Publications by authors named "Clayton C Petro"

31 Publications

Does PROVE-IT Really Prove Anything of Value?-Reply.

JAMA Surg 2021 Apr 28. Epub 2021 Apr 28.

Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, The Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jamasurg.2021.0957DOI Listing
April 2021

Can Hernia Sac to Abdominal Cavity Volume Ratio Predict Fascial Closure Rate for Large Ventral Hernia? Reliability of the Tanaka Score.

J Am Coll Surg 2021 Apr 5. Epub 2021 Apr 5.

Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH.

Background: The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias.

Methods: Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values).

Results: A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049).

Conclusions: In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.03.009DOI Listing
April 2021

The Efficacy of Liposomal Bupivacaine On Postoperative Pain Following Abdominal Wall Reconstruction: A Randomized, Double-Blind, Placebo-Controlled Trial.

Ann Surg 2020 Dec 2. Epub 2020 Dec 2.

Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH 44195.

Objective: To study the efficacy of liposomal bupivacaine on postoperative opioid requirement and pain following abdominal wall reconstruction.

Summary Background Data: Despite the widespread use of liposomal bupivacaine in transversus abdominis plane block, there is inadequate evidence demonstrating its efficacy in open abdominal wall reconstruction. We hypothesized that liposomal bupivacaine plane block would result in decreased opioid requirements compared to placebo in the first 72 hours after surgery.

Methods: This was a single-center double-blind, placebo-controlled prospective study conducted between July 2018 and November 2019. Adult patients (at least 18 years of age) undergoing open, elective, ventral hernia repairs with mesh placed in the retromuscular position were enrolled. Patients were randomized to surgeon-performed transversus abdominis plane block with liposomal bupivacaine, simple bupivacaine, or normal saline (placebo). The main outcome was opioid requirements in the first 72 hours after surgery. Secondary outcomes included total inpatient opioid use, pain scores determined using a 100 mm visual analog scale, length of hospital stay, and patient-reported quality of life.

Results: Of the 164 patients that were included in the analysis, 57 patients received liposomal bupivacaine, 55 patients received simple bupivacaine and 52 received placebo. There were no differences in the total opioid used in the first 72 hours after surgery as measured by morphine milligram equivalents when liposomal bupivacaine was compared to simple bupivacaine and placebo (325 ± 225 vs. 350 ± 284 vs. 310 ± 272, respectively, p = 0.725). Similarly, there were no differences in total inpatient opioid use, pain scores, length of stay, and patient-reported quality of life.

Conclusions: There are no apparent clinical benefits to using liposomal bupivacaine transversus abdominis plane block when compared to simple bupivacaine and placebo for open abdominal wall reconstruction.
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http://dx.doi.org/10.1097/SLA.0000000000004424DOI Listing
December 2020

Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh: The PROVE-IT Randomized Clinical Trial.

JAMA Surg 2021 Jan;156(1):22-29

Cleveland Clinic Center for Abdominal Core Health, Digestive Diseases and Surgery Institute, The Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio.

Importance: Despite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach.

Objective: To determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain.

Design, Setting, And Participants: A registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair.

Interventions: Patients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh.

Main Outcomes And Measures: The trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost.

Results: Seventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness enterotomies or unplanned reoperations. There were no significant differences in NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically, median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61). Likewise, postoperative Patient-Reported Outcomes Measurement Information System 3a and hernia-specific quality-of-life scores, as well as length of stay and complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13 vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85; P < .001).

Conclusions And Relevance: Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable outcomes. The increased operative time and proportional cost of the robotic approach are not offset by a measurable clinical benefit.

Trial Registration: ClinicalTrials.gov Identifier: NCT03283982.
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http://dx.doi.org/10.1001/jamasurg.2020.4569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578919PMC
January 2021

Registry-Based Randomized Controlled Trials: A New Paradigm for Surgical Research.

J Surg Res 2020 11 30;255:428-435. Epub 2020 Jun 30.

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: Randomized controlled trials (RCTs) are the gold standard to establish evidence for surgical practice but can be hindered by high costs, complexity, and time requirements. Recently, observational registries have been leveraged as platforms for clinical trials to address these limitations, though few registry-based surgical RCTs have been conducted. Here, we present our group's approach to surgical registry-based RCTs and early results.

Materials And Methods: To facilitate these trials, we focused on registry integration into surgeons' workflows, routine collection of patient-reported outcomes at clinic visits, and pragmatic trial design featuring broad inclusion criteria and standard of care follow-up. These features maximize generalizability and facilitate follow-up by minimizing visits and tests outside of normal practice.

Results: Since 2017, our group has completed enrollment in 4 registry-based RCTs with another 5 trials ongoing. Of these, 4 trials have been multicenter. Over 1000 patients have been enrolled in these studies, with follow-up rates of 90% or greater. Most of these trials are on track to complete enrollment in approximately 2 y from their start date. Beyond salary support, resource utilization is low. None of our trials has been terminated due to lack of resources or futility.

Conclusions: Registry-based RCTs allow for efficient conduct of pragmatic surgical trials. Thoughtful study design, registry integration into surgeons' routines, and a team culture embracing research are paramount. We believe registry-based trials are the future of affordable, high-level, prospective surgical research.
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http://dx.doi.org/10.1016/j.jss.2020.05.069DOI Listing
November 2020

Patient-reported opioid use after open abdominal wall reconstruction: How low can we go?

Surgery 2020 07 2;168(1):141-146. Epub 2020 Jun 2.

Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH.

