Publications by authors named "Michael R Arnold"

19 Publications

  • Page 1 of 1

Deer Stand Fall Epidemiology: An Opportunity for Injury Prevention.

Am Surg 2019 Dec;85(12):e579-e581

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December 2019

Advancing the Use of Laparoscopy in Trauma: Repair of Intraperitoneal Bladder Injuries.

Am Surg 2019 Dec;85(12):1402-1404

Traumatic intraperitoneal bladder rupture (IBR) requires surgical repair. Traditionally performed laparotomy, experience with laparoscopic bladder repair (LBR) after blunt trauma is limited. Benefits of laparoscopy include decreased length of stay (LOS), less pain, early return to work, fewer adhesions, and lower risk of incisional hernia. The aim of this series is to demonstrate the potential superiority of LBR in select trauma patients. This is a retrospective review performed of all IBR patients from 2008 to 2016. Demographics, clinical management, outcomes, and follow-up were compared between LBR and open bladder repair (OBR) patients. Twenty patients underwent OBR, and seven underwent LBR. There was no significant difference in gender, age, or Injury Severity Score. There were no deaths or reoperations in either group. Average hospital length of stay and ICU days were similar between groups. There was one patient with UTI and one with readmission in each group. There were two incisional hernias and two bowel obstructions in the OBR group, with one patient requiring operative intervention. No such complications occurred in the LBR group. LBR for traumatic IBR can be safely performed in select patients, even in those with multiple extra-abdominal injuries.
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December 2019

Mesh fistula after ventral hernia repair: What is the optimal management?

Surgery 2020 03 26;167(3):590-597. Epub 2019 Dec 26.

Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. Electronic address:

Background: A mesh-related intestinal fistula is an uncommon and challenging complication of ventral hernia repair. Optimal management is unclear owing to lack of prospective or long-term data.

Methods: We reviewed our prospective data for mesh-related intestinal fistulas from 2004 to 2017and compared suture repair versus ventral hernia repair with mesh at the time of mesh-related intestinal fistula takedown.

Results: Eighty-two mesh-related intestinal fistulas were treated; none of the fistulas had closed spontaneously, and all fistula persisted at the time of our treatment. Mean age was 61 ± 12 years with 33-month follow-up. Comorbidities were similar between groups. Defects were 2.5-times larger in ventral hernia repair with mesh (324 ± 392 cm vs 1301 ± 133 cm; P = .044). Components separation (64% vs 21%; P = .0003) and panniculectomy (35% vs 7%; P = .0074) were more common in ventral hernia repair with mesh. Mortality occurred in 4 patients. Complications were similar. In patients undergoing ventral hernia repair with non-bridged, acellular, porcine dermal matrix, hernia recurrence was less than in patients without mesh (26% vs 66%; P = .0030). Only partial excision of the mesh involved with the fistula resulted in a substantial increase in developing another fistula (29% vs 6%; P < .05).

Conclusion: Patients undergoing preperitoneal ventral hernia repair with mesh for mesh-related intestinal fistula had a lesser rate of hernia recurrence and similar complications compared to suture repair despite larger hernias. Complete mesh excision decreases the risk of fistula recurrence. We maintain that ventral hernia repair with mesh during mesh-related intestinal fistula takedown represents the best opportunity for a durable herniorrhaphy.
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http://dx.doi.org/10.1016/j.surg.2019.09.020DOI Listing
March 2020

Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP.

Am Surg 2019 Sep;85(9):1001-1009

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% 3.6% for any SSI). Postoperative sepsis (5.8% 1.5%), septic shock (4.7% 0.6%), length of stay (8.1 2.9 days), and mortality (3.6% 0.4%) were increased in emergent surgery; < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11-1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.
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September 2019

Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage.

Am J Emerg Med 2020 06 29;38(6):1097-1101. Epub 2019 Jul 29.

Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., Medical Education Building, 6th floor, Charlotte, NC 28203, United States of America. Electronic address:

Objectives: Mild traumatic brain injury (mTBI) is defined as Glasgow Coma Score (GCS) of 14 or 15. Despite good outcomes, patients are commonly transferred to trauma centers for observation and/or neurosurgical consultation. The aim of this study is to assess the value of redefining mTBI with novel radiographic criteria to determine the appropriateness of interhospital transfer for neurosurgical evaluation.

Methods: A retrospective study of patients with blunt head injury with GCS 13-15 and CT head from Jan 2014-Dec 2016 was performed. A novel criteria of head CT findings was created at our institution to classify mTBI. Outcomes included neurosurgical intervention and transfer cost.

Results: A total of 2120 patients were identified with 1442 (68.0%) meeting CT criteria for mTBI and 678 (32.0%) classified high risk. Two (0.14%) patients with mTBI required neurosurgical intervention compared with 143 (21.28%) high risk TBI (p < 0.0001). Mean age (55.8 years), and anticoagulation (2.6% vs 2.8%) or antiplatelet use (2.1% vs 3.0%) was similar between groups (p > 0.05). Of patients with mTBI, 689 were transferred without receiving neurosurgical intervention. Given an average EMS transfer cost of $700 for ground and $5800 for air, we estimate an unnecessary transfer cost of $733,600.

Conclusion: Defining mTBI with the described novel criteria clearly identifies patients who can be safely managed without transfer for neurosurgical consultation. These unnecessary transfers represent a substantial financial and resource burden to the trauma system and inconvenience to patients.
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http://dx.doi.org/10.1016/j.ajem.2019.158379DOI Listing
June 2020

The impact of abnormal BMI on surgical complications after pediatric colorectal surgery.

J Pediatr Surg 2019 Nov 3;54(11):2300-2304. Epub 2019 May 3.

Division of Pediatric Surgery, Levine Children's Hospital, 1900 Randolph Rd, #210, Charlotte, NC 28207.

Background/purpose: While childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after elective colorectal procedures.

Methods: Children ages 2-18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts.

Results: 858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p=0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p=0.04). Incremental increase in BMI by 1.0kg/m was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS.

Conclusions: Increasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.04.020DOI Listing
November 2019

Laparoscopic Weight Loss Surgery in the Elderly: An ACS NSQIP Study on the Effect of Age on Outcomes.

Am Surg 2019 Mar;85(3):273-279

In an era of rising obesity and an aging population, there are conflicting data regarding outcomes of laparoscopic weight loss surgery in older Americans. The aim of this study was to characterize the short-term outcomes of laparoscopic weight loss surgery in the elderly. The ACS NSQIP database was queried for obese patients aged ≥40 years undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. Patients were subdivided into age groups: 40 to 49, 50 to 59, 60 to 64, 65 to 69, and ≥70 years, and compared with univariate and multivariate analyses. Fifty-three thousand five hundred thirty-three patients were identified. Roux-en-Y gastric bypass was performed in 57.5 per cent of cases and was more common than sleeve gastrectomy in all age groups ( < 0.05). Comorbidities increased significantly with increasing age. There was an increase in minor (4.6% 9.1%; < 0.0001) and major complications (2.2% 6.3%; < 0.0001), and 30-day mortality (0.1% 0.5%; = 0.0001) between the 40 to 49 and ≥70 years age groups. Increased age was independently associated with major complications. Mortality also increased with age. Older patients undergoing laparoscopic weight loss surgery have increased morbidity and mortality. When controlling for comorbidities, increases in age continued to impact major and minor complications and mortality.
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March 2019

Trauma Recidivism and Mortality Following Violent Injuries in Young Adults.

J Surg Res 2019 May;237:140-147

Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina. Electronic address:

Background: Trauma recidivism accounts for approximately 44% of emergency department admissions and remains a significant health burden with this patient cohort carrying higher rates of morbidity and mortality.

