Publications by authors named "Eric M Pauli"

72 Publications

Endoscopomics: quantifying the gut luminal size.

Authors:
Eric M Pauli

Gastrointest Endosc 2021 Apr 19. Epub 2021 Apr 19.

Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA.

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http://dx.doi.org/10.1016/j.gie.2021.03.002DOI Listing
April 2021

Endoscopy in the CT Scanner: a Multidisciplinary Approach to Difficult Cases.

J Gastrointest Surg 2021 03 9;25(3):866-867. Epub 2020 Nov 9.

Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.

Endoscopic interventions have been made safer with the use of fluoroscopy. This technique has limitations in patients with challenging anatomy. The combined use of endoscopy and CT fluoroscopy provides the added precision necessary to accomplish difficult interventions. In this video, we present two cases where endoscopy and CT fluoroscopy were used concurrently. While other publications have demonstrated the use of CT guidance to perform endoscopic interventions, this video also demonstrates the reverse-how endoscopic guidance can be used to make a CT-guided procedure possible. This video demonstrates the enhanced patient care possible when a multidisciplinary approach between interventional radiologists and surgeons is followed.
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http://dx.doi.org/10.1007/s11605-020-04840-yDOI Listing
March 2021

Endoscopic Management of Postoperative Complications.

Surg Clin North Am 2020 Dec 10;100(6):1115-1131. Epub 2020 Oct 10.

Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Health, 500 University Drive, PO Box 850, Hershey, PA 17033, USA. Electronic address:

Gastrointestinal surgery is increasingly being performed. Despite improving technology and outcomes, complications are not completely avoidable. Frequently, surgical complications require invasive procedures for management. However, with increasing availability of flexible endoscopy and a wider array of tools, more often these complications can be managed with an endolumenal approach. This article is an in-depth review of endoscopic management of surgical complications.
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http://dx.doi.org/10.1016/j.suc.2020.08.007DOI Listing
December 2020

Laparoscopic sleeve gastrectomy in patients with complex abdominal wall hernias.

Surg Endosc 2020 Jul 28. Epub 2020 Jul 28.

Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, M.C. H149, Hershey, PA, 17033, USA.

Background: Patients with severe obesity and complex abdominal wall hernias (CAWH) present a challenging clinical dilemma. Their body mass index (BMI) is often prohibitive of successful ventral hernia repair (VHR) and the CAWH presents technical challenges when pursuing bariatric surgery. Our hernia center policy is to refer patients with severe obesity for evaluation with the surgical weight loss program. This study describes outcomes of laparoscopic sleeve gastrectomy (LSG) in patients with both severe obesity and CAWH.

Methods: A retrospective analysis was performed on data prospectively collected between 2014 and 2020. CAWH patients referred for and undergoing LSG were included. Revisional bariatric surgery patients were excluded. The dataset was augmented with operative time, BMI changes, length of stay (LOS), hernia characteristics, postoperative complications, time from referral to weight loss surgery, and time from LSG to VHR.

Results: Twenty patients (10 males, mean age 54.3 years) met inclusion criteria. Mean BMI at LSG was 45.6 ± 6.1 kg/m. Mean hernia area was 494.9 ± 221.2 cm and 90% had hernia extension into the subxiphoid and/or epigastric regions. Mean time from bariatric referral to LSG was 10.5 ± 5.4 months. Mean LSG operative time was 121.2 ± 50.3 min, and mean LOS was 1.6 ± 0.8 days. One patient had postoperative bleeding necessitating laparoscopic re-exploration. There were no readmissions. Sixteen patients subsequently underwent VHR on average13.5 ± 11.7 months later and on average 22.6 ± 12.5 months after initial hernia consultation. Two patients had a hernia-related complication between the period of initial hernia consultation and ultimate repair. Mean BMI was 37.5 ± 7.5 kg/m (mean 20.7 ± 12.3% decrease, p < 0.0001) at mean follow-up of 27.2 ± 17.2 months.

Conclusions: LSG can be performed successfully even in patients with CAWH. Outcomes do not appear to differ significantly from typical patients undergoing LSG. Further study with larger cohorts is warranted to better delineate complication rates in this population as well as to determine long-term outcomes.
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http://dx.doi.org/10.1007/s00464-020-07831-xDOI Listing
July 2020

Enteral Feeding: Percutaneous Endoscopic Gastrostomies, Tubes, and Formulas.

Adv Surg 2020 09 17;54:231-249. Epub 2020 Jun 17.

Department of Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA. Electronic address:

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http://dx.doi.org/10.1016/j.yasu.2020.05.009DOI Listing
September 2020

Stoma closure and reinforcement (SCAR): A study protocol for a pilot trial.

Contemp Clin Trials Commun 2020 Sep 9;19:100582. Epub 2020 Jun 9.

Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.

A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.
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http://dx.doi.org/10.1016/j.conctc.2020.100582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300121PMC
September 2020

Teamwork really does make the dream work.

Muscle Nerve 2020 07 12;62(1):5-6. Epub 2020 May 12.

Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA.

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http://dx.doi.org/10.1002/mus.26900DOI Listing
July 2020

Concomitant Anterior and Posterior Component Separations: Absolutely Contraindicated?

Surg Innov 2020 Aug 23;27(4):328-332. Epub 2020 Mar 23.

Penn State Hershey Medical Center, Hershey, PA, USA.

Many experts in abdominal wall reconstruction believe that the combination of simultaneous ipsilateral anterior component separation (ACS) and posterior component separation (PCS) is contraindicated. We performed ipsilateral endoscopic ACS and either endoscopic or open PCS-transversus abdominis release (TAR) in 5 fresh cadaver models. The full length of the semilunar line and the lateral abdominal wall remained well reinforced by 2 complete layers, comprising the internal oblique (IO) and TA muscles and their investing fasciae. Myofascial releases occurred 4 cm (median) apart. Additionally, we reviewed computed tomography images at 1 month and 1 year after PCS-TAR in 17 patients (30 PCS-TARs). Lateral displacement of the TA relative to the rectus abdominis (RA) was significant only at the superior mesenteric artery level, where it was <1 cm (median). Muscle mass changed minimally over time. Several studies showed that abdominal wall reconstruction after PCS-TAR results in compensatory muscular hypertrophy of the RA, external oblique (EO), and IO muscles and provides better quality of life and improved core physiology. These changes did not occur when the midline was not restored. Theoretically, endoscopic ACS-EO may be added to PCS-TAR to avoid partially bridged mesh repair in patients in whom complete midline restoration is impossible via PCS-TAR alone. Nevertheless, we advise most surgeons to perform a small-bridged repair instead of risking increased morbidity by attempting a highly complicated procedure.
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http://dx.doi.org/10.1177/1553350620914195DOI Listing
August 2020

SAGES masters program: determining the seminal articles for each pathway.

Surg Endosc 2020 04 12;34(4):1465-1481. Epub 2020 Feb 12.

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Background: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has recently developed and announced its Masters Program that aims to address existing needs of practicing surgeons for lifelong learning and consists of eight clinical pathways each containing three anchoring procedures. The objective of this study was to select the seminal articles for each anchoring procedure of these pathways using a systematic methodology.

Methods: A systematic literature search of Web of Science was conducted for the most cited articles for each of the anchoring procedures of the SAGES Masters pathways. The most relevant identified articles were then reviewed by expert members of the relevant SAGES pathway committees and task forces and the seminal articles chosen for each anchoring procedure using expert consensus.

Results: 578 highly cited articles were identified by the original search of the literature and the seminal articles were selected for each anchoring procedure after expert review and consensus. Articles address procedural outcomes, disease pathophysiology, and surgical technique and are presented in this paper.

Conclusions: We have identified seminal articles for each anchoring procedure of the SAGES Masters program pathways using a systematic methodology. These articles provide surgeon participants of this program with a great resource to improve their procedure-specific knowledge and may further benefit the larger surgical community by focusing its attention to must-read impactful work that may inform best practices.
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http://dx.doi.org/10.1007/s00464-020-07392-zDOI Listing
April 2020

Endoscopic visualization of annular pancreas after duodenoduodenostomy.

VideoGIE 2020 Jan 1;5(1):22-23. Epub 2019 Nov 1.

Division of Gastroenterology and Hepatology, Division of Pediatric Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA.

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http://dx.doi.org/10.1016/j.vgie.2019.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945228PMC
January 2020

Concomitant laparoscopic cholecystectomy and antegrade wire, rendezvous cannulation of the biliary tree may reduce post-ERCP pancreatitis events.

Surg Endosc 2020 07 5;34(7):3216-3222. Epub 2019 Sep 5.

Division of Minimally Invasive and Bariatric Surgery, Department of General Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17033, USA.

Introduction: For patients with a gallbladder in situ, choledocholithiasis is a common presenting symptom. Both two-session endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy (CCY) and single-stage (simultaneous CCY/ERCP) have been described. We utilize an antegrade wire, rendezvous cannulation (AWRC) technique to facilitate ERCP during CCY. We hypothesized that AWRC would eliminate episodes of post-ERCP pancreatitis (PEP).

Methods: An IRB approved, retrospective review of patients who underwent ERCP via AWRC for choledocholithiasis during CCY was performed. Patient characteristics, pre/postoperative laboratory values, complications, and readmissions were reviewed. AWRC was conducted during laparoscopic or open CCY for evidence of choledocholithiasis with or without preoperative biliary pancreatitis or cholangitis. Following confirmatory intraoperative cholangiogram, a flexible tip guidewire was inserted antegrade into the cystic ductotomy, through the bile duct across the ampulla and retrieved in the duodenum with a duodenoscope. Standard ERCP maneuvers to clear the bile duct are then performed over the wire.