Background: Little data exist to inform discharge opioid prescribing for patients undergoing abdominal wall reconstruction. The aim of this study was to evaluate postoperative, patient-reported opioid use after abdominal wall reconstruction. We hypothesized that the majority of patients undergoing open abdominal wall reconstruction would require between 16 and 30 opioid tablets after discharge.

Methods: Postoperative, patient-reported opioid use was collected prospectively for all patients undergoing elective, open abdominal wall reconstruction at a single high-volume center. All opioid medications were converted to an equivalent number of 5 mg oxycodone tablets. The primary outcome was the total number of opioid tablets taken within 30 days of hospital discharge after abdominal wall reconstruction.

Results: Ninety-eight patients were included. Median hernia width was 15 cm (interquartile range 12-19), 42% were recurrences, and all underwent transversus abdominis release. At the 30-day follow-up visit, 24% reported no postdischarge opioid use, and 76% reported taking 15 tablets or fewer. Of the 23 patients who used no opioids on the day before discharge, 16 (70%) reported taking no opioids after discharge.

Conclusion: Most patients reported taking fewer opioid tablets than prescribed and fewer than our hypothesis within 30 days of abdominal wall reconstruction. Opioid use on the day before discharge may allow for prognostication of outpatient opioid requirements to prevent overprescribing.
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http://dx.doi.org/10.1016/j.surg.2020.04.008DOI Listing
July 2020

What Surgeons Need to Know About the Bouffant Scandal.

JAMA Surg 2019 11;154(11):989-990

Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jamasurg.2019.2107DOI Listing
November 2019

Impact of modifiable comorbidities on 30-day wound morbidity after open incisional hernia repair.

Surgery 2019 07 13;166(1):94-101. Epub 2019 May 13.

Center for Abdominal Core Health, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, OH.

Background: We aimed to assess the impact of modifiable comorbidities-obesity, diabetes, and smoking-and their aggregate effect on wound complications after incisional hernia repair.

Methods: Data on all open, elective, incisional hernia repair with permanent synthetic mesh in clean wounds were collected from the Americas Hernia Society Quality Collaborative and reviewed. Three groups were defined: those with 0, 1, or 2+ modifiable comorbidities, with associations described for each specific comorbid condition. Primary outcomes included surgical site occurrences, surgical site infections, and surgical site occurrences requiring procedural intervention.

Results: A total of 3,908 subjects met the inclusion criteria. Mean hernia width was 9.6 ± 6.5 cm, mean body mass index was 32.1 ± 6.6 kg/m, 21% of patients had diabetes, and 9% were smokers. Of those, 31% had no modifiable comorbidities, 49% had 1 modifiable comorbidity, and 20% had 2+ modifiable comorbidities. Compared with having no modifiable comorbidities, having 1 modifiable comorbidity, or 2+ modifiable comorbidities significantly increased the odds of a surgical site occurrence (odds ratios 1.33 and 1.61, respectively). However, only patients with 2+ modifiable comorbidities had significantly increased odds of surgical site occurrences requiring procedural intervention compared with no modifiable comorbidities and 1 modifiable comorbidity (odds ratios 2.02 and 1.65, respectively). Patients with all 3 comorbidities had a two-fold increase in odds for all wound morbidity, followed similarly by obese patients with diabetes.

Conclusion: The presence of any number of comorbidities (1 modifiable comorbidity or 2+ modifiable comorbidities) increases the odds for wound events. However, having multiple comorbidities was associated with more procedural interventions for wound management. This was most evident in patients with all 3 comorbidities, and, in obese diabetics, underscoring the importance of preoperative counseling on expected recovery in such patients.
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http://dx.doi.org/10.1016/j.surg.2019.03.011DOI Listing
July 2019

History of surgical site infection increases the odds for a new infection after open incisional hernia repair.

Surgery 2019 07 23;166(1):88-93. Epub 2019 Mar 23.

Center for Abdominal Core Health, Department of General Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, OH.

Background: It is unclear whether a history of surgical site infection is associated with developing a new infection after subsequent operations. We aim to investigate the impact of an earlier abdominal wall surgical site infection on future 30-day infectious wound complications after open incisional hernia repair with mesh.

Methods: Patients undergoing elective, clean open incisional hernia repair were identified within the Americas Hernia Society Quality Collaborative and were divided into those with and without a history of a surgical site infection. Predictors of a surgical site infection and a surgical site infection requiring a procedural intervention were investigated using logistic regression and propensity-matched analysis. A subgroup analysis was done to investigate whether an earlier methicillin-resistant Staphylococcus aureus surgical site infection specifically increases odds for infectious complications.

Results: Of 3,168 identified patients, 589 had a history of a surgical site infection and experienced higher rates of postoperative surgical site infection (6.5% vs 2.9%, P < .001) and surgical site infections requiring procedural intervention (5.3% vs 1.9%, P < .001). After adjusting for identified confounders, a previous surgical site infection was independently associated with developing another surgical site infection (odds ratio 2.04, 95% confidence interval 1.32-3.10, P < .001) and a surgical site infection requiring procedural intervention (odds ratio 2.2, 95% confidence interval 1.35-3.55, P = .001). Propensity-matched analysis controlling for additional confounders confirmed the association of an earlier surgical site infection with the outcomes of interest (odds ratio 2.1 and 2.8, respectively). A subgroup analysis found that an earlier methicillin-resistant Staphylococcus aureus infection specifically did not incur higher rates of surgical site infection when compared with non-methicillin-resistant Staphylococcus aureus pathogens.