Methods: A level 1 trauma center registry was queried for patients aged 18-25 y presented between 2009 and 2015. Patients with nonaccidental gunshot wounds, stab wounds, or blunt assault-related injuries were categorized as violent injuries. Primary outcomes included mortality and recidivism, which were defined as patients with two unrelated traumas during the study period. Hospital records and the Social Security Death Index were used to aid in outcomes.

Results: A total of 6484 patients presented with 1215 (18.7%) sustaining violent injuries (87.4% male, median age 22.2 y). Mechanism of violent injuries included 64.4% gunshot wound, 21.1% stab, and 14.8% blunt assault. Compared with nonviolent injuries, violent injury patients had increased risk of mortality (9.3% versus 2.1%, P < 0.0001). Out-of-hospital mortality was 2.6% (versus 0.5% nonviolent, P < 0.0005), with an average time to death being 6.4 mo from initial injury. Recidivism was 24.9% with mean time to second violent injury at 31.9 ± 21.0 mo; 14.9% had two trauma readmissions, and 8.0% had ≥3. Ninety percent of subsequent injuries occurred within 5 y, with 19.1% in the first year.

Conclusions: The burden of injury after violent trauma extends past discharge as patients have significantly higher mortality rates following hospital release. Over one-quarter present with a second unrelated trauma or death. Improved medical, psychological, and social collaborative treatment of these high-risk patients is needed to interrupt the cycle of violent injury.
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http://dx.doi.org/10.1016/j.jss.2018.09.006DOI Listing
May 2019

Short-term Outcomes of Esophagectomies in Octogenarians-An Analysis of ACS-NSQIP.

J Surg Res 2019 03 16;235:432-439. Epub 2018 Nov 16.

Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina. Electronic address:

Background: In the face of an increasingly aged population, surgical management in the elderly will rise. This study assesses the short-term outcomes of esophagectomies in octogenarians.

Material And Methods: The National Surgical Quality Improvement Program database was queried for esophagectomy cases from 2005 to 2014. Patients aged <80 and ≥80 y were compared in univariate and multivariate analysis, controlling for confounding variables.

Results: Among 9354 esophagectomies, 4.3% were performed in patients aged ≥80 y. Ivor Lewis was the most common approach, comprising 43% of cases. Octogenarians more frequently had dependent functional status (P < 0.0001) and cardiovascular disease (P < 0.0001), whereas younger patients were more likely obese (P < 0.0001), smokers (P < 0.0001), and have excess preoperative weight loss (P = 0.0043). Compared to younger patients, in multivariate analysis, elderly patients were noted to have increased risk of 30-d mortality (odds ratio [OR] 1.67; confidence interval [CI] 1.03-2.67), discharge to facility (OR 3.08; CI 2.36-4.02), myocardial infarction (OR 2.49; CI 1.29-4.82), and pneumonia (OR 1.47; CI 1.12-1.910). However, regardless of age, dependent functional status demonstrated the strongest association with mortality (OR 3.41; CI 2.14-6.61). Within the elderly, each additional year above 80 y old increased the risk of discharge to a facility by 17% (OR 1.17; CI 1.04-1.30). Cases requiring nongastric intestinal conduit were also more likely to suffer from early mortality (OR 2.87; CI 1.87-4.40).

Conclusions: Age is independently associated with multiple adverse outcomes, including mortality, discharge to facility, and postoperative cardiopulmonary complications. Functional dependence is even more so associated with poor outcomes. Careful selection of very elderly patients is required to minimize additional risk.
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http://dx.doi.org/10.1016/j.jss.2018.07.044DOI Listing
March 2019

Comparison of Outcomes After Partial Versus Complete Mesh Excision.

Ann Surg 2020 07;272(1):177-182

Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.

Objective: Evaluate outcomes of patients undergoing mesh explantation following partial mesh excision (PME) and complete mesh excision (CME).