Results: Thirty-seven patients (27 female, age 19-77, BMI 21-50 kg/m) underwent intraoperative ERCP via AWRC technique during CCY. Seventeen underwent CCY for acute cholecystitis. Fifteen patients underwent transgastric ERCP in the setting of previous Roux-en-Y gastric bypass. Mean total operative time was 214 min. Mean ERCP time was 31 min. Thirty-three patients had biliary stents placed. There were no cannulations or injections of the pancreatic duct. There were no intraoperative complications associated with the ERCP and no patients developed PEP. Three patients developed a postoperative subhepatic abscess requiring drainage.

Conclusion: AWRC is a useful technique for safe and efficient bile duct cannulation for therapeutic ERCP in the setting of choledocholithiasis at the time of CCY. Despite supine (rather than the traditional prone) positioning, total ERCP times were short and we eliminated any manipulation of the pancreatic duct. No patients in our series developed PEP or post-sphincterotomy bleeding.
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http://dx.doi.org/10.1007/s00464-019-07074-5DOI Listing
July 2020

Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects.

Surg Endosc 2020 06 26;34(6):2690-2702. Epub 2019 Jul 26.

Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.

Background: Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period.

Methods: A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure.

Results: We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5 months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention.

Conclusions: Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery.
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http://dx.doi.org/10.1007/s00464-019-07030-3DOI Listing
June 2020

The Role of Genetic Variant rs13266634 in SLC30A8/ZnT8 in Post-Operative Hyperglycemia after Major Abdominal Surgery.

J Clin Endocrinol Metab 2019 Apr 10. Epub 2019 Apr 10.

Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA.

Context: Following major surgery, post-operative hyperglycemia (POHG) is associated with suboptimal outcomes, among diabetics and non-diabetics. A specific genetic variant, rs13266634 (c.973C>T; p.ARG325TRP) in zinc transporter SLC30A8/ZnT8, is associated with protection against Type-2 Diabetes, suggesting it may be actionable for predicting and preventing POHG.

Objective: To determine independent and mediated influences of a genetic variant on POHG in patients undergoing a model major operation, complex abdominal ventral hernia repair (cVHR).

Patients And Methods: For 110 patients (mean BMI 34.9±5.8, T2D history 28%) undergoing cVHR at a tertiary referral center (January 2012 to March 2017), multivariate regression was used to correlate the rs13266634 variant to pre-operative clinical, laboratory and imaging-based indices of liver steatosis and central abdominal adiposity to POHG. Causal Mediation Analysis (CMA) was used to determine direct and mediated contributions of SLC30A8/ZnT8 status to POHG.

Results: Variant rs13266634 was present in 61 patients (55.4%). In univariate models, when compared to patients with rs13266634, the homozygous wild-genotype (C/C, n=49) was associated with significantly higher risks of POHG (OR= 0.30 95%CI =0.14, 0.67, P=0.0038). Multivariate regression indicated that the association was independent (OR= 0.39 95%CI 0.15-0.97, p=0.040). In addition, CMA suggested that rs13266634 protects against POHG directly and indirectly through its influence on liver steatosis and central adiposity.

Conclusions: In medically complex patients undergoing major operations, the rs13266634 variant protects against POHG and its associated outcomes, through independent and mediated contributions. In C/C patients undergoing major operations, SLC30A8/ZnT8 may prove useful to stratify risk of POHG and potentially as a therapeutic target.
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http://dx.doi.org/10.1210/jc.2018-02588DOI Listing
April 2019

Exhortation to lose weight prior to complex ventral hernia repair: Nudge or noodge?

Am J Surg 2020 01 19;219(1):136-139. Epub 2019 Apr 19.

Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, 17033, USA. Electronic address:

Background: Exercise and weight loss are recommended for patients with obesity undergoing elective complex ventral hernia repair (cVHR).

Methods: Weight and BMI trajectory data on 230 obese patients undergoing cVHR from 2012 to 2017 were retrospectively analyzed from 12 months prior to first visit with the hernia surgeon to 12 months after surgery.

Results: One year prior to initial visit, 76 (33%) patients had lost > 1kg/m, 98 (43%) had gained> 1kg/m, and 56 (24%) had no change in body mass index (BMI). Between initial visit and operation, 53 (23%) lost >1kg/m, 43 (19%) gained, and 134 (58%) had no change. Post-operative hyperglycemia was associated with BMI> 40kg/m at time of operation. Twelve months post-operatively, 69 (35%) had lost >1kg/m, while 52 (26%) had gained, and 108 (47%) had no change.

Conclusions: Exhortations for pre-operative and post-operative weight management are not often successful or sustainable, implying a need for individualized holistic approaches.
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http://dx.doi.org/10.1016/j.amjsurg.2019.04.013DOI Listing
January 2020

Endoscopic Management of Acute Biliopancreatic Disorders.

J Gastrointest Surg 2019 05 28;23(5):1055-1068. Epub 2019 Feb 28.

Division of Minimally Invasive and Bariatric Surgery, Department of General Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17033, USA.

Purpose: Endoscopy is playing an ever-increasing role in the management of acute biliopancreatic disorders. With the management paradigm shifting away from more invasive surgical approaches, surgeons need to be aware of the treatment options available to improve patient care. Our manuscript serves to improve surgeons' knowledge and understanding of these emerging treatment modalities to expand their algorithmic approach to biliopancreatic disorders.