Conclusion: History of a surgical site infection increases the odds for new infectious complications after open incisional hernia repair in a clean wound. Investigations on perioperative interventions to ameliorate the negative impact of such association are necessary.
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http://dx.doi.org/10.1016/j.surg.2019.01.032DOI Listing
July 2019

Prevalence of posttraumatic stress disorder (PTSD) in patients with an incisional hernia.

Am J Surg 2019 11 7;218(5):934-939. Epub 2019 Mar 7.

Comprehensive Hernia Center, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.

Background: We investigate the prevalence of PTSD in patients with an incisional hernia presenting for evaluation at our institution.

Methods: Study patients were screened for PTSD using the PCL-5 checklist for DSM-5. Patient-reported quality of life and pain scores were assessed using validated tools (HerQLes and PROMIS Pain Intensity 3a survey).

Results: The prevalence of PTSD in 131 patients was 32.1% [95% CI 24%-40%]. Patients screening positive (PTSD+) reported lower quality of life scores on HerQles (17.3 ± 14.3 vs. 47.7 ± 29.6, P < 0.001), and higher pain scores on the PROMIS scale (54.2 ± 9.1 vs. 44.2 ± 10, p < 0.001). PTSD + patients also reported significantly higher numbers of previous hernia repairs and abdominal operations, as well as a higher rate of a history of an open abdomen.

Conclusion: Our study found a significant prevalence of positive screening for PTSD in patients seeking consultation regarding an incisional hernia. We have begun routine preoperative evaluations by a behavioral medicine specialist to address some of these complex issues in high-risk patients. Other high volume hernia programs caring for this challenging patient population should consider such assessments.
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http://dx.doi.org/10.1016/j.amjsurg.2019.03.002DOI Listing
November 2019

Response to: Active smoking really matters before ventral hernia repair.

Surgery 2019 04 8;165(4):853-858. Epub 2019 Feb 8.

Cleveland Clinic, Department of General Surgery, Cleveland Clinic Comprehensive Hernia Center, Cleveland, OH.

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http://dx.doi.org/10.1016/j.surg.2018.12.013DOI Listing
April 2019

The effect of increasing body mass index on wound complications in open ventral hernia repair with mesh.

Am J Surg 2019 09 25;218(3):560-566. Epub 2019 Jan 25.

Comprehensive Hernia Center Department of Surgery, University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Boulevard, Madison, WI, 53718, USA.

Background: There is a paucity of data delineating the relationship between body mass index (BMI) and wound complications. We investigated the association between BMI and wound morbidity following open ventral hernia repair with mesh (OVHR).

Design: Patients undergoing elective OVHR were identified within the Americas Hernia Society Quality Collaborative. Multivariate logistic regression identified predictors of 30-day surgical site infection (SSI) and surgical site occurrences requiring procedural intervention (SSOPI). BMI was treated as a continuous variable in the models.

Results: 8949 patients were included (median age 58, median BMI 31.3 kg/m, median defect width of 7 cm). Repairs typically included synthetic mesh (89%), placed as a sublay (70%). SSI rate was 4.5% and SSOPI was 6.7%. BMI was associated with increased relative log-odds for SSI (p = 0.01) and SSOPI (<0.0001), with a proportional increase in relative log-odds for complications according to escalations in BMI.

Conclusion: Escalating BMI progressively increases relative log-odds for SSI and SSOPI after OVHR. Further studies are necessary to determine whether preoperative weight loss can reduce the impact of this association.
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http://dx.doi.org/10.1016/j.amjsurg.2019.01.022DOI Listing
September 2019

Hernia repair in patients with chronic liver disease - A 15-year single-center experience.

Am J Surg 2019 01 16;217(1):59-65. Epub 2018 Oct 16.

Comprehensive Hernia Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: Elective hernia repairs in chronic liver disease (CLD) patients are often avoided due to the fear of hepatic decompensation and mortality, leaving the patient susceptible to an emergent presentation.

Methods: CLD patients undergoing ventral or inguinal hernia repair in emergent and non-emergent settings at our institution (2001-2015) were analyzed. Predictors of 30-day morbidity and mortality (M&M) were determined using univariate analysis and multivariate logistic regression.

Results: A total of 186 non-emergent repairs identified acceptable rates of M&M (27%) and 90-day mortality (3.7%, 0/21 for MELD≥15). Meanwhile, 67 emergent repairs had higher rates of M&M (60%) and 90-day mortality (10%; 25% for MELD≥15). M&M was associated with elevated MELD scores in emergent cases (14 ± 6 vs 11 ± 4; p = 0.01) and intraoperative drain placement in non-emergent cases (OR1.31,p < 0.01).

Conclusion: In patients with advanced CLD, non-emergent hernia repairs carry acceptable rates of M&M, while emergent repairs have increased M&M rates associated with higher MELD scores.
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http://dx.doi.org/10.1016/j.amjsurg.2018.10.020DOI Listing
January 2019

Does active smoking really matter before ventral hernia repair? An AHSQC analysis.

Surgery 2019 02 13;165(2):406-411. Epub 2018 Sep 13.

Cleveland Clinic Department of General Surgery, Cleveland Clinic Comprehensive Hernia Center, OH.

Background: Many studies implicate active smoking as a risk factor for postoperative wound complications and all 30-day morbidity, but the definitions of inclusion and exclusion criteria as well as outcome parameters are inconsistent. Critically, the ability of large databases and meta-analyses to generate statistically significant associations of active smoking with morbidity do not address whether those relationships are actually clinically meaningful. We investigated this relationship after open ventral hernia repair.

Study Design: Patients undergoing elective open ventral hernia repair in clean wounds with 30-day follow-up were extracted from the Americas Hernia Society Quality Collaborative. Current smokers (within 30 days of surgery) were 1:1 propensity matched to patients who had never smoked based on demographics, comorbidities, and operative characteristics. Wound complications and all 30-day morbidity were assessed.

