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A multi-institutional, propensity-score-matched comparison of post-operative outcomes between general anesthesia and monitored anesthesia care with intravenous sedation in umbilical hernia repair

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M. M. Vu
M. M. Vu
M. M. Vu
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R. D. Galiano
R. D. Galiano
R. D. Galiano
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J. M. Souza
J. M. Souza
J. M. Souza
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C. Du Qin
C. Du Qin
C. Du Qin
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Purpose: Monitored anesthesia care with intravenous sedation (MAC/IV), recently proposed as a good choice for hernia repair, has faster recovery and better patient satisfaction than general anesthesia; however the possibility of oversedation and respiratory distress is a widespread concern. There is a paucity of the literature examining umbilical hernia repairs (UHR) and optimal anesthesia choice, despite its importance in determining clinical outcomes. Methods: A retrospective analysis of anesthesia type in UHR was performed in the National Surgical Quality Improvement Program 2005-2013 database. General anesthesia and MAC/IV groups were propensity-score-matched (PSM) to reduce treatment selection bias. Surgical complications, medical complications, and post-operative hospital stays exceeding 1 day were the primary outcomes of interest. Pre-operative characteristics and post-operative outcomes were compared between the two anesthesia groups using univariate and multivariate statistics. Results: PSM removed all observed differences between the two groups (p > 0.05 for all tracked pre-operative characteristics). MAC/IV cases required fewer post-operative hospital stays exceeding 1 day (3.5 vs 6.3 %, p < 0.001). Univariate analysis showed that overall complication rate did not differ (1.7 vs 1.8 %, p = 0.569), however MAC/IV cases resulted in fewer incidences of septic shock (<0.1 vs 0.1 %, p = 0.016). After multivariate logistic regression, MAC/IV was revealed to yield significantly lower chances of overall medical complications (OR = 0.654, p = 0.046). Conclusion and relevance: UHR under MAC/IV causes fewer medical complications and reduces post-operative hospital stays compared to general anesthesia. The implications for surgeons and patients are broad, including improved surgical safety, cost-effective care, and patient satisfaction.
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ORIGINAL ARTICLE
A multi-institutional, propensity-score-matched comparison
of post-operative outcomes between general anesthesia
and monitored anesthesia care with intravenous sedation
in umbilical hernia repair
M. M. Vu
1
•R. D. Galiano
1
•J. M. Souza
1
•C. Du Qin
1
•J. Y. S. Kim
1
Received: 27 August 2015 / Accepted: 29 December 2015 / Published online: 9 February 2016
ÓSpringer-Verlag France 2016
Abstract
Purpose Monitored anesthesia care with intravenous
sedation (MAC/IV), recently proposed as a good choice for
hernia repair, has faster recovery and better patient satis-
faction than general anesthesia; however the possibility of
oversedation and respiratory distress is a widespread con-
cern. There is a paucity of the literature examining
umbilical hernia repairs (UHR) and optimal anesthesia
choice, despite its importance in determining clinical
outcomes.
Methods A retrospective analysis of anesthesia type in
UHR was performed in the National Surgical Quality
Improvement Program 2005–2013 database. General
anesthesia and MAC/IV groups were propensity-score-
matched (PSM) to reduce treatment selection bias. Surgical
complications, medical complications, and post-operative
hospital stays exceeding 1 day were the primary outcomes
of interest. Pre-operative characteristics and post-operative
outcomes were compared between the two anesthesia
groups using univariate and multivariate statistics.
Results PSM removed all observed differences between
the two groups (p[0.05 for all tracked pre-operative
characteristics). MAC/IV cases required fewer post-oper-
ative hospital stays exceeding 1 day (3.5 vs 6.3 %,
p\0.001). Univariate analysis showed that overall com-
plication rate did not differ (1.7 vs 1.8 %, p=0.569),
however MAC/IV cases resulted in fewer incidences of
septic shock (\0.1 vs 0.1 %, p=0.016). After
multivariate logistic regression, MAC/IV was revealed to
yield significantly lower chances of overall medical com-
plications (OR =0.654, p=0.046).
