forum Abstracts
compared to general anesthesia (GA) in a prospective multicenter study. METHODS: The prospective International Hernia Mesh Registry was queried for open UHR (2007-2012). Carolinas Comfort Scale (CCS) was used to compare postoperative quality of life (QOL) outcomes for LA versus GA. Standard statistical methods were used, and p<0.05 was significant. RESULTS: In total, 289 open UHR patients were performed; 68(23.5%) LA and 221(76.5%) GA. Average age was 5114 years, 77% were male, and 97% were primary repairs. Between groups, there was no difference in age, gender, race, BMI, steroid use, smoking, COPD, prior UHR, preoperative pain, OR time, postoperative infection, seroma, hematoma, recurrence, or reoperation. Average defect size was larger in LA compared to GA (4.21.6cm vs 3.52.5cm; p¼0.0002). UHR under LA required less inpatient hospitalization than GA (5.9% vs 48.9%; p<0.0001). Postoperative follow up was 88%, 70%, and 72%, at 1, 6, and 12 months, respectively. More LA patients returned to work by their first follow up compared to GA (85.2% vs 65.9%; p¼0.008). There was no difference in postoperative pain, activity limitation, or mesh sensation between LA and GA at any follow-up. CONCLUSIONS: This study demonstrates open UHR under local anesthesia can be performed on larger defects with similar postoperative outcomes and QOL at up to one year follow up. Additionally, LA required less inpatient hospitalization and was associated with more rapid return to work compared to GA. Valproic acid (VPA), a histone deacetylase inhibitor that reduces intraabdominal adhesions modulates peritoneal plasma extravasation and genes that regulate fibrin deposition and stability Matthew Thomas Brady, MD Boston University School of Medicine, Boston, MA INTRODUCTION: Intraabdominal adhesions occur in nearly 100% of patients following abdominopelvic surgery. We have previously shown that VPA administered intraperitoneally (IP) at the time of laparotomy significantly reduces adhesions in a rat model; however, the mechanism remains unclear. We hypothesized that VPA reduces plasma extravasation of the fibrinous exudate at the site of peritoneal injury thus inhibiting fibrin formation in the postoperative period. METHODS: Twenty-five rats underwent laparotomy with creation of adhesive ischemic buttons as previously described. VPA (50mg/ kg) or saline was administered IP intraoperatively followed immediately by a tail vein injection of Evans Blue (25mg/kg). To measure plasma extravasation, animals were sacrificed after 3 hrs and Evans Blue accumulation was quantified in peritoneal tissue. In additional experiments, adhesive buttons were collected 3 hrs postoperatively for RNA extraction and real-time PCR analysis to quantify mRNA levels of: 1) vascular endothelial growth factor (VEGF; promotes vascular permeability); 2) thrombomodulin (TM; complexes thrombin to inhibit fibrinolysis); 3) tissue factor
J Am Coll Surg
(TF; receptor critical to thrombin formation); and 4) proteaseactivated-receptor-1 (PAR1; thrombin activated receptor whose signal increases fibrin formation). Four untreated rats served as non-operated controls. RESULTS: The results demonstrate that VPA reduces plasma extravasation into inflamed peritoneal tissue surrounding ischemic buttons. In concert with this effect VPA significantly reduces expression of each of the above genes in adhesive ischemic tissue compared with saline controls (Table).
Saline
Peritoneal extravasation (ul/mg tissue) VEGF mRNA1 Tissue factor mRNA1 Thrombomodulin mRNA1 PAR-1 mRNA1
0.16 9.2 14.2 262.2 41.8
0.02 1.3 3.7 11.6 11.2
VPA
0.11 3.4 4.2 49.5 10.1
0.02* 0.9* 1.8* 27.7* 4.2*
Data are shown as mean SEM; n¼4-6 per group. *p<0.05 compared with saline. 1 Fold change compared with non-operated.