Results: After matching 418 current smokers to 418 patients who had never smoked, the groups were similar with the exception of minor differences in body mass index (31.4 vs 33.3, P < .001) and incidence of chronic obstructive pulmonary disease (18% vs 6%, P < .001). Rates of surgical site occurrence were greater in active smokers (12.0% vs 7.4%, P = .03) driven by increased rates of wound cellulitis (2.4% vs 1.2%) and seroma (5.5% vs 1.2%); however, rates of surgical site infection (4.1 vs 4.1, P = .98), surgical site occurrences requiring a procedural intervention (6.2% vs 5.0%, P = .43), reoperation (1.9% vs 1.2%, P = .39), and all 30-day morbidity (7.5 vs 6.6, P = .60) were not significantly increased in active smokers. There were no instances of mesh excision.

Conclusion: Active smoking prior to elective clean OVHR is associated with clinically insignificant differences in wound morbidity. Surgeons allowing perioperative smoking should monitor their outcomes to assure these findings are replicable in their own practice.
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http://dx.doi.org/10.1016/j.surg.2018.07.039DOI Listing
February 2019

Emergent groin hernia repair: A single center 10-year experience.

Surgery 2019 02 12;165(2):398-405. Epub 2018 Sep 12.

Comprehensive Hernia Center, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH.

Background: Emergent groin hernia repair can be a challenging clinical scenario. We aimed to evaluate the perioperative and long-term outcomes of emergent groin hernia repair at our institution over the last 10 years, with particular interest in surgical approach and mesh use for such cases.

Methods: Adult patients who underwent emergent groin hernia repair from 2005-2015 were retrospectively reviewed. Outcomes included surgical site infections, perioperative complications, readmissions, reoperations, mortality, and long-term hernia recurrence. Predictors of surgical site infection and perioperative complications were investigated using multivariate logistic regression.

Results: A total of 257 patients met inclusion criteria (62% males, median age 72). Hernias were most often indirect inguinal (40.9%) and femoral (33.5%), and 45 cases (17.5%) required a bowel resection. Laparoscopic repair was performed in 3 patients (1.2%). Synthetic mesh was placed in 70% of repairs but in only 15% of cases associated with a bowel resection. The medical complications rate was 16.7%; 3.6% had an surgical site infection, and 30-day mortality rate was 3.1%. Older age (odds ratio 1.05) and gross contamination (odds ratio 4.3) were independently associated with complications. Mesh use was not associated with surgical site infection (odds ratio 1.83, P = .49) or perioperative complications (odds ratio 1.02, P = .96). With a median follow-up of 43 months, there were no mesh infections and recurrence rates were similar between mesh and tissue repairs (6.3% vs 6.8%, P = .91).

Conclusion: Emergent groin hernia repair has high rates of morbidity and mortality most closely associated with increasing age and the presence of contamination. Although mesh use appears to be well tolerated when used in the absence of contamination during emergent groin hernia repair, recurrence rates were similar to tissue repairs.
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http://dx.doi.org/10.1016/j.surg.2018.08.001DOI Listing
February 2019

A Current Review of Long-Acting Resorbable Meshes in Abdominal Wall Reconstruction.

Plast Reconstr Surg 2018 09;142(3 Suppl):84S-91S

From the Cleveland Clinic.

Concern for chronic infection of a permanent synthetic material in contaminated and "high risk" ventral hernia repairs has led to the development and dissemination of slowly resorbable biosynthetic materials at a lower cost compared with biologic mesh counterparts. Here, we review the preclinical and clinical data available for each long-acting resorbable mesh, with a candid comparison to biologic and synthetic equivalents.
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http://dx.doi.org/10.1097/PRS.0000000000004859DOI Listing
September 2018

Fight or Flight: The Role of Staged Approaches to Complex Abdominal Wall Reconstruction.

Plast Reconstr Surg 2018 09;142(3 Suppl):38S-44S

From the Cleveland Clinic.

Surgeons' comfort with abdominal wall reconstruction techniques and use of prosthetic reinforcement in contaminated fields has made repair of complex hernias during concomitant procedures an attractive endeavor. Understanding the precarious nature of this practice, tenets of thoughtful patient selection, and principles of repair that mitigate morbidity can allow for an educated thought process when deciding whether or not to pursue concomitant abdominal wall reconstruction.
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http://dx.doi.org/10.1097/PRS.0000000000004847DOI Listing
September 2018

Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort.

Surg Endosc 2019 02 9;33(2):475-485. Epub 2018 Jul 9.

Comprehensive Hernia Center, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.

Background: The advent of newer second-line medical therapies (SLMT) for immune thrombocytopenia (ITP) has contributed to decreased rates of splenectomy, following a trend to avoid or delay surgery. We aimed to characterize the long-term outcomes of laparoscopic splenectomy (LS) for ITP at our institution, examining differences in LS efficiency when performed before or after SLMTs.

Methods: Adults with primary ITP who underwent LS between 2002 and 2016 were identified. Retrospective review of electronic medical records was supplemented with telephone interviews. Treatment response was defined according to current guidelines as complete responders (CR), responders (R), and non-responders (NR). Kaplan-Meier estimates assessed relapse-free rates, and predictors of long-term response were investigated using logistic regression.