Conclusion and relevance UHR under MAC/IV causes
fewer medical complications and reduces post-operative
hospital stays compared to general anesthesia. The impli-
cations for surgeons and patients are broad, including
improved surgical safety, cost-effective care, and patient
satisfaction.
Keywords Umbilical hernia repair General anesthesia
Monitored anesthesia care 30-day complications
Hospital stay
Introduction
The choice of anesthesia type is often a complex decision
that takes into account not only the anesthetic requirements
for specific procedure but often patient and surgeon pref-
erences. When compared to cases performed under seda-
tion, general anesthesia cases often have a slower recovery
of cognitive function, higher pain scores, longer time to
home readiness, and lower patient satisfaction [1,2].
Outcomes associated with monitored anesthesia care with
IV sedation (MAC/IV) have generally been favorable in
vascular surgery, outpatient plastic surgery, general sur-
gery, urological surgery, and gynecological surgery [3–8].
However, the possibility of oversedation and consequent
respiratory distress has been a classic concern of using
MAC/IV [9]. When there is a lack of established outcomes
that extend beyond the immediate post-operative period,
this precludes the use of objective information when
physicians and patients are making perioperative decisions
about the type of anesthesia for a given case. Therefore,
&J. Y. S. Kim
jokim@nm.org
1
Division of Plastic and Reconstructive Surgery, Northwestern
University Feinberg School of Medicine, 675 North St. Clair
Street Galter Suite 19-250, Chicago, IL 60611, USA
123
Hernia (2016) 20:517–525
DOI 10.1007/s10029-015-1455-5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Even though some studies show the absence of complications in patients with special needs treated under GA [3], this is often associated with considerable cost and there is a disproportional increase in costs associated with dental treatment under general anesthesia respect to intravenous sedation in NORA [18,19]. ...
Effectiveness and Safety of Intravenous Sedation with Propofol in Non-Operating Room Anesthesia (NORA) for Dental Treatment in Uncooperative Paediatric Patients
Article
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  • Jul 2021
Background: Uncooperative children require sedative approach for dental treatment. The aim was to assess the effectiveness of Propofol in "Non-Operating Room Anesthesia" (NORA) for paediatric dental treatment; intraoperative side effects; postoperative side effects; post-discharge effects. Methods: a prospective study, involving 109 uncooperative children undergoing sedation in NORA using Propofol for dental treatment, was performed. Working sessions, success/failure, intraoperative and postoperative side effects, number of treatment; type of procedure were assessed. Parents completed a post-discharge questionnaire on: pain; crying; fever; vomiting; headache; drowsiness; excitability; irritability; ability to eat; drugs and medical care needing. Results: Success: 96.7%. Intraoperative side effects: 33.3%. Postoperative side effects: 6.4%. Statistically significant association between: intraoperative side effects and age (p = 0.001), health status (p = 0.0007), weight (p = 0.038), respectively; intraoperative side effects and number/ type of dental treatment (p = 0.0055) and scaling (p = 0.0001), respectively. For post-discharge questionnaires, statistically significant association between: age and crying (p = 0.0001) and headache (p = 0.002), respectively; health status and crying (p = 0.015) and drugs needing (p = 0.04), respectively; weight and crying (p = 0.0004); extraction and pain (p = 0.0001) and crying (p= 0.0073), respectively; scaling and crying (p = 0.04), excitability and irritability (p = 0.03), respectively. Conclusion: Propofol in NORA was effective with minimal side effects.
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... For most patients with a defect larger than 5 cm who are likely to tolerate general anesthesia, we recommend laparoscopic IPOM under general anesthesia. Patients with the concomitant disease are at some risk of complications, not only from the surgical procedure itself but also from the anesthesia, especially those with associated multiple comorbidities [22]. Thus, local anesthesia is a good choice for ventral hernia repair in patients with the concomitant disease. ...
