Publications by authors named "Rebeccah Baucom"

35 Publications

Update: Telehealth in Colon and Rectal Surgery.

Dis Colon Rectum 2021 Jun;64(6):642-644

Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, California.

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http://dx.doi.org/10.1097/DCR.0000000000002019DOI Listing
June 2021

Parastomal Varices with Recurrent Bleeding in the Absence of Liver Cirrhosis.

Case Rep Gastrointest Med 2020 14;2020:2653848. Epub 2020 Sep 14.

Department of Medical Education, Texas Tech University Health Sciences Center, Lubbock, TX, USA.

Gastrointestinal (GI) bleeding is a common problem in patients with portal hypertension. One of the most common causes of GI bleeding are varices (e.g., esophageal varices). In some instances, varices can develop between an intestinal stoma and the abdominal wall vasculature, known as parastomal varices. Specifically, parastomal varices are common in patients with a preexisting stoma and concurrent chronic portal hypertension. These patients often present with recurrent bleeding and may require regular transfusions. Herein, we report on a patient with parastomal varices and portal hypertension without hepatic cirrhosis. Given the high morbidity and mortality associated with surgical interventions, most clinical guidelines encourage observation and medical management of bleeding from parastomal varices. Among the nonsurgical interventions, manual compression and local maneuvers often successfully stop the bleeding. However, subsequent rebleeding from parastomal varices can remain a problem requiring additional treatment. Further research is needed to investigate appropriate medical or surgical alternatives for managing parastomal varices bleeding.
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http://dx.doi.org/10.1155/2020/2653848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509571PMC
September 2020

What Every Colorectal Surgeon Should Know About Telemedicine.

Dis Colon Rectum 2020 04;63(4):418-419

On behalf of the Healthcare Economics Committee of the American Society of Colon and Rectal Surgeons.

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http://dx.doi.org/10.1097/DCR.0000000000001635DOI Listing
April 2020

Benchmarking patient satisfaction scores in a colorectal patient population.

Surg Endosc 2021 01 10;35(1):309-316. Epub 2020 Feb 10.

Division of General Surgery, Colon and Rectal Surgery, Vanderbilt University Medical Center, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA.

Background: Healthcare reimbursement is rapidly moving away from a fee-for-service model toward value-based purchasing. An integral component of this new focus on quality is patient-centered outcomes. One metric used to define patient satisfaction is the Press Ganey Patient Satisfaction Survey. Data are lacking to accurately benchmark these scores based on diagnosis. We sought to identify if different colorectal disease processes affected a patient's perception of their healthcare experience.

Methods: Adult colorectal patients seen between July 2015 and September 2016 in a tertiary hospital colorectal clinic were mailed a Press Ganey survey. Patients were stratified based on diagnosis: neoplasia, IBD, anorectal and benign colorectal disease. Survey scores were compared across the groups with adjustment for confounding variables.

Results: 312 patients responded and formed the cohort. The mean age was 61 (range 18-93) and 56% were women. The cohort breakdown was 38% neoplasia, 32% anorectal, 21% benign, and 9% IBD. In a multivariable model, there was a difference in PG scores by diagnosis; patients with neoplasia had higher Overall scores (β 10.2; Std Error 4.0; p = 0.01), Care Provider scores (β 8.5; Std Error 4.2; p = 0.04), Nurse Assistant scores (β 15.0; Std Error 5.7; p = 0.01), and Personal Issues scores (β 11.8; Std Error 5/0; p = 0.01).

Conclusion: Press Ganey scores were found to vary significantly. Patients with a neoplasia diagnosis reported higher overall satisfaction, Care Provider, Nurse Assistant, and Personal Issues scores. Adjustment for disease condition is important when assessing patient satisfaction as an indicator of quality and as a metric for reimbursement. This study adds to increasing evidence about bias in these scores.
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http://dx.doi.org/10.1007/s00464-020-07401-1DOI Listing
January 2021

Nodal Disease in Rectal Cancer Patients With Complete Tumor Response After Neoadjuvant Chemoradiation: Danger Below Calm Waters.

Dis Colon Rectum 2017 Dec;60(12):1260-1266

1 Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 2 Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota.

Background: A subset of patients with rectal cancer who undergo neoadjuvant chemoradiation therapy will develop a complete pathologic tumor response. Complete nodal response is not universal in these patients and is difficult to assess clinically. Quantifying the risk of nodal disease would allow for targeted therapy with either radical resection or "watchful waiting."

Objective: This study aimed to identify risk factors for residual nodal disease in ypT0 rectal adenocarcinoma.

Design: This is a retrospective case control study.

Settings: The National Cancer Database 2006 to 2014 was used to identify patients for this study.

Patients: Patients with stage II/III rectal adenocarcinoma who completed chemoradiation therapy followed by resection and who had ypT0 tumors were included. Patients with metastatic disease and <2 lymph nodes evaluated were excluded. Patients were divided into