CONCLUSIONS: These data mechanistically support that fibrin deposition and stability early in the postoperative period is critical to adhesiogenesis and its regulation is a viable therapeutic approach for adhesion prevention. Risk factors and incidence of Clostridium difficile infection after colorectal surgery Craig A Messick, MD, Elena Manilich, PhD, Chao Sun, MD, PhD, Jeffery P Hammel, MS, Meagan M Costedio, MD Cleveland Clinic, Cleveland, OH INTRODUCTION: Clostridium difficile (C.diff ) infection (CDI) is a recognized post-operative (post-op) infection with significant morbidity. Despite its low incidence in the general surgical population, it is unclear if colorectal surgery (CORS), associated diagnoses, or medical therapy increases the risk of CDI. This study evaluates index post-op CDI in CORS patients in attempt to identify risk factors for CDI. METHODS: All patients with an ELISA or PCR-proven C.diff stool assay (CDA) were identified and included using an electronic medical records query from 01/2002-06/2012. We defined post-op CDI as any positive CDA within 30 days following surgery. Basic patient demographics, surgical diagnoses, immunomodulators, and laboratory data were recorded. RESULTS: Approximately 24,700 CORS operations were performed and 0.9% of CORS patients developed post-op CDI. Risk factors for CDI are shown in the Table. The incidence of CDI varied by diagnosis and was higher in diverticulitis patients (p<0.001), who also had the greatest BMI, p¼0.015. Steroids and immunomodulator use in patients with inflammatory bowel disease did not increase the risk of CDI. Sigmoid colectomy was the most frequent procedure followed by right colectomy, and CDI developed in 12% of all stoma closures.
Surgical Forum Abstracts
(2.81 vs 0.93 days, p<0.001) and abscess formation (OR 14.8, p<0.001). CT to OR time
<3 <6 <9 >9
hours hours hours hours
% Perforation
Odds ratio
P-Value
10% 16% 27% 25%
2.38 1.88 1.92 1.15
0.059 0.011 0.38 0.71
CONCLUSIONS: Time from diagnosis to OR of less than 3 hours decreased risk of perforation. Patients without perforated appendicitis had 2 days less hospitalization and significantly fewer complications. Best outcomes require OR and surgical team availability 24 hours per day. A multicenter prospective observational cohort study of permanent synthetic mesh versus biologic mesh reinforcement for open ventral hernia repair in cleancontaminated and contaminated surgical sites Jaime Ann Cavallo, MD, MPH, Cory Criss, MD, Benjamin K Poulose, MD, MPH, FACS, Brent D Matthews, MD, FACS, William S Cobb IV, MD, FACS, Alfredo M Carbonell II, DO, FACS, Yuri W Novitsky, MD, Michael J Rosen, MD, FACS Washington University School of Medicine, Saint Louis, MO INTRODUCTION: The emergence of lightweight macroporous permanent synthetic meshes (PSM) with improved performance in clean-contaminated and contaminated fields challenges the previously-held belief that PSM use is contraindicated in contaminated fields. We hypothesized that PSM reinforcement would incur significantly reduced rates of hernia recurrence (HR), surgical site occurrences (SSO), and surgical site occurrences requiring procedural intervention (SSOPI) when compared to biologic mesh (BM) reinforcement of open ventral hernia repair (OVHR) in clean-contaminated and contaminated surgical sites.
S25
and contaminated surgical sites. These data constitute the first observational cohort study of the comparative effectiveness of PSM versus BM reinforcement in clean-contaminated and contaminated OVHR. The impact of mesh position on open umbilical hernia repair outcomes: a comparison of preperitoneal and intraperitoneal placement in a prospective multicenter study Blair A Wormer, MD, Dimitrios Stefanidis, MD, PhD, FACS, Kris B Williams, MD, Joel F Bradley III, MD, Vedra A Augenstein, MD, B Todd Heniford, MD, FACS Carolinas Medical Center, Charlotte, NC INTRODUCTION: Mesh is becoming more commonly utilized in umbilical hernia repairs (UHR) but little is known about technique-related outcomes. The goal of this study was to compare outcomes of preperitoneal (PP) versus intraperitoneal (IP) mesh placement after open UHR. METHODS: The International Hernia Mesh Registry, a prospective database from over 35 institutions in Europe, Australia, Canada, and the USA, was queried for open UHR (2007-2012). Carolinas Comfort Scale (CCS) was used to compare postoperative quality of life (QOL) at 1, 6, 12, and 24 months. Standard statistical methods were used. RESULTS: Of 288 open UHR, 161(55.9%) underwent PP and 127(44.1%) IP repair. Patient age was 5114 years. 97% were primary repairs. Patients undergoing PP repair were more often male (82.1% vs 71.7%; p¼0.04), had a higher BMI (30.25.5 vs 28.74.7; p¼0.03), and larger defect size (4.12.3cm vs 3.22.1cm; p<0.001). There were no differences in age, race, steroid use, smoking status, prior UHR, and preoperative pain scores. PP had longer OR duration (36.716.1min vs 28.612.2min; p<0.0001), and a lower rate of postoperative skin and soft tissue infection (0% vs 3.9%; p¼0.01) compared with IP repair. There was no difference in seroma, hematoma, recurrence, reoperation, postoperative pain, activity limitation, or mesh sensation between the two techniques at any follow-up time point.