Repair of a medium-sized ventral hernia with the UltraPro Hernia System
Article
  • Nov 2020
Mesh repairs are widely accepted as a suitable option for ventral hernia repair. Among the various devices and surgical approaches used for ventral hernia repair, the UltraPro Hernia System (UHS) is considered an effective method of open repair for patients with medium ventral hernia defects between 3 and 5 cm in diameter. However, few clinical studies on this system have been reported. We describe a simple and safe UHS mesh technique for open ventral hernia repair, which was performed successfully under local anesthesia in 23 patients with medium ventral hernia defects. Minor postoperative complications included seroma (n = 3) and a superficial infection (n = 1). There was no incidence of recurrence in 12 months of follow-up. Our results show that the UHS is simple and easily reproducible for medium ventral hernia defects between 3 and 5 cm in diameter.
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... This finding is supported by other studies comparing sedation vs GA in patients undergoing thyroidectomy, 25 breast surgery, 26 aortic valve replacement, 27 aortic aneurysm repair, 28 or hernia repair. 29 It would be important to evaluate if some of the mechanism leading to longer LOS and higher vulnerability to adverse discharge with GA compared with sedation can be prevented. ...
Outcomes after endoscopic retrograde cholangiopancreatography with general anaesthesia versus sedation
Article
  • Oct 2020
Background: We tested the primary hypothesis that use of general anaesthesia vs sedation increases vulnerability to adverse discharge (in-hospital mortality or new discharge to a nursing facility) after endoscopic retrograde cholangiopancreatography (ERCP). Methods: In this retrospective cohort study, adult patients undergoing ERCP with general anaesthesia or sedation at a tertiary care hospital were included. We calculated adjusted absolute risk differences between patients receiving general anaesthesia vs sedation using provider preference-based instrumental variable analysis. We also used mediation analysis to determine whether intraoperative hypotension during general anaesthesia mediated its effect on adverse discharge. Results: Among 17 538 patients undergoing ERCP from 2007 through 2018, 16 238 received sedation and 1300 received GA. Rates of adverse discharge were 5.8% (n=938) after sedation and 16.2% (n=210) after general anaesthesia. Providers' adjusted mean predicted probabilities of using general anaesthesia for ERCP ranged from 0.2% to 63.2% of individual caseloads. Utilising provider-related variability in the use of general anaesthesia for instrumental variable analysis resulted in an 8.6% risk increase (95% confidence interval, 4.5-12.6%; P<0.001) in adverse discharge among patients receiving general anaesthesia vs sedation. Intraoperative hypotensive events occurred more often during general anaesthesia and mediated 23.8% (95% confidence interval, 3.9-43.7%: P=0.019) of the primary association. Conclusions: These results suggest that use of sedation during ERCP facilitates reduced adverse discharge for patients for whom general anaesthesia is not clearly indicated. Intraoperative hypotension during general anaesthesia for ERCP partly mediates the increased vulnerability to adverse discharge.
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... 4 In studies that directly compared general anesthesia with monitored anesthesia care for the same surgical procedure, mortality was greater and perioperative complications were consistently worse with general anesthesia. [5][6][7] As an alternative, interspinous process decompression is a minimally invasive procedure that builds on the concept that back extension is a seminal factor in the causative chain that instigates neurogenic claudication, the cardinal symptom of lumbar spinal stenosis. This procedure involves the implantation of a standalone interspinous spacer that functions by serving as a lumbar vertebral joint extension blocker to prevent compression of neural elements in extension. ...