Methods: Specific acute biliopancreatic disorders were identified from the literature and personal practice to create a structured review of common problems experienced by a surgeon of the gastrointestinal tract. An exhaustive literature review was performed to identify and analyze endoscopic treatment modalities for these disorders.

Results: Endoscopic therapies continue to expand rapidly with a robust supportive literature. Data on endoscopic treatment strategies for acute biliopancreatic disorders demonstrate valuable improvements in outcomes in a number of these disorders.

Discussion: Acute biliopancreatic disorders represent one of the most challenging pathophysiologies that a surgeon of the gastrointestinal tract may face. This manuscript represents a review of available endoscopic instrumentation as well as the author's interpretation of the current literature regarding indications and outcomes of endoscopic management for acute biliopancreatic disorders. Although this article does not supplant formal training in therapeutic endoscopy, surgeons reading this article should understand the role endoscopy plays in the management of acute biliopancreatic disorders.
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http://dx.doi.org/10.1007/s11605-019-04143-xDOI Listing
May 2019

Nonalcoholic Fatty Liver Disease as a High-Value Predictor of Postoperative Hyperglycemia and Its Associated Complications in Major Abdominal Surgery.

J Am Coll Surg 2018 10 27;227(4):419-429.e6. Epub 2018 Jul 27.

Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA; Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA. Electronic address:

Background: For patients undergoing major abdominal operations, acute postoperative hyperglycemia (POHG) is associated with suboptimal outcomes and higher costs of care. This study was performed to determine whether CT-derived indices of nonalcoholic fatty liver disease (hepatic steatosis) or visceral adiposity may serve as predictors of POHG and its consequences in such patients.

Study Design: We reviewed records and preoperative abdominal CT images of 129 patients undergoing complex open ventral hernia repair (cVHR) from 2012 to 2016, with 90-day follow-up. Univariate and multivariate regressions were performed to estimate associations between CT-detected steatosis or visceral adiposity with POHG (serum glucose > 140 mg/dL within 48 hours), surgical site occurrence (SSO), and subsequent interventions (SSO-I).

Results: Type-2 diabetes (T2D) was present in 23% and POHG in 52%; SSO events occurred in 28% and SSO-I in 21%. Highest-effect associations with POHG were observed for T2D (odds ratio [OR] 21.54; 95% CI 4.85, 95.58), hepatic steatosis (OR 2.20, 95% CI 1.07, 4.52), and waist circumference-to-height ratio (WCHR > 0.65; OR 2.37, 95% CI 1.16, 4.83). After multivariate analysis, the effects of T2D (OR 16.73; CI 5.42, 73.87; p < 0.0001) and steatosis (OR 2.55; CI 1.17, 5.69; p = 0.02) remained independently associated with POHG. Independent associations with SSO were observed for steatosis (OR 3.31; CI 1.41, 8.06; p = 0.007), POHG (OR 2.85; CI 1.17, 7.38; p = 0.024), and WCHR (OR 2.68; CI 1.11, 6.85; p = 0.03).

Conclusions: Image-based indices of chronic metabolic disturbance in the liver and adipose tissues may offer novel opportunities for identifying patients at risk for POHG and those who would benefit from preoperative metabolic optimization.
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http://dx.doi.org/10.1016/j.jamcollsurg.2018.07.655DOI Listing
October 2018

Incisional Hernia in the United States: Trends in Hospital Encounters and Corresponding Healthcare Charges.

Am Surg 2018 Jan;84(1):118-125

Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.
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January 2018

Delineating the burden of chronic post-operative pain in patients undergoing open repair of complex ventral hernias.

Am J Surg 2018 Apr 2;215(4):610-617. Epub 2018 Feb 2.

The Pennsylvania State University, College of Medicine, Department of Surgery, Hershey, PA 17033-0850, USA. Electronic address:

Background: After open complex ventral hernia repair (cVHR), chronic pain has a significant impact on quality of life and processes of care.

Methods: Records of 177 patients undergoing cVHR were reviewed in order to characterize the burden of managing postoperative pain in the first post-operative year following open cVHR.

Results: In this cohort, 91 patients initiated at least one unsolicited complaint of pain, though phone call (37), unscheduled clinic visit (45) or evaluation in the emergency room (9); among these an actionable diagnosis was found in 38 (41.8%). Among 41 patients who initiated additional unsolicited complaints of pain, an actionable diagnosis was found in only 3 patients. Risk factors for such complaints included pre-operative pain and the use of synthetic mesh.

Conclusions: Even in the absence of an actionable diagnosis, significant resources are utilized in evaluation and management of unsolicited complaints of pain in the first year after cVHR.
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http://dx.doi.org/10.1016/j.amjsurg.2018.01.030DOI Listing
April 2018

Cost-effectiveness of per oral endoscopic myotomy relative to laparoscopic Heller myotomy for the treatment of achalasia.