Results: 109 patients met inclusion criteria, from which 42% were treated with an SLMT before referral to LS. LS was completed in all cases, with no conversions or intraoperative complications. The perioperative morbidity was 7.3%, including 3 deep vein and 2 portal vein thrombosis, one reoperation for bleeding, and no mortalities. Splenectomy was initially effective in 99 patients (CR + R = 90.8%), and 10 patients were NR. At a median 62-month follow-up, 25 patients relapsed, resulting in a 68% CR + R rate. Proportion of CR + R was similar in patients who previously received SLMT and those who did not (61 vs. 76.7%, p = 0.08). CR + R patients were younger (45 vs. 53, p = 0.03), had higher preoperative platelet counts (36 vs. 19, p = 0.01), and experienced a higher increment in platelet counts during hospital stay (117 vs. 38, p < 0.001) as well as 30-days postoperatively (329 vs. 124, p < 0.001). Only a robust response in platelet count at 30-days postoperatively was independently associated with long-term response (OR 1.005, p = 0.006).

Conclusion: LS was curative in 68% of patients, with no statistically significant difference when performed before or after SLMTs. Outcomes remain challenging to predict preoperatively, with only a robust increase in platelet counts on short term being associated with long-term response.
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http://dx.doi.org/10.1007/s00464-018-6321-yDOI Listing
February 2019

Preoperative Planning and Patient Optimization.

Surg Clin North Am 2018 Jun 4;98(3):483-497. Epub 2018 Apr 4.

Department of Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Electronic address:

This article reviews the literature that supports routine expectations for smoking cessation; weight loss; diabetic, nutritional, or metabolic optimization; and decolonization techniques before ventral hernia repair. These methods diminish postoperative complications. In an era of value-centric care, an upfront investment in patient optimization can improve the quality of the repair by reducing wound morbidity and hernia recurrence, naturally translating to a reduction in cost. The adoption of these practices and further study aimed at identifying other effective optimization techniques are encouraged.
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http://dx.doi.org/10.1016/j.suc.2018.01.005DOI Listing
June 2018

Using Modified Frailty Index to Predict Safe Discharge Within 48 Hours of Ileostomy Closure.

Dis Colon Rectum 2017 Jan;60(1):76-80

1 Department of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio 2 Department of Surgical Oncology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt 3 Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery.

Objective: The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure.

Design: This was a retrospective review.

Settings: The study was conducted at a tertiary referral center.

Patients: Patients who underwent ileostomy closure (2006-2015) were stratified into early (≤48 hours) and late discharge groups.

Main Outcome Measures: The Modified Frailty Index, morbidity, and readmission rates were measured.

Results: A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ≤1 and ≤2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of <1, and 5.9% for a Modified Frailty Index score of <2, for which there was not an association based on univariate logistic regression (Modified Frailty Index = 0, p = 0.13; <1, p = 0.55; <2, p = 0.53).

Limitations: The study was limited by nature of being a retrospective review.

Conclusions: Patients undergoing ileostomy closure with a Modified Frailty Index score of 0 are associated with higher rates of discharge within 48 hours of ileostomy closure surgery than those with a higher Modified Frailty Index, without higher readmission rates. This information can be helpful to better manage patient and resource use expectations for the duration of inpatient recovery.
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http://dx.doi.org/10.1097/DCR.0000000000000722DOI Listing
January 2017

Development of a novel murine model for treatment of infected mesh scenarios.

Surg Endosc 2017 02 28;31(2):922-927. Epub 2016 Jun 28.

Department of Surgery, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, OH, 44106, USA.

Background: Indications regarding hernia repair after removal of previously infected prostheses remain unclear. Patients may receive staged primary repair or single-stage reconstructions, neither of which may be ideal. Although animal models have simulated contamination by direct inoculation of implants with bacteria, there remains a paucity of literature, which simulates a field following mesh infection and removal. We aimed to develop a murine model to mimic this complex scenario to allow for further testing of various implants.

Methods: Thirty-six female CL57BL/6J mice underwent implantation of a 0.7 × 0.7 cm polyester mesh in the dorsal subcutaneous position. Wounds were closed and inoculated with 100 µL containing 1 × 10 CFU of GFP-labeled MSSA. After 2 weeks, the infected mesh was removed and the cavity was copiously irrigated with saline. Mice were split into four groups: with three groups receiving new polyester, polypropylene, and porcine mesh and remaining as non-mesh controls. Mice were survived for another 2 weeks and underwent necropsy. Gross infection was evaluated at 2 and 4 weeks. Tissue homogenization and direct plating to recover GFP MSSA was completed at 4 weeks.

Results: At 2 weeks, all mice were noted to have gross mesh infection. One animal died due to overwhelming infection and wound breakdown. At 4 weeks, 5/6 (83 %) control mice who did not have a second mesh implantation had full clearance of their wounds. In contrast, 9/10 (90 %) mice with re-implantation of polypropylene were noted to have pus and recovery of GFP MSSA on plating. This was also observed in 100 % of mice with polyester and porcine mesh.

Conclusion: Our novel murine model demonstrates that mesh re-implantation after infected mesh removal results in infection of the newly placed prosthesis, regardless of the material characteristic or type. This model lays foundation for development and investigation of implants for treatment strategies following infected mesh removal.
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http://dx.doi.org/10.1007/s00464-016-5056-xDOI Listing
February 2017

An in vivo analysis of Miromesh--a novel porcine liver prosthetic created by perfusion decellularization.

J Surg Res 2016 Mar 20;201(1):29-37. Epub 2015 Oct 20.

Department of General Surgery, Cleveland Clinic Comprehensive Hernia Center, Cleveland Clinic, Cleveland, Ohio.