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... 4 In studies that directly compared general anesthesia with monitored anesthesia care for the same surgical procedure, mortality was greater and perioperative complications were consistently worse with general anesthesia. [5][6][7] As an alternative, interspinous process decompression is a minimally invasive procedure that builds on the concept that back extension is a seminal factor in the causative chain that instigates neurogenic claudication, the cardinal symptom of lumbar spinal stenosis. This procedure involves the implantation of a standalone interspinous spacer that functions by serving as a lumbar vertebral joint extension blocker to prevent compression of neural elements in extension. ...
Superion® InterSpinous Spacer Treatment of Moderate Spinal Stenosis: 4-year Results
Article
  • May 2017
Objective: To determine the 4-year clinical outcomes in patients with moderate lumbar spinal stenosis treated with minimally-invasive stand-alone interspinous process decompression using the Superion® device. Methods: The 4-year Superion® data were extracted from a randomized, controlled FDA Investigational Device Exemption trial. Patients with intermittent neurogenic claudication relieved with back flexion who failed at least 6 months of nonsurgical management were enrolled. Outcomes included Zurich Claudication Questionnaire (ZCQ) symptom severity (ss), physical function (pf) and patient satisfaction (ps) subdomains, leg and back pain visual analog scale (VAS), and Oswestry Disability Index (ODI). At the 4-year follow-up interval, 89 of the 122 active Superion® patients (73%) provided complete clinical outcome evaluations. Results: Four years after the index procedure, 75 of 89 Superion® patients (84.3%) demonstrated clinical success on at least 2 of 3 ZCQ domains. The individual component responder rates were 83% (74/89), 79% (70/89) and 87% (77/89) for ZCQss, ZCQpf, and ZCQps, 78% (67/86) and 66% (57/86) for leg and back pain VAS, and 62% (55/89) for ODI. Superion® patients also demonstrated percentage improvements over baseline of 41%, 40%, 73%, 69% and 61% for ZCQss, ZCQpf, leg and back pain VAS, and ODI, respectively. Within-group effect sizes were all classified as very large (i.e., > 1.0): 1.49, 1.65, 1.42, 1.12 and 1.46 for ZCQss, ZCQpf, leg and back pain VAS, and ODI, respectively. Conclusions: Minimally-invasive implantation of the Superion® interspinous spacer provides long-term, durable relief of symptoms of intermittent neurogenic claudication for patients with moderate lumbar spinal stenosis.
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Pain control for interstitial cystitis/bladder pain syndrome patients undergoing pelvic reconstructive surgery
Article
  • Aug 2019
Introduction Scant research exists on pain control for interstitial cystitis patients undergoing pelvic reconstructive surgery. Our aim was to compare the perioperative courses in patients with and without interstitial cystitis undergoing pelvic reconstructive surgery performed using primarily monitored anesthesia care with local anesthesia. Methods A retrospective chart review of surgical cases performed at a single site from November 2015 to July 2018 was performed. Joint non-gynecologic cases were excluded. Data including demographics, intraoperative variables, medication requirements, and postoperative courses were abstracted. Chi-square, independent t, and Mann–Whitney U tests were used to compare interstitial cystitis with non-interstitial cystitis patients. Results In total, 65 separate cases met inclusion criteria and were analyzed, with 57 individual subjects. Out of the 65 cases, 33 cases were performed on interstitial cystitis patients. Only 2 of the 33 interstitial cystitis patient cases required general anesthesia. Interstitial cystitis patients did not require higher concentrations of 1% lidocaine with epinephrine (average of 3.8 mg/kg) compared to patients without (2.8 mg/kg). There was no difference between groups in perioperative complications, length of recovery, or postoperative narcotic consumption. Conclusion Perioperative outcomes and pain control do not differ in those with and without interstitial cystitis undergoing pelvic reconstructive surgery. Prolapse surgery can be safely performed on a patient population with a high proportion of chronic pelvic pain using monitored anesthesia care with local anesthesia, without increased morbidity or difficultly with perioperative pain control.