Background: Ventral hernia repair (VHR) with mesh remains one of the most commonly performed procedures worldwide. Management of previously placed mesh during reexploration remains unclear. Studies describing PME as a feasible alternative have been limited.

Methods: The AHSQC registry was queried for VHR patients who underwent mesh excision. Variables used for propensity-matching included age, BMI, race, diabetes, COPD, OR time>2 hours, immunosuppressants, smoking, active infection, ASA class, elective case, wound classification, and history of abdominal wall infection.

Results: A total of 1904 VHR patients underwent excision of prior mesh. After propensity matching, complications were significantly higher (35% vs 29%, P = 0.01) after PME, including SSI/SSO, SSOPI, and reoperation. No differences were observed in patients with clean wounds, however in clean-contaminated, PME more frequently resulted in SSOPI (24% vs 9%, P = 0.02). In mesh infection/fistulas, higher rates of SSOPI (46% vs 24%, P = 0.04) and reoperation (21% vs 6%, P = 0.03) were seen after PME. Odds-ratio analysis showed increased likelihood of SSOPI (OR 1.5, 95% CI 1.05-2.14; P = 0.023) and reoperation (OR 2.2, 95% CI 1.13-4.10; P = 0.015) with PME.

Conclusions: With over 350,000 VHR performed annually and increasing mesh use, guidelines for management of mesh during reexploration are needed. This analysis of a multicenter hernia database demonstrates significantly increased postoperative complications in PME patients with clean-contaminated wounds and mesh infections/fistulas, however showed similar outcomes in those with clean wounds.
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http://dx.doi.org/10.1097/SLA.0000000000003198DOI Listing
July 2020

Long-term assessment of surgical and quality-of-life outcomes between lightweight and standard (heavyweight) three-dimensional contoured mesh in laparoscopic inguinal hernia repair.

Surgery 2019 04 16;165(4):820-824. Epub 2018 Nov 16.

Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC. Electronic address:

Background: Mesh weight is a possible contributor to quality-of-life outcomes after inguinal hernia repair. This study compares lightweight mesh versus heavyweight mesh in laparoscopic inguinal hernia repair.

Methods: A prospective, single-center, hernia-specific database was queried for all adult laparoscopic inguinal hernia repair with three-dimensional contoured mesh (3-D Max, Bard, Inc, New Providence, NJ) from 1999 to June 2016. Demographics and outcomes were analyzed. Quality of life was evaluated preoperatively and after 2 weeks, 4 weeks, 6 months, 12 months, and 24 months, using the Carolinas Comfort Scale. Univariate analysis and multivariate logistic regression were performed.

Results: A total of 1,424 laparoscopic inguinal hernia repair were performed with three-dimensional contoured mesh, with 804 patients receiving lightweight mesh and 620 receiving heavyweight mesh. Patients receiving lightweight mesh were somewhat younger (52.6 ± 14.8 years vs 56.3 ± 13.7 years, P < .0001), with slightly lower body mass indices (26.4 ± 9.9 vs 27.1 ± 4.3, P < .0001). Lightweight mesh was used less often in incarcerated hernias (12.5% vs 16.8%, P = .02). There were a total of 3 surgical site infections. There were no differences in complications between groups except for seroma. Although on univariate analysis, seromas appeared to occur more frequently with heavyweight mesh (21.5% vs 7.9%). On multivariate analysis, heavyweight mesh was not independently associated with seroma formation. Average follow-up was 20 months. Recurrence rates were similar between lightweight mesh and heavyweight mesh (0.7 vs 0.6% P > .05). At all points of follow-up (4 week to 3 years), quality-of-life outcomes of discomfort, mesh sensation, and movement limitation scores were similar between lightweight mesh and heavyweight mesh.

Conclusion: Contoured lightweight mesh and heavyweight mesh in laparoscopic inguinal hernia repair yield excellent recurrence rates and no difference in postoperative complications or quality of life. Considering the lack of outcome difference with long-term follow-up, heavyweight mesh may be considered for use in laparoscopic inguinal hernia repair patients.
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http://dx.doi.org/10.1016/j.surg.2018.10.016DOI Listing
April 2019

Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open.