Background: Bioprosthetics derived from human or porcine dermis and intestinal submucosa have dense, homogenous, aporous collagen structures that potentially limit cellular penetration, undermining the theoretical benefit of a "natural" collagen scaffold. We hypothesized that Miromesh-a novel prosthetic derived from porcine liver by perfusion decellularization-provides a more optimal matrix for tissue ingrowth.

Methods: Thirty rats underwent survival surgery that constituted the creation of a 4 × 1 cm abdominal defect and simultaneous bridged repair. Twenty rats were bridged with Miromesh, and 10 rats were bridged with non-cross-linked porcine dermis (Strattice). Ten Miromesh and all 10 Strattice were rinsed in vancomycin solution and inoculated with 10(4) colony-forming units of green fluorescent protein-labeled Staphylococcus aureus (GFP-SA) after implantation. Ten Miromesh controls were neither soaked nor inoculated. No animals received systemic antibiotics. All animals were euthanized at 90 d and underwent an examination of their gross appearance before being sectioned for quantitative bacterial culture and histologic grading. A pathologist scored specimens (0-4) for cellular infiltration, acute inflammation, chronic inflammation, granulation tissue, foreign body reaction, and fibrous capsule formation.

Results: All but one rat repaired with Strattice survived until the 90-d euthanization. All quantitative bacterial cultures for inoculated specimens were negative for GFP-SA. Of nine Strattice explants, none received a cellular infiltration score >0, consistent with a poor tissue-mesh interface observed grossly. Of 10 Miromesh explants also inoculated with GFP-SA, seven of 10 demonstrated cellular infiltration with an average score of +2.7 ± 0.8, whereas sterile Miromesh implants received an average score of 0.8 ± 1.0. Two inoculated Miromesh implants demonstrated acute inflammation and infection on histology.

Conclusions: A prosthetic generated from porcine liver by perfusion decellularization provides a matrix for superior cellular infiltration compared with non-cross-linked porcine dermis.
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http://dx.doi.org/10.1016/j.jss.2015.10.009DOI Listing
March 2016

Risk factors for wound morbidity after open retromuscular (sublay) hernia repair.

Surgery 2015 Dec 20;158(6):1658-68. Epub 2015 Jun 20.

Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH. Electronic address:

Background: Retrorectus repairs (RR) of abdominal wall hernias are growing in popularity, yet wound morbidity and predictors in this context have been characterized poorly. Models aimed at predicting wound morbidity typically do not control for technique and/or location of mesh. Our aim was to describe wound morbidity and risk factors specifically in the context of RR hernia repair. Our hypothesis was that the incidence of wound morbidity with mesh sublay would be less than predicted by a model that does not control for mesh position.

Methods: Consecutive RR hernia repairs with at least a 90-day follow-up were identified in our prospective database and analyzed. The primary outcome measures were the incidence of surgical-site occurrence (SSO) and surgical-site infection (SSI) via modern, standardized definitions. For predictors of SSO, statistical analysis was performed with univariate analysis, χ(2), and logistic regression as well as multivariate regression.

Results: A total of 306 patients met the inclusion criteria. Eighty-four SSOs identified in 72 (23.5%) patients included 48 (15.7%) SSIs, 14 (4.6%) instances of wound cellulitis, 12 (3.9%) skin dehiscences, 6 (2.0%) seromas, and 4 (1.3%) hematomas but no instances of mesh excision or fistula formation. Treatment entailed antibiotics alone in 30 patients, 14 bedside drainage procedures, 9 radiographically assisted drainage procedures, and 10 returns to the operating room for debridement. After multivariate analysis, diabetes (OR 2.41), hernia width >20 cm (OR 2.49), and use of biologic mesh (OR 2.93) were statistically associated with the development of a SSO (P < .05). Notably, the mere presence of contamination was not independently associated with wound morbidity (OR 1.83, P = .11). SSO and SSI rates anticipated by a recent risk prediction model were 50-80% and 17-83%, respectively, compared with our actual rates of 20-46% and 7-32%.

Conclusion: Based on a large cohort of patients, we identified factors contributing to SSOs specifically for RR hernia repairs. Paradoxically, biologic mesh was an independent predictor of wound morbidity. The development of clinically important mesh complications and rates of wound morbidity less than anticipated by recent predictive models suggest that the retromuscular (sublay) mesh position may be more advantageous.
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http://dx.doi.org/10.1016/j.surg.2015.05.003DOI Listing
December 2015

Permissible Intraabdominal Hypertension following Complex Abdominal Wall Reconstruction.

Plast Reconstr Surg 2015 Oct;136(4):868-881

Cleveland, Ohio From the Case Comprehensive Hernia Center and the Department of Anesthesiology and Perioperative Medicine, University Hospitals Case Medical Center.

Background: Repair of hernias with loss of domain can lead to elevated intraabdominal pressure. The authors aimed to characterize the effects of elective hernia repair on intraabdominal pressure, as well as its predictors and association with negative outcomes.

Methods: Patients undergoing elective hernia repair requiring myofascial release had intraabdominal and pulmonary plateau pressures measured preoperatively, postoperatively, and on the morning of the first postoperative day. Loss of domain was measured by preoperative computed tomography. Outcome measures included predictors of an increase in plateau pressure, respiratory complications, and acute kidney injury.