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Safety of Deep Sedation in Patients Undergoing Full-Thickness Skin Graft Harvesting and Skin Graft Reconstruction for Limb Salvage: An Outcome Analysis
Article
  • Nov 2018
Background:: Studies on obtaining donor skin graft using intravenous sedation for patients undergoing major foot surgeries in the same operating room visit have not previously been reported. The objective of this retrospective study is to demonstrate that intravenous sedation in this setting is both adequate and safe in patients undergoing skin graft reconstruction of the lower extremities in which donor skin graft is harvested from the same patient in one operating room visit. Methods:: Medical records of 79 patients who underwent skin graft reconstruction of the lower extremities by one surgeon at the Yale New Haven Health System between November 1, 2008, and July 31, 2014, were reviewed. The patients' demographic characteristics, American Society of Anesthesiologists class, comorbid conditions, intraoperative analgesic administration, estimated blood loss, total operating room time, total postanesthesia care unit time, and postoperative complications within the first 72 hours were reviewed. Results:: This study found minimal blood loss and no postoperative complications, defined as any pulmonary or cardiac events, bleeding, admission to the intensive care unit, or requirement for invasive monitoring, in patients who underwent major foot surgery in conjunction with full-thickness skin graft. Conclusions:: We propose that given the short duration and peripheral nature of the procedures, patients can safely undergo skin graft donor harvesting and skin graft reconstruction procedures with intravenous sedation regardless of American Society of Anesthesiologists class in one operating room visit.
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Identifying Risk Factors for Surgical Site Complications after Laparoscopic Ventral Hernia Repair: Evaluation of the Ventral Hernia Working Group Grading System
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Full-text available
  • Apr 2014
  • Surg Infect
Background: In 2010, the Ventral Hernia Working Group (VHWG) published a grading system to assess the risk of surgical site complications in patients undergoing ventral hernia repair. This study evaluated the predictive value of the VHWG classification for the surgical outcomes of laparoscopic ventral hernia repair (LVHR) and identified independent factors associated with surgical site infection (SSI) and surgical site occurrence (SSO). Methods: A retrospective review was performed of all patients who underwent LVHR over a 10-year period at two institutions. The U.S. Centers for Disease Control and Prevention definition of SSI and the VHWG definition of SSO were used. Univariable analysis was performed using the Student t-test, analysis of variance, chi-square test, or Fisher exact test, as appropriate. Multivariable analysis was used to identify independent factors associated with SSI and SSO. Results: Differences in American Society of Anesthesiologists class, body mass index, diabetes mellitus, chronic obstructive pulmonary disease, tobacco use, hernia type, prior abdominal surgery, prior ventral hernia repair, hernia size, and total infections were identified by grade. There was no difference in SSI or SSO by grade. Multivariable analysis revealed institution and number of prior abdominal operations to be associated with SSI. Institution, prostate disease, and prior ventral hernia repair were associated with SSO. Conclusions: The VHWG classification was unable to predict SSI and SSO and may not be applicable in LVHR. This study identified independent factors associated with SSI and SSO in LVHR. Although further study is warranted to validate these results, the factors presented may be a useful tool to stratify patient risk of SSI and SSO with LVHR.
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A comparison of 12 algorithms for matching on the propensity score
Article
Full-text available
  • Mar 2014
  • STAT MED
Propensity-score matching is increasingly being used to reduce the confounding that can occur in observational studies examining the effects of treatments or interventions on outcomes. We used Monte Carlo simulations to examine the following algorithms for forming matched pairs of treated and untreated subjects: optimal matching, greedy nearest neighbor matching without replacement, and greedy nearest neighbor matching without replacement within specified caliper widths. For each of the latter two algorithms, we examined four different sub-algorithms defined by the order in which treated subjects were selected for matching to an untreated subject: lowest to highest propensity score, highest to lowest propensity score, best match first, and random order. We also examined matching with replacement. We found that (i) nearest neighbor matching induced the same balance in baseline covariates as did optimal matching; (ii) when at least some of the covariates were continuous, caliper matching tended to induce balance on baseline covariates that was at least as good as the other algorithms; (iii) caliper matching tended to result in estimates of treatment effect with less bias compared with optimal and nearest neighbor matching; (iv) optimal and nearest neighbor matching resulted in estimates of treatment effect with negligibly less variability than did caliper matching; (v) caliper matching had amongst the best performance when assessed using mean squared error; (vi) the order in which treated subjects were selected for matching had at most a modest effect on estimation; and (vii) matching with replacement did not have superior performance compared with caliper matching without replacement. © 2013 The Authors. Statistics in Medicine published by John Wiley & Sons, Ltd.