Surg Endosc 2018 Jan 7;32(1):39-45. Epub 2017 Dec 7.

Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, H151, Hershey, PA, 17033-0850, USA.

Background: Per oral endoscopic myotomy (POEM) has recently emerged as a viable option relative to the classic approach of laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. In this cost-utility analysis of POEM and LHM, we hypothesized that POEM would be cost-effective relative to LHM.

Methods: A stochastic cost-utility analysis of treatment for achalasia was performed to determine the cost-effectiveness of POEM relative to LHM. Costs were estimated from the provider perspective and obtained from our institution's cost-accounting database. The measure of effectiveness was quality-adjusted life years (QALYs) which were estimated from direct elicitation of utility using a visual analog scale. The primary outcome was the incremental cost-effectiveness ratio (ICER). Uncertainty was assessed by bootstrapping the sample and computing the cost-effectiveness acceptability curve (CEAC).

Results: Patients treated within an 11-year period (2004-2016) were recruited for participation (20 POEM, 21 LHM). During the index admission, the mean costs for POEM ($8630 ± $2653) and the mean costs for LHM ($7604 ± $2091) were not significantly different (P = 0.179). Additionally, mean QALYs for POEM (0.413 ± 0.248) were higher than that associated with LHM (0.357 ± 0.338), but this difference was also not statistically significant (P = 0.55). The ICER suggested that it would cost an additional $18,536 for each QALY gained using POEM. There was substantial uncertainty in the ICER; there was a 48.25% probability that POEM was cost-effective at the mean ICER. At a willingness-to-pay threshold of $100,000, there was a 68.31% probability that POEM was cost-effective relative to LHM.

Conclusions: In the treatment of achalasia, POEM appears to be cost-effective relative to LHM depending on one's willingness-to-pay for an additional QALY.
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http://dx.doi.org/10.1007/s00464-017-5629-3DOI Listing
January 2018

Erratum to: First human use of hybrid synthetic/biologic mesh in ventral hernia repair: a multicenter trial.

Surg Endosc 2018 03;32(3):1131-1132

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.

Some values in the pages 1, 3, and 5 of the original article are corrected and also an updated Table 5 is displayed.
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http://dx.doi.org/10.1007/s00464-017-5879-0DOI Listing
March 2018

First human use of hybrid synthetic/biologic mesh in ventral hernia repair: a multicenter trial.

Surg Endosc 2018 03 19;32(3):1123-1130. Epub 2017 Jul 19.

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: Mesh options for reinforcement of ventral/incisional hernia (VIH) repair include synthetic or biologic materials. While each material has known advantages and disadvantages, little is understood about outcomes when these materials are used in combination. This multicenter study reports on the first human use of a novel synthetic/biologic hybrid mesh (Zenapro Hybrid Hernia Repair Device) for VIH repair.

Methods: This prospective, multicenter post-market clinical trial enrolled consecutive adults who underwent elective VIH repair with hybrid mesh placed in the intraperitoneal or retromuscular/preperitoneal position. Patients were classified as Ventral Hernia Working Group (VHWG) grades 1-3 and had clean or clean-contaminated wounds. Outcomes of ventral and incisional hernia were compared using appropriate parametric tests.

Results: In all, 63 patients underwent VIH repair with hybrid mesh. Most were females (54.0%), had a mean age of 54.8 ± 10.9 years and mean body mass index of 34.5 ± 7.8 kg/m, and classified as VHWG grade 2 (87.3%). Most defects were midline (92.1%) with a mean area of 106 ± 155 cm. Cases were commonly classified as clean (92.1%) and were performed laparoscopically (60.3%). Primary fascial closure was achieved in 82.5% with 28.2% requiring component separation. Mesh location was frequently intraperitoneal (69.8%). Overall, 39% of patients available for follow-up at 12 months suffered surgical site events, which were generally more frequent after incisional hernia repair. Of these, seroma (23.7%) was most common, but few (8.5%) required procedural intervention. Other surgical site events that required procedural intervention included hematoma (1.7%), wound dehiscence (1.7%), and surgical site infection (3.4%). Recurrence rate was 6.8% (95% CI 2.2-16.6%) at 12-months postoperatively.

Conclusion: Zenapro Hybrid Hernia Repair Device is safe and effective in VHWG grade 1-2 patients with clean wounds out to 12 months. Short-term outcomes and recurrence rate are acceptable. This hybrid mesh represents a novel option for reinforcement during VIH repair.
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http://dx.doi.org/10.1007/s00464-017-5715-6DOI Listing
March 2018

Design Strategies and Applications of Biomaterials and Devices for Hernia Repair.

Bioact Mater 2016 Sep 30;1(1):2-17. Epub 2016 May 30.

Department of Biomedical Engineering, Materials Research Institute, The Huck Institutes of The Life Sciences, The Pennsylvania State University, University Park, PA 16802, USA.