Results: Following 50 consecutive cases, diagnoses of intraabdominal hypertension (92 percent), abdominal compartment syndrome (16 percent), and abdominal perfusion pressure less than 60 mmHg (24 percent) were determined. Changes in intraabdominal pressure (preoperative, 12.7 ± 4.0 mmHg; postoperative, 18.2 ± 5.4 mmHg; postoperative day 1, 12.9 ± 5.2 mmHg) and abdominal perfusion pressure (preoperative, 74.7 ± 15.7; postoperative, 70.0 ± 14.4; postoperative day 1, 74.9 ± 11.6 mmHg) consistently resolved by postoperative day 1, and were not associated with respiratory complications or acute kidney injury. Patients who remained intubated postoperatively for an elevation in pulmonary plateau pressure (≥6 mmHg) all demonstrated an improvement in plateau pressure by postoperative day 1 (preoperative, 18.9 ± 4.5 mmHg; postoperative, 27.4 ± 4.0 mmHg; postoperative day 1, 20.1 ± 3.7 mmHg), and could be identified preoperatively as having a hernia volume of greater than 20 percent of the abdominal cavity (p < 0.001), but were still more likely to have postoperative respiratory events (p = 0.01).

Conclusions: Elevated intraabdominal pressure following elective hernia repair requiring myofascial releases is common but transient. Change in plateau pressure by 6 mmHg or more following repair can be expected with a loss of domain greater than 20 percent and is a more useful surrogate than intraabdominal pressure measurements with regard to predicting postoperative pulmonary complications. The perception and management of elevated intraabdominal pressure should be considered distinct and "permissible" in this context.
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http://dx.doi.org/10.1097/PRS.0000000000001621DOI Listing
October 2015

A Multidisciplinary Approach to Medical Weight Loss Prior to Complex Abdominal Wall Reconstruction: Is it Feasible?

J Gastrointest Surg 2015 Aug 23;19(8):1399-406. Epub 2015 May 23.

Cleveland Clinic Comprehensive Hernia Center, Cleveland Clinic Foundation, 9500 Euclid Avenue A10-425, Cleveland, OH, 44195, USA,

Obesity is a major risk factor for perioperative morbidity, especially for patients undergoing complex incisional hernia repair. The feasibility and effectiveness of medical weight loss programs prior to complex abdominal wall reconstruction have not been well characterized. Here, we report our experience collaborating with a medical weight loss specialist utilizing a protein sparing modified fast in order to optimize weight loss prior to complex abdominal wall reconstruction. Morbidly obese patients (body mass index (BMI) > 35 kg/m(2)) evaluated by our medical weight loss specialist prior to complex ventral hernia repair were identified within our prospective database. Our primary outcome measure was the amount of weight lost prior to surgical intervention. Our secondary outcome measure was to determine the maintenance of weight loss during long-term follow-up after the surgical intervention. A total of 25 patients with a BMI > 35 kg/m(2) were evaluated by our medical weight loss specialist prior to undergoing a planned incisional hernia repair. The mean weight of the patients preoperatively was 128 kg ± 25 (range 96-205 kg) (mean ± standard deviation), and the mean BMI was 49 kg/m(2) ± 10 (range 36-85). After completion of the preoperative modified protein sparing fast, the mean preoperative weight loss of the group was 24 kg ± 21 (range 2-80 kg). The overall change in BMI for the group prior to surgery was 9 kg/m(2) ± 8 (0.6 to 33). The percentage of excess BMI loss and total BMI loss preoperatively was 37 % ± 23 (2 to 83) and 18 % ± 12 (1 to 43), respectively. Of the 24 patients that initially lost weight in the program preoperatively, 22 (88 %) successfully maintained their weight loss for the entire study period for an average of 18 months. Collaboration with a medical weight loss specialist and a surgeon with a structured approach using a modified protein sparing fast can successfully result in meaningful weight loss prior to complex abdominal wall reconstruction. The majority of patients in this study were able to maintain their weight loss during long-term follow-up. Utilization of a protein sparing modified fast in collaboration with a medical weight loss specialist is a valuable resource for guiding weight loss in patients with morbid obesity prior to elective complex surgical procedures.
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http://dx.doi.org/10.1007/s11605-015-2856-6DOI Listing
August 2015

Posterior component separation and transversus abdominis muscle release for complex incisional hernia repair in patients with a history of an open abdomen.

J Trauma Acute Care Surg 2015 Feb;78(2):422-9

From the Case Comprehensive Hernia Center (C.C.P., S.Y., A.S.P., Y.W.N., M.J.R.), University Hospitals Case Medical Center; and Division of Trauma Critical Care, Burns, and Acute Care Surgery (C.C.P., J.J.C., S.Y.), MetroHealth Medical Center, Cleveland, Ohio.

Background: The best reconstructive approach for large fascial defects precipitated from a previous open abdomen has not been elucidated to date. We use a posterior component separation with transversus abdominis muscle release (TAR) in this scenario.

Methods: Patients with a history of an open abdomen who ultimately underwent complex hernia repair with TAR from 2010 to 2013 at Case Medical Center were identified in our prospective database and analyzed.

Results: Of 34 patients (mean [SD] age, 54 [11.3] years; mean [SD] body mass index, 32.5 [7.2]) with a history of an open abdomen, the fascia was closed primarily in 11 and skin alone closed primarily in 4 patients after a mean (SD) of 5.9 (6.7) days. Those unable to achieve primary closure either received a skin graft (n = 16) or healed by secondary intention (n = 3). Patients presented to our institution a mean (SD) of 25.1 (26.5) months after their initial operation, eight having already undergone at least one hernia repair, including four anterior component separations. Operations consisted of 21 (61.8%) contaminated cases, including 7 enterocutaneous fistula takedowns, 2 stoma revisions, 2 stoma reversals, and 3 excisions of infected mesh. Wound morbidity consisted of 12 (35%) surgical site occurrences: 1 wound dehiscence, 2 hematomas, 1 seroma, 8 surgical site infections (23.5%; 3 superficial, 3 deep, and 2 organ space), and no enterocutaneous fistulas or chronic mesh infections. One reoperation was necessary for debridement of a hematoma and deep surgical site infection. With a mean follow-up of 18 months (range, 3-42 months), two (5.9%) new parastomal hernias and three (8.8%) midline recurrences have been documented.