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Standardizing the power of the Hosmer-Lemeshow goodness of fit test in large data sets
Article
Full-text available
  • Jan 2013
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The Hosmer-Lemeshow test is a commonly used procedure for assessing goodness of fit in logistic regression. It has, for example, been widely used for evaluation of risk-scoring models. As with any statistical test, the power increases with sample size; this can be undesirable for goodness of fit tests because in very large data sets, small departures from the proposed model will be considered significant. By considering the dependence of power on the number of groups used in the Hosmer-Lemeshow test, we show how the power may be standardized across different sample sizes in a wide range of models. We provide and confirm mathematical derivations through simulation and analysis of data on 31,713 children from the Collaborative Perinatal Project. We make recommendations on how to choose the number of groups in the Hosmer-Lemeshow test based on sample size and provide example applications of the recommendations. Copyright © 2012 John Wiley & Sons, Ltd.
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Readmission following ventral hernia repair: a model derived from the ACS-NSQIP datasets
Article
  • Dec 2014
Background: Institutions are now incentivized to decrease rates of preventable readmissions. The purpose of this study was to examine readmissions following open ventral hernia repair (VHR), to ultimately create a model to preoperatively identify high-risk patients. Study design: Utilizing the 2011 and 2012 ACS-NSQIP datasets, patients undergoing open VHR were identified by CPT codes. Patients who were readmitted in 2011 within 30 days of the procedure were compared to those who were not with regard to preoperative and operative characteristics. A bootstrap analysis was performed to identify internally validated risk factors to be included in the final logistic regression, which was utilized to create a weighted model to predict the risk of readmission. This model was then validated with VHR patients in 2012. Results: Overall, 10,745 patients were included for model generation. Of these, 850 (7.9%) patients were readmitted within 30 days. The final bootstrap analysis demonstrated that active smoking, ASA ≥ 3, a history of bleeding disorder or anemia, long operative time, inpatient status, and concurrent panniculectomy were all independently associated with readmission following ventral hernia repair. Significant variables were assigned a weighted score, ranging from 1 to 3. Each patient was then placed into one of four cohorts according to their summed score. The internally validated model [Hernia Readmission Risk (HERR) Score] demonstrated that risk increased in a linear fashion, with the highest risk cohort having a 21% risk of 30-day readmission. Conclusions: Perioperative predictors of readmission following VHR include smoking, ASA score, operative magnitude, concurrent panniculectomy, and preoperative anemia and bleeding disorders. The presented model based on these factors can aid in perioperative risk stratification for readmission.