Hernia repair is one of the most commonly performed surgical procedures worldwide, with a multi-billion dollar global market. Implant design remains a critical challenge for the successful repair and prevention of recurrent hernias, and despite significant progress, there is no ideal mesh for every surgery. This review summarizes the evolution of prostheses design toward successful hernia repair beginning with a description of the anatomy of the disease and the classifications of hernias. Next, the major milestones in implant design are discussed. Commonly encountered complications and strategies to minimize these adverse effects are described, followed by a thorough description of the implant characteristics necessary for successful repair. Finally, available implants are categorized and their advantages and limitations elucidated, including non-absorbable and absorbable (synthetic and biologically derived) prostheses, composite prostheses, and coated prostheses. This review not only summarizes the state of the art in hernia repair, but also suggests future research directions toward improved hernia repair utilizing novel materials and fabrication methods.
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http://dx.doi.org/10.1016/j.bioactmat.2016.05.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5365083PMC
September 2016

Force Comparison of Commercially Available Transfascial Suture Passers.

Surg Innov 2017 Jun 8;24(3):301-308. Epub 2017 Feb 8.

1 The Pennsylvania State University, Hershey, PA, USA.

Background: Transfascial suture passers (TSPs) are a commonly used surgical tool available in a wide array of tip configurations. We assessed the insertion force of various TSPs in an ex vivo porcine model.

Methods: Uniform sections of porcine abdominal wall were secured to a 3D-printed platform. Nine TSPs were passed through the abdominal wall both without and with prolene suture under the following scenarios: abdominal wall only and abdominal wall plus underlay ePTFE or composite ePTFE/polypropylene mesh. Insertion forces were recorded in Newton (N).

Results: When passed without suture through the abdominal wall, smaller diameter TSPs required less insertional force (1.50 ± 0.17 N vs 9.68 ± 1.50 N [ P = 0.00072]). Through composite mesh, the solid tipped TSPs required less force than hollow tipped ones (3.87 ± 0.25 N vs 7.88 ± 0.20 N [ P = 0.00026]). Overall, smaller diameter TSPs required less force than the larger TSPs when passed through ePTFE empty (Gore 2.95 ± 0.83 N vs Carter-Thomason 16.07 ± 2.10 N [ P = .0005]) or with suture (Gore 8.37 ± 2.59 N vs Carter-Thomason 19.12 ± 1.10 N [ P = .003]).

Conclusions: Diameter plays the greatest role in the force required for TSP penetration. However, when passed through underlay mesh or while holding suture, distal tip shape, the mechanism of suture holding, and shaft diameter all contribute to the forces necessary for penetration. These factors should be considered when choosing a TSP for intraoperative use.
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http://dx.doi.org/10.1177/1553350617691709DOI Listing
June 2017

Comparative analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs.

Surgery 2016 10 21;160(4):828-838. Epub 2016 Jul 21.

Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH. Electronic address:

Background: Contaminated operative fields pose significant challenges for surgeons performing ventral hernia repair. Although biologic meshes have been utilized increasingly in these fields, recent evidence suggests that synthetic meshes represent a viable option. We analyzed the outcomes of biologic and synthetic mesh utilized in patients undergoing major ventral hernia repair in clean-contaminated/contaminated fields.

Methods: We conducted a multicenter, retrospective review of patients undergoing open ventral hernia repair in clean-contaminated/contaminated fields using biologic or synthetic mesh. Patient and hernia details were characterized. Primary outcomes included 90-day surgical site event, surgical site infection, and hernia recurrence.

Results: A total of 126 patients undergoing major ventral hernia repair in clean-contaminated/contaminated fields (69 biologic and 57 synthetic meshes) were analyzed. Groups were similar in both patient and hernia characteristics. There were 13 (22.8%) surgical site events in the synthetic cohort compared to 29 (42.0%) in the biologic cohort, P = .024. Similarly, surgical site infections were less frequent in the synthetic group, with 7 (12.3%) vs 22 (31.9%), P = .01. With a mean follow-up of 20 months, there were more recurrences in the biologic group: 15 (26.3%) vs 4 (8.9%) in the synthetic group, P = .039.

Conclusion: The choice of mesh for clean-contaminated/contaminated ventral hernia repair remains debatable. We demonstrated that using synthetic sublay mesh resulted in a significantly lower wound morbidity and more durable outcomes versus a similar cohort of biologic repairs. This is likely secondary to improved bacterial clearance and faster integration of macroporous synthetics. Overall, our findings not only support suitability of synthetic mesh in contaminated settings but also challenge the purported advantage of biologics in clean-contaminated/contaminated ventral hernia repairs.
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http://dx.doi.org/10.1016/j.surg.2016.04.041DOI Listing
October 2016

Differences in midline fascial forces exist following laparoscopic and open transversus abdominis release in a porcine model.

Surg Endosc 2017 02 28;31(2):829-836. Epub 2016 Jun 28.

Division of Minimally Invasive Surgery, Department of Surgery, College of Medicine, The Pennsylvania State University, 500 University Drive, Hershey, PA, 17033-0850, USA.