METHODS: Data from consecutive patients presenting for cleancontaminated or contaminated OVHR with PSM or BM reinforcement to Greenville Hospital System or Case Medical Center (2008-2013) were prospectively recorded and analyzed for HR, SSO, and SSOPI rates. Observed rates of HR, SSO, and SSOPI were compared between PSM and BM cohorts using two-tailed z-tests with alpha¼0.05.
CONCLUSIONS: Preperitoneal and intraperitoneal mesh position in open UHR results in similar QOL outcomes. However, the infection rate was lower in preperitoneal repair despite heavier patients with larger defects and longer OR duration. Preperitoneal mesh placement, therefore, may be favored over IP for open UHR.
RESULTS: Data from 200 subjects (111 PSM:89 BM) were collected with a mean follow-up of 13.4512.70 months. Mean age at time of OVHR was 57.6713.83 years and 60.4913.19 years for the BM and PSM cohorts, respectively (p¼0.1441). HR rates were 29.21% versus 9.01% (p¼0.0003), SSO rates were 46.07% versus 31.53% (p¼0.0356), and SSOPI rates were 39.02% versus 9.01% (p<0.0001) for the BM and PSM cohorts, respectively.
Local versus general anesthesia in open umbilical hernia repair (UHR): results from a prospective, international study Blair A Wormer, MD, Joel F Bradley III, MD, Kristopher B Williams, MD, Vedra A Augenstein, MD, Amanda Walters, MS, Amy E Lincourt, PhD, B Todd Heniford, MD, FACS Carolinas Medical Center, Charlotte, NC
CONCLUSIONS: Short-term rates of HR, SSO, and SSOPI were significantly reduced for subjects following OVHR with PSM reinforcement compared to BM reinforcement in clean-contaminated
INTRODUCTION: The goal of this study was to evaluate outcomes in patients undergoing open UHR with local anesthesia (LA)
S26
Surgical Forum Abstracts
compared to general anesthesia (GA) in a prospective multicenter study. METHODS: The prospective International Hernia Mesh Registry was queried for open UHR (2007-2012). Carolinas Comfort Scale (CCS) was used to compare postoperative quality of life (QOL) outcomes for LA versus GA. Standard statistical methods were used, and p<0.05 was significant. RESULTS: In total, 289 open UHR patients were performed; 68(23.5%) LA and 221(76.5%) GA. Average age was 5114 years, 77% were male, and 97% were primary repairs. Between groups, there was no difference in age, gender, race, BMI, steroid use, smoking, COPD, prior UHR, preoperative pain, OR time, postoperative infection, seroma, hematoma, recurrence, or reoperation. Average defect size was larger in LA compared to GA (4.21.6cm vs 3.52.5cm; p¼0.0002). UHR under LA required less inpatient hospitalization than GA (5.9% vs 48.9%; p<0.0001). Postoperative follow up was 88%, 70%, and 72%, at 1, 6, and 12 months, respectively. More LA patients returned to work by their first follow up compared to GA (85.2% vs 65.9%; p¼0.008). There was no difference in postoperative pain, activity limitation, or mesh sensation between LA and GA at any follow-up. CONCLUSIONS: This study demonstrates open UHR under local anesthesia can be performed on larger defects with similar postoperative outcomes and QOL at up to one year follow up. Additionally, LA required less inpatient hospitalization and was associated with more rapid return to work compared to GA. Valproic acid (VPA), a histone deacetylase inhibitor that reduces intraabdominal adhesions modulates peritoneal plasma extravasation and genes that regulate fibrin deposition and stability Matthew Thomas Brady, MD Boston University School of Medicine, Boston, MA INTRODUCTION: Intraabdominal adhesions occur in nearly 100% of patients following abdominopelvic surgery. We have