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Wound risk assessment in ventral hernia repair: generation and internal validation of a risk stratification system using the ACS-NSQIP
Article
  • Dec 2014
There is a need for validated risk models to better stratify surgical site occurrences (SSO) following open ventral hernia repair (OVHR). The addition of more generalizable and validated risk models will serve to improve perioperative care in OVHR patients. We reviewed the 2005-2011 ACS-NSQIP databases identifying encounters for OVHR. The dependent outcome measure of interest was SSO, defined as superficial surgical site infection, deep infection, organ space infection, or wound dehiscence. Multivariate logistic regression of independently associated factors was performed and internally validated using a bootstrap technique. A composite risk score, the Hernia Wound Risk Assessment Tool (HW-RAT) was created using weighted beta coefficients. The HW-RAT was compared to existing models from the literature. A total of 60,187 patients who met inclusion criteria were identified in the 2005-2011 ACS-NSQIP databases. The incidence of SSO in the study was 6.2 % (N = 3,732). SSO risk factors were broken down based on rounded risk scores into the following groups: mild, intermediate, moderate, and severe risk. Severe risk factors related to operative time and degree of wound contamination. Moderate risk factors included class III obesity, component separation, dependent functional status, and inpatient hernia surgery. Patient stratification was performed based on total risk score into HW-RAT risk groups 1 through 5 which demonstrated significant discrimination between and across each group (P < 0.01, C-statistic = 0.71) with an incidence of SSO that ranged from 3.3 to 26.5 %. We present an internally validated risk model of SSO in OVHR (HW-RAT), which complements and builds upon current risk models. Prognostic/risk category, level II.
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Analysis of the NSQIP Database in 34541 Patients Undergoing Incisonal/Ventral Hernia Repair
Article
  • Oct 2014
  • PLAST RECONSTR SURG
Background: Patients undergoing incisonal/ventral hernia repair are at risk of developing several postoperative complications particularly venous thromboembolism (VTE) which is a major cause of morbidity and mortality. (1-5) The aim of this study was to assess 30-day postoperative morbidity and mortality of patients undergoing incisional/ventral hernia repair and to determine the association between component separation and VTE. Methods: We reviewed the 2005-2011 ACS-NSQIP databases to identify patients undergoing incisional/ventral hernia repair. Preoperative variables and postoperative outcomes were compared between a component separation group and a non-component separation group. Chi-square tests and Fisher’s exact test were used for categorical variables and t-tests for continuous variables. Logistic regression analysis was performed to determine preoperative predictors for complications in both groups. Results 34,541 patients were included in our study; 501 patients underwent a component separation procedure. A higher rate of wound complications, minor/major morbidity, mortality and return to the operating room (OR) occurred in the component separation group. However, there was no statistically significant difference in deep vein thrombosis/thrombophlebitis and pulmonary embolism rates between the two groups (p=0.780 and p=0.591, respectively). Several risk factors were significantly associated with postoperative complications in both groups. Conclusions Component separation is used for large and complex incisional/ventral hernia repairs to achieve tension-free midline closure. Although it is associated with higher incidence of wound complication, morbidity and mortality, perhaps due to the complexity of the defects, it does contribute to increased VTE rates. This may suggest it improves abdominal wall physiology thereby preventing VTE in these patients.
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Risk factors for 30-day readmission in patients undergoing ventral hernia repair
Article
  • Dec 2013
Background Ventral hernia repair (VHR), an increasingly common procedure, may have a larger impact on healthcare costs than is currently appreciated. Readmissions have the potential to further increase these costs and negatively impact patient outcomes. New national registry data allows for an in-depth look at the predictors and rates of readmission after VHR. Methods The American College of Surgeon’s National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all patients who underwent only an incisional or ventral hernia repair in 2011. Patients who had any concomitant procedure were excluded from the study. Using readmission as the dependent variable, a multivariate logistic regression model was created to identify independent predictors of readmission. Results Ventral hernia repair had a 4.9% thirty-day readmission rate in 2011. Deep/incisional (12.6%) and superficial site infections (10.5%) were the most common wound complications seen in readmitted patients (both p<0.001), while sepsis/septic shock (10.14%, p<0.001) was the most common systemic complication. Higher-class body mass index is not associated with readmission (p=0.320). Smoking and chronic obstructive pulmonary disease function as predictors of readmission independently from their association with complications (OR 1.3, 95% CI 1.1-1.6; OR 1.6, 95% CI 1.1-2.3, respectively). Operative factors such as the use of mesh (OR 1.3, 95% CI 0.995-1.7) or laparoscopy (OR 1.2, 95% CI 0.96-1.6) do not increase likelihood of readmission. Conclusions There is room for improvement in VHR readmission rates. Though complications are the main driver of readmission, surgeons must be aware of the comorbidities that independently increase odds of readmission even when a complication does not occur.