Introduction: Posterior component separation herniorrhaphy via transversus abdominis release (TAR) permits midline reapproximation of large fascial defects. To date, no report delineates the reduction in tensile force to reapproximate midline fascia following TAR. We hypothesized that open and laparoscopic TAR would provide similar reductions in midline reapproximation forces in a porcine model.

Methods: Under general anesthesia, a 20-cm midline laparotomy was created and bilateral lipocutaneous flaps were raised to expose the anterior rectus sheath. Five stainless steel hooks were placed at 1-cm intervals lateral to the midline at three locations: 5 cm above, at, and 5 cm below the umbilicus bilaterally. Baseline force measurements were taken by pulling each lateral point to midline. Laparoscopic TAR was performed unilaterally by incising the parietal peritoneum and transversus muscle lateral to the linea semilunaris. Open TAR was performed contralaterally, and force measurements were repeated. Comparisons were made to baseline and between the groups.

Results: Following laparoscopic TAR, 87 % (13/15) of points showed significant reduction compared to baseline forces, whereas only 20 % (3/15) of open TAR points had significant force reductions. Compared to open TAR, three locations favored the laparoscopic approach [1 cm lateral to midline, 5 cm above the umbilicus (p = 0.04; 95 % CI 0.78-1.00), 2 cm lateral to midline at the umbilicus (p = 0.04; 95 % CI 0.80-1.00), and 1 cm lateral to midline 5 cm below the umbilicus (p = 0.05; 95 % CI 0.79-1.00)]. The mean length of TAR was longer for laparoscopic than open at 27.29 versus 19.55 cm (p < 0.0001; 95 % CI 6.46-9.02).

Conclusions: Open TAR reduced midline tensile force at few locations, suggesting that the mechanism by which TAR facilitates herniorraphy may not solely be through reductions in linea alba tensile forces. At specific locations, laparoscopic TAR provides superior reduction in midline closure force compared to open TAR, likely as a result of a longer muscle release.
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http://dx.doi.org/10.1007/s00464-016-5040-5DOI Listing
February 2017

Colonoscopic-assisted percutaneous endoscopic gastrostomy tube placement.

Surg Endosc 2017 02 28;31(2):972-973. Epub 2016 Jun 28.

Penn State Hershey Medical Center, 500 University Ave. M.C. H149, Hershey, PA, 17033, USA.

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http://dx.doi.org/10.1007/s00464-016-5000-0DOI Listing
February 2017

Reduced postoperative pain scores and narcotic use favor per-oral endoscopic myotomy over laparoscopic Heller myotomy.

Surg Endosc 2017 02 23;31(2):795-800. Epub 2016 Jun 23.

Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA.

Introduction: Per-oral endoscopic myotomy (POEM) is a less invasive therapy for achalasia with a shorter hospitalization but with similar short- and long-term outcomes as a laparoscopic Heller myotomy (LHM). Previous literature comparing POEM to LHM has focused primarily on postoperative outcome parameters such as complications, dysphagia scores and gastro-esophageal reflux severity. This study specifically compares postoperative pain following POEM to pain following LHM, the current gold-standard operation.

Methods: A retrospective review of all patients undergoing POEM or LHM for achalasia was performed from 2006 to 2015. Data collection included demographics, comorbidities, length of stay (LOS) and pain scores (arrival to the recovery room, 1 h postoperative, average first 24 h and upon discharge). Statistical analysis was performed using Student's t test and Chi-square test.

Results: Forty-four POEM patients and 122 LHM patients were identified. The average age (52.2 ± 20.75 vs 50.9 ± 17.89 years, p = 0.306) and BMI (28.1 ± 7.62 vs 27.6 ± 7.07 kg/m, p = 0.824) did not differ between the POEM and LHM groups, respectively; however, the American Society of Anesthesiology scores were higher in the POEM patients (2.43 ± 0.62 vs 2.11 ± 0.71, p = 0.011). There were no differences in rates of smoking, diabetes, cardiac disease or pulmonary disease. The average pain scores upon arrival to the recovery room and 1 h postoperatively were lower in the POEM group (2.3 ± 3.014 vs 3.61 ± 3 0.418, p = 0.025 and 2.2 ± 2.579 vs 3.46 ± 3.063, p = 0.034, respectively). There was no difference in the average pain score over the first 24 h (2.7 ± 2.067 vs 3.29 ± 1.980, p = 0.472) or at the time of discharge (1.6 ± 2.420 vs 2.09 ± 2.157, p = 0.0657) between the POEM and LHM groups. After standardizing opioid administration against 10 mg of oral morphine, the POEM group used significantly less narcotics that the LHM group (35.8 vs 101.8 mg, p < 0.001) while hospitalized. The average LOS for the POEM group was 31.2 h and 55.79 for the LHM group (p < 0.0001). At discharge, fewer POEM patients required a prescription for a narcotic analgesic (6.81 vs 92.4 %, p < 0.0001).