J Am Coll Surg 2019 01 22;228(1):54-65. Epub 2018 Oct 22.

Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. Electronic address:

Background: The decision to perform laparoscopic or open ventral hernia repair (VHR) is multifactorial. This study evaluates the impact of operative approach, BMI, and hernia size on outcomes after VHR.

Study Design: The International Hernia Mesh Registry was queried for VHR (2007-2017). A predictive algorithm was constructed, factoring the impact of BMI, hernia size, age, sex, diabetes, and operative approach on outcomes.

Results: Of the 1,906 VHRs, 58.8% were performed open, patient mean age was 54.9 ± 13.5 years, BMI was 31.2 ± 6.8 kg/m, and defect area was 44.8 ± 88.1 cm. Patients undergoing open VHRs were more likely to have an infection develop (3.1% vs 0.3%; p < 0.0001), but less likely to have a seroma develop (6.8% vs 15.3%; p < 0.0001) at mean follow-up 23.2 ± 12.0 months. With multivariate regression controlling for confounding variables, patients undergoing laparoscopic VHR had increased risk of seroma (odds ratio [OR] 1.78; 95% CI 1.05 to 3.03), a decreased risk of infection (OR 0.05; 95% CI 0.01 to 0.42), and had worse quality of life at 1, 6, 12, and 24 months postoperatively compared with patients undergoing open repair. Recurrent hernias were associated with subsequent recurrence (OR 2.69; 95% CI 1.24 to 5.81) and need for reoperation (OR 4.93; 95% CI 2.24 to 10.87). Multivariate predictive models demonstrated independent predictors of infection, including open approach, recurrent hernias, and low ratio of BMI to defect size.

Conclusions: Ideal outcomes are dependent on both patient and operative factors. Open repair in thin patients with large defects should be considered due to reduced complications and improved quality of life. Laparoscopic repair in obese patients and recurrent hernias can decrease the associated risk of infection.
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http://dx.doi.org/10.1016/j.jamcollsurg.2018.09.004DOI Listing
January 2019

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial.

Pediatr Surg Int 2018 Dec 14;34(12):1257-1268. Epub 2018 Sep 14.

Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA.

Purpose: To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis.

Methods: This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared.

Results: Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001).

Conclusion: Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.
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http://dx.doi.org/10.1007/s00383-018-4343-0DOI Listing
December 2018

Building a Multidisciplinary Hospital-Based Abdominal Wall Reconstruction Program: Nuts and Bolts.

Plast Reconstr Surg 2018 09;142(3 Suppl):201S-208S

From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center.

Background: A nationwide trend toward "centers of excellence" for medical and surgical care has led to development and scrutiny of high-volume surgical specialty centers. The prevalence of hernias and the complexity of successful repair have led to the establishment of specialty practices. Herein we review and discuss the components of the successful establishment of a tertiary hernia referral center.

Methods: Literature on establishment and impact of hernia specialty centers was reviewed, including the authors' own practice. Factors and outcomes concerning the coordination, development, funding, and staffing of a hernia center were discussed and tabulated.

Results: After establishment of a tertiary hernia center or center of excellence, institutions have reported an increase in surgical case volume, hernia complexity, patient comorbidity, and the area from which patients will travel. Driving factors for this practice development are varied and include team development, improvement in patient preoperative factors, and surgical outcomes assessment, among others.

Conclusions: Establishment of a successful tertiary hernia referral center often includes institution participation, surgical expertise, interdisciplinary collaboration, and ongoing evaluation of outcomes. Success may be marked by increased case volume and tertiary referrals, but it is most evidenced by improved patient outcomes.
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http://dx.doi.org/10.1097/PRS.0000000000004879DOI Listing
September 2018

Measuring Success in Complex Abdominal Wall Reconstruction: The Role of Validated Outcome Scales.