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Hernia Complexity Predicts Operative Time and Length of Stay in Laparoscopic Ventral Hernia Repairs
Article
  • Feb 2013
  • J SURG RES
Laparoscopic ventral hernia repair (LVHR) is associated with shorter hospitalization and lower complication rates compared to open ventral hernia repair. We sought to determine if hernia-related factors, such as defect size and re-operative status correlate with postoperative complications, operative times and length of stay (LOS). The study is a retrospective review of 30-day perioperative outcomes following LVHR in 91 patients who underwent surgery at a single institution from August 2009 through June 2012. A single surgeon performed all procedures. Indications for surgery were recurrent incisional hernia in 33 % of patients and primary incisional or ventral abdominal hernias in the rest. Coated polyester mesh with an average size of 348 cm(2) (±214; range 113-1,036) was used. Mean operative time was 132 min (±66.1; range 53-412). The mean LOS was 4.0 days (±3.5; range 1-22). Complications occurred in 13 patients for overall morbidity of 16.5 % and no mortality. There was one recurrence in 30 days (1.1 %). Patients who had a surgery >120 min or a LOS >1 day were statistically more likely to have multiple hernias, larger defect sizes (>40 cm(2)), larger mesh sizes (>300 cm(2)) or a history of recurrent hernia (P < 0.05). No other clinical or demographic variable evaluated in this study correlated with operative time or LOS. LVHR is safe with a low incidence of perioperative complications. Patients with multiple, larger and recurrent hernias have longer operative times and LOS. This information can be used to guide preoperative planning for the patient, surgeon and treating institution.
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Umbilical Hernia Repair in Patients With Signs of Portal Hypertension
Article
  • Sep 2012
Objectives To compare the outcomes of umbilical hernia repair in patients with and without signs of portal hypertension, such as esophageal varices or ascites; to assess the effect of emergency surgery on complication rates; and to identify predictors of postoperative mortality. Design Database search from January 1, 2005, through December 31, 2009. Setting North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program initiative. Patients We studied patients who underwent umbilical hernia repair. Those with congestive heart failure, disseminated malignant tumor, or chronic renal failure while undergoing dialysis were excluded. Main Outcome Measures Preoperative variables and perioperative course were analyzed. Main outcome measures were morbidity and mortality after umbilical hernia repair. Results A total of 390 patients with ascites and/or esophageal varices formed the study group, and the remaining 22 952 patients formed the control group. The overall morbidity and mortality rates for the study group were 13.1% and 5.1%, whereas these rates were 3.9% and 0.1% for the control group, respectively (P < .001). For the study group, the mortality after elective repair among patients with a model for end-stage liver disease (MELD) score greater than 15 was 11.1% compared with 1.3% in patients with a MELD score of 15 or less. The patients with ascites and/or esophageal varices underwent emergency surgery more frequently than the control group (37.7% vs 4.9%; P < .001). Emergency surgery for the study group was associated with a higher morbidity than elective surgery (20.8% vs 8.3%; P < .001) but not a significantly higher mortality (7.4% vs 3.7%; P = .11). However, logistic regression analysis showed that age older than 65 years, MELD score higher than 15, albumin level less than 3.0 g/dL (to convert to grams per liter, multiply by 10), and sepsis at presentation were more predictive of postoperative mortality. Conclusions Umbilical hernia repair in the presence of ascites and/or esophageal varices is associated with significant postoperative complication rates. Emergency surgery is associated with higher morbidity rates but not significantly higher mortality rates. Elective repair of umbilical hernia should be avoided for those with adverse predictors, such as age older than 65 years, MELD score higher than 15, and albumin level less than 3.0 g/dL.
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