Conclusion: POEM demonstrated significantly less postoperative pain upon arrival to the recovery room and 1 h postoperatively. To achieve similar pain scores during the first 24 h and at discharge, LHM patients required more narcotic analgesic administration. Despite a significantly shorter LOS, fewer POEM patients require a prescription for narcotic analgesics compared to LHM. POEM is a less painful procedure for achalasia than LHM, permitting earlier hospital discharge with little need for home narcotic use.
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http://dx.doi.org/10.1007/s00464-016-5034-3DOI Listing
February 2017

Reply: Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction.

Plast Reconstr Surg 2016 09;138(3):563e-564e

Division of Minimally Invasive and Bariatric Surgery Penn State Hershey Medical Center Hershey, Pa.

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http://dx.doi.org/10.1097/PRS.0000000000002454DOI Listing
September 2016

Changing attitudes and improving skills: demonstrating the value of the SAGES flexible endoscopy course for fellows.

Surg Endosc 2017 01 2;31(1):147-152. Epub 2016 May 2.

Houston Methodist Hospital, Houston, TX, USA.

Background: The purpose of this study was to examine the effectiveness of the SAGES flexible endoscopy course in improving fellows' attitudes, confidence, and skills related to implementing endoscopy in practice.

Methods: Fellows participated in a 2-day course consisting of case presentations, expert panels, and hands-on laboratory training. Before and after the course, fellows completed a questionnaire assessing demographics, experiences in residency, practice plans, plans to implement flexible endoscopy in practice, and level of confidence performing 15 endoscopic procedures. Half of the fellows were randomly assigned to complete pre- and post-skills testing using a previously validated endoscopic targeting model.

Results: Fifty-four fellows (90 %; age 33.5 ± 2.8; 58 % male) completed the pre- and post-questionnaire. All MIS fellowship types were represented. Almost half (48 %) reported none or very little flexible endoscopy in their current fellowship. The average prior case volume among those completing an ACGME-approved residency (42/54) was 76 upper and 75 lower endoscopies with one-third reporting no experience in therapeutic EGD (33 %) or polypectomy (31 %). Intentions to implement flexible endoscopy in practice significantly improved after the course overall (3.72 ± .85-3.92 ± .69, p < 0.05; 1 = never; 5 = very frequently). Prior to the course, 39 % of fellows reported plans to use endoscopy in practice "occasionally" or "rarely." After, this decreased to 28 with 72 % planning to implement "frequently" or "very frequently." Mean levels of confidence performing all 15 endoscopic tasks improved significantly after the course. Skills performance for the 27 fellows improved significantly as well; participants decreased their time to perform the targeting task by 40 % (222.3 ± 119.8-133.0 ± 70.1 s; p < 0.001) and decreased errors by 49 % (2.9 ± 1.7-1.5 ± 1.5; p < 0.001).

Conclusions: These results indicate that the SAGES flexible endoscopy course increases fellow confidence to implement endoscopic techniques, expands the ways in which they plan to include endoscopy in practice, and enhances their endoscopic skills.
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http://dx.doi.org/10.1007/s00464-016-4944-4DOI Listing
January 2017

Transversus Abdominis Release for Abdominal Wall Reconstruction: Early Experience with a Novel Technique.

J Am Coll Surg 2016 08 21;223(2):271-8. Epub 2016 Apr 21.

Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA. Electronic address:

Background: Ventral hernias are common sequelae of abdominal surgery. Recently, transversus abdominis release has emerged as a viable option for large or recurrent ventral hernias. Our objective was to determine the outcomes of posterior component separation via transversus abdominis release for the treatment of abdominal wall hernias in the first series of patients at one institution.

Methods: We performed a retrospective review of a prospectively maintained database of open ventral hernia repair patients to identify patients who underwent posterior component separation via transversus abdominis release at one institution from 2012 to 2015. Patients who were at least 1 year out from surgery were included. Patient demographic characteristics, operative details, perioperative and postoperative complications, and recurrences were analyzed. Postoperative imaging was reviewed for evidence of morbidity or recurrence.

Results: Thirty-seven patients met inclusion criteria; 23 (62.2%) of these patients were female, with a mean age of 57.5 ± 11 years and median BMI of 32.1 kg/m(2) (range 23.6 to 44.0 kg/m(2)). All patients underwent repair with mesh (81.1% polypropylene, 5.4% porcine dermal matrix, and 13.5% biologic/permanent synthetic hybrid). Median defect size was 392 cm(2) (range 250 to 2,700 cm(2)) and median mesh area was 930 cm(2) (range 600 to 3,600 cm(2)). Approximately 24% (9 of 37) of patients experienced a postoperative complication; ileus was the most common (4 patients). Surgical site events requiring intervention (ie drainage and antibiotics) developed in 2 patients. Median follow-up period was 21 months (range 12 to 42 months), during which one recurrence was identified (2.7%).

Conclusions: Posterior component separation via transversus abdominis release is a safe and effective method of ventral herniorrhaphy with favorable rates of wound morbidity and recurrence.
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http://dx.doi.org/10.1016/j.jamcollsurg.2016.04.012DOI Listing
August 2016