previously shown that VPA administered intraperitoneally (IP) at the time of laparotomy significantly reduces adhesions in a rat model; however, the mechanism remains unclear. We hypothesized that VPA reduces plasma extravasation of the fibrinous exudate at the site of peritoneal injury thus inhibiting fibrin formation in the postoperative period. METHODS: Twenty-five rats underwent laparotomy with creation of adhesive ischemic buttons as previously described. VPA (50mg/ kg) or saline was administered IP intraoperatively followed immediately by a tail vein injection of Evans Blue (25mg/kg). To measure plasma extravasation, animals were sacrificed after 3 hrs and Evans Blue accumulation was quantified in peritoneal tissue. In additional experiments, adhesive buttons were collected 3 hrs postoperatively for RNA extraction and real-time PCR analysis to quantify mRNA levels of: 1) vascular endothelial growth factor (VEGF; promotes vascular permeability); 2) thrombomodulin (TM; complexes thrombin to inhibit fibrinolysis); 3) tissue factor
J Am Coll Surg
(TF; receptor critical to thrombin formation); and 4) proteaseactivated-receptor-1 (PAR1; thrombin activated receptor whose signal increases fibrin formation). Four untreated rats served as non-operated controls. RESULTS: The results demonstrate that VPA reduces plasma extravasation into inflamed peritoneal tissue surrounding ischemic buttons. In concert with this effect VPA significantly reduces expression of each of the above genes in adhesive ischemic tissue compared with saline controls (Table).
Saline
Peritoneal extravasation (ul/mg tissue) VEGF mRNA1 Tissue factor mRNA1 Thrombomodulin mRNA1 PAR-1 mRNA1
0.16 9.2 14.2 262.2 41.8
0.02 1.3 3.7 11.6 11.2
VPA
0.11 3.4 4.2 49.5 10.1
0.02* 0.9* 1.8* 27.7* 4.2*
Data are shown as mean SEM; n¼4-6 per group. *p<0.05 compared with saline. 1 Fold change compared with non-operated.
CONCLUSIONS: These data mechanistically support that fibrin deposition and stability early in the postoperative period is critical to adhesiogenesis and its regulation is a viable therapeutic approach for adhesion prevention. Risk factors and incidence of Clostridium difficile infection after colorectal surgery Craig A Messick, MD, Elena Manilich, PhD, Chao Sun, MD, PhD, Jeffery P Hammel, MS, Meagan M Costedio, MD Cleveland Clinic, Cleveland, OH INTRODUCTION: Clostridium difficile (C.diff ) infection (CDI) is a recognized post-operative (post-op) infection with significant morbidity. Despite its low incidence in the general surgical population, it is unclear if colorectal surgery (CORS), associated diagnoses, or medical therapy increases the risk of CDI. This study evaluates index post-op CDI in CORS patients in attempt to identify risk factors for CDI. METHODS: All patients with an ELISA or PCR-proven C.diff stool assay (CDA) were identified and included using an electronic medical records query from 01/2002-06/2012. We defined post-op CDI as any positive CDA within 30 days following surgery. Basic patient demographics, surgical diagnoses, immunomodulators, and laboratory data were recorded. RESULTS: Approximately 24,700 CORS operations were performed and 0.9% of CORS patients developed post-op CDI. Risk factors for CDI are shown in the Table. The incidence of CDI varied by diagnosis and was higher in diverticulitis patients (p<0.001), who also had the greatest BMI, p¼0.015. Steroids and immunomodulator use in patients with inflammatory bowel disease did not increase the risk of CDI. Sigmoid colectomy was the most frequent procedure followed by right colectomy, and CDI developed in 12% of all stoma closures.