Plast Reconstr Surg 2018 09;142(3 Suppl):163S-170S

From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center; and Department of Surgery, New Hanover Regional Medical Center, UNC-Chapel Hill.

Background: Diminished quality of life (QOL) often drives patients to hernia repair, and patient-reported outcomes have gained importance in hernia research. Functional outcomes provide a patient-centered evaluation of a treatment, and improved QOL is a desired outcome assessing treatment effectiveness.

Methods: Properties of validated QOL measure are reviewed and distinctions between generic and disease-specific measures are discussed. Based on a review of the literature, current validated outcome scales are evaluated and compared.

Results: Currently, there is little agreement over the best means to measure QOL. As a result, several measures have been created, focusing on several distinct aspects of QOL. While generic measures provide global assessments, disease-specific measures report changes as they relate to the hernia itself and hernia surgery. With the introduction of new QOL measures, it is important to understand the properties of a good QOL measure.

Conclusions: Several questions remain unanswered regarding QOL, including which measures best assess hernia patients, what is the ideal time to evaluate QOL, and for how long postoperatively should QOL be measured. The introduction of guidelines to address these issues may enable improvement in value assessment.
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http://dx.doi.org/10.1097/PRS.0000000000004873DOI Listing
September 2018

Prevention and Treatment Strategies for Mesh Infection in Abdominal Wall Reconstruction.

Plast Reconstr Surg 2018 09;142(3 Suppl):149S-155S

From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center.

Background: Mesh infection remains the most feared complication after abdominal wall reconstruction, requiring prolonged hospitalizations and often, mesh removal. Understanding of current prevention and treatment strategies is necessary in the management of a common surgical problem.

Methods: A comprehensive review of the current surgical literature was performed to determine risk factors of mesh infection after abdominal wall reconstruction and best practices in their prevention and surgical management.

Results: Patient-related risk factors for mesh infections include smoking, obesity, diabetes mellitus, and COPD. Surgical risk factors such as prolonged operative time and prior enterotomy should also be considered. Prevention strategies emphasize reduction of modifiable risk factors, including obesity and diabetes among other comorbidities. Biologic or biosynthetic mesh is recommended in contaminated fields and use of delayed wound closure or vacuum-assisted closure therapy should be considered in high-risk patients. Conservative treatment with antibiotics, percutaneous or surgical drainage, and negative-pressure vacuum-based therapies have demonstrated limited success in mesh salvage. Mesh infection often requires mesh explantation followed by abdominal wall reconstruction. Staged repairs can be performed; however, definitive hernia repair with biologic mesh has shown promising results.

Conclusions: Management of mesh infections is a complex, yet commonly faced problem. Strategies used in the prevention and surgical treatment of infected mesh should continue to be supported by high-quality evidence from prospective studies.
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http://dx.doi.org/10.1097/PRS.0000000000004871DOI Listing
September 2018

Epiphrenic Diverticulum: 20-Year Single-Institution Experience.

Am Surg 2018 Jul;84(7):1159-1163

Epiphrenic diverticula are pulsion-type outpouchings of the distal esophagus associated with motility disorders. They can present with chronic symptoms of dysphagia, regurgitation, reflux, and aspiration. A prospectively collected surgical outcomes database was queried for patients who underwent surgical treatment of epiphrenic diverticula at a single institution between August 1997 and August 2018. Patient demographics, presenting symptoms, operative intervention, and perioperative data were retrospectively reviewed. Twenty-seven patients with a symptomatic epiphrenic diverticulum were identified. Abnormal esophageal motility was diagnosed in 16 patients (59.2%), most commonly achalasia (29.6%). All patients had a minimally invasive (26 laparoscopic, one thoracoscopic) diverticulectomy with no conversions to open required. Concurrent myotomy was performed in 88.9 per cent patients and anti-reflux procedure in 85.2 per cent patients. There was minimal morbidity with no esophageal leaks, mortalities, or recurrent diverticula noted after 35.8 months of follow-up. Dysphagia was the most common persistent symptom and occurred in 11.1 per cent; overall resolution of symptoms was achieved with surgery in 89.9 per cent of patients. As minimally invasive techniques have advanced, laparoscopic diverticulectomy seems to be an excellent surgical approach for symptomatic epiphrenic diverticula. Long-term resolution of symptoms was achieved in most patients, with a very low complication rate.
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July 2018