Conclusion: To our knowledge, this is the first report describing the use of TAR in patients with a history of an open abdomen for definitive abdominal wall reconstruction. We have demonstrated that this approach is associated with low significant perioperative morbidity and recurrence.

Level Of Evidence: Therapeutic study, level V.
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http://dx.doi.org/10.1097/TA.0000000000000495DOI Listing
February 2015

Transversus abdominis muscle release for repair of complex incisional hernias in kidney transplant recipients.

Am J Surg 2015 Aug 26;210(2):334-9. Epub 2015 Jan 26.

Division of Transplant Surgery, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, OH 44106, USA.

Background: Incisional hernias in kidney transplant recipients (KTRs) can be complex because of adjacent bony structures, proximity of the allograft/transplant ureter, and context of immunosuppression. We hypothesized that our novel posterior component separation with transversus abdominis muscle release (TAR) and retromuscular mesh reinforcement offers a safe and durable repair.

Methods: KTRs with incisional hernias repaired using the aforementioned technique were identified within our prospective database (2007 to 2013) and analyzed.

Results: Eleven patients were identified (median age 49 years, body mass index 32). The median hernia size was 30 cm(2) (range 88 to 1,040 cm(2)) and 8 of the 11 patients were recurrent. Intraoperative morbidity consisted of one transplant ureter injury repaired primarily over a stent. Postoperative morbidity consisted of 2 superficial surgical site infections that resolved and 1 readmission for a blood transfusion. There were no instances of mesh infection, explantation, graft loss, or graft dysfunction. With a median follow-up of 12 months (range 3 to 69), 1 (9%) lateral recurrence has been documented.

Conclusions: For complex incisional hernias in KTRs, TAR is associated with low perioperative morbidity and durable repair.
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http://dx.doi.org/10.1016/j.amjsurg.2014.08.043DOI Listing
August 2015

Enhanced recovery after surgery pathway for abdominal wall reconstruction: pilot study and preliminary outcomes.

Plast Reconstr Surg 2014 Oct;134(4 Suppl 2):151S-159S

Cleveland, Ohio From the Department of Surgery, Case Comprehensive Hernia Center, University Hospitals Case Medical Center.

Summary: Enhanced recovery after surgery (ERAS) pathways represent a multimodal approach to improve the quality of postoperative care by diminishing the stress response to the trauma of an operation, thereby minimizing hospital length of stay and potentially complications. At a time when healthcare costs are being intensely scrutinized, efforts to reduce patient morbidity and hospital stay are imperative and timely. The success of ERAS fast-track surgery pathways-thoroughly studied in the colorectal literature-has led to their application in other fields. Herein, we present our ERAS pathway for patients undergoing abdominal wall repairs, including the rationale and supporting evidence behind each of its components and our early clinical results after implementation. Although hastened patient recovery is clearly multifactorial, our pathway, incorporating alvimopan, early feeding strategies, and multimodal pain therapy with an emphasis on the reduction of opiate usage as well as precise intraoperative nerve block with novel longer-acting local anesthetic Exparel, appears to provide significant improvement in postoperative pain, bowel function recovery, and shorter hospital stay. Although a prospective evaluation of the entire ERAS pathway as well as contribution of its various components is currently ongoing at our Hernia Center, we believe ours or similar ERAS pathways will soon become standard for the vast majority of patients undergoing abdominal wall surgery.
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http://dx.doi.org/10.1097/PRS.0000000000000674DOI Listing
October 2014

Single-center experience with parastomal hernia repair using retromuscular mesh placement.

J Gastrointest Surg 2014 Sep 19;18(9):1673-7. Epub 2014 Jun 19.

Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA.

Background: Parastomal hernias (PHs) are frequent complications of enterostomies. We aimed to evaluate our outcomes of open PH repair with retromuscular mesh reinforcement.

Methods: From 2006 to 2013, 48 parastomal hernias were repaired in 46 consecutive patients undergoing open retromuscular repair. Surgical technique included stoma relocation, retromuscular dissection, posterior component separation, and retromuscular mesh placement. All stomas were prophylactically reinforced with cruciate incisions through mesh. Main outcome measures included demographics, perioperative details, wound complications (classified according to the CDC guidelines), and recurrences.

Results: There were 24 male and 22 female patients with a mean age of 61.8 and body mass index (BMI) of 31.7 kg/m(2). Twenty-four patients had recurrent PH with an average of 3.8 prior repairs. Ostomies included 18 colostomies, 20 ileostomies, and 10 ileal conduits. Thirty-two patients had a concurrent repair of a midline incisional hernia. All patients underwent mesh repair with either biologic (n = 29), lightweight polypropylene (n = 15), or absorbable synthetic mesh (n = 2). There were 15 superficial surgical site infections (SSIs) and 6 deep SSIs. There was one case of an ischemic ostomy requiring surgical revision. No mesh grafts required removal and there were no mesh erosions. At a mean follow-up time of 13 months, five patients (11%) developed a recurrence; three patients required re-repair.

Conclusion: In this largest series of complex open repairs with retromuscular mesh reinforcement and stoma relocation, we demonstrate that this results in an effective repair. This technique should be considered for complex parastomal hernia repair.
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http://dx.doi.org/10.1007/s11605-014-2575-4DOI Listing
September 2014