Thoracoscopic Versus Open Congenital Diaphragmatic Hernia Repair: Single Tertiary Center Review.

J Laparoendosc Adv Surg Tech A 2017 Nov 4;27(11):1209-1216. Epub 2017 Oct 4.

2 Pediatric Surgical Associates, Levine Children's Hospital , Charlotte, North Carolina.

Background: Congenital diaphragmatic hernia (CDH) can be repaired open or through thoracoscopy. Thoracoscopic CDH repair could improve cosmesis and avoid the complications of laparotomy, but may have higher recurrence rates. The purpose of this study was to examine the outcomes of thoracoscopic versus open CDH repair, with regard to recurrence, perioperative parameters, and postoperative complications.

Methods: We performed a retrospective review of open versus thoracoscopic CDH repairs over an 8.5-year period. The primary outcome was hernia recurrence. Secondary outcomes included intraoperative partial pressure of carbon dioxide (pCO) levels, length of stay, and postoperative complications. All statistical analyses were performed using standard statistical methods.

Results: A total of 54 infants underwent CDH repair during the study period, of whom 25 underwent successful thoracoscopic repair. Two patients who had undergone open repair developed recurrent diaphragmatic hernias (recurrence rate 3.7%). Operative time and intraoperative pCO levels did not differ between groups. Length of stay was shorter in the thoracoscopic cohort. Four patients in the open cohort developed ventral hernias and five developed bowel obstructions during follow-up. No long-term complications were identified in the thoracoscopic cohort. The median follow-up was 27 months.

Conclusions: In our experience, thoracoscopic CDH repair was performed safely and with similar outcomes compared to open repair. In addition to improved cosmesis, thoracoscopic repair may avoid some of the long-term complications of laparotomy. In our series, none of the thoracoscopic CDH repairs recurred. We conclude that thoracoscopic CDH repair is a safe and appropriate technique for select neonates.
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http://dx.doi.org/10.1089/lap.2017.0298DOI Listing
November 2017

Assessing the need for knowledge on injury management among high school athletic coaches in South Dakota.

S D Med 2010 Jul;63(7):241-5

University of South Dakota School of Health Sciences, Department of Physical Therapy, Vermillion, SD, USA.

Background: A lack of health coverage at athletic competitions and practices poses concern over the knowledge coaches have in providing adequate health care to high school (HS) athletes. Therefore, the purpose of this study was to determine the need for education of coaches in the prevention, assessment and management of sports-related injuries in South Dakota (SD).

Methods: Survey link e-mailed to 1,050 HS athletic head coaches in SD; 247 (23.5 percent) completed the prospective, web-based survey.

Results: Of the respondents, 74.91 percent reported HS enrollments less than 300, with 79.36 percent in rural/frontier counties and 28.74 percent in medically underserved areas. Coaches from 14 sports responded. The majority indicated they were responsible for the immediate medical care of athletes at practices (89.07 percent) and competitions (74.90 percent); and 79.76 percent of coaches agreed or strongly agreed they needed more injury management education. Results also indicated less than 50.00 percent had current certifications in CPR/BLS (46.65 percent) and first aid (47.4 percent).

Conclusions: Due to the demand placed on head coaches to be the initial caregivers for injured athletes, there is a need for increased education of SD coaches related to the management of acute sports injuries. Additionally, policy changes may be indicated to address the lack of medical personnel available during HS athletic competitions and practices.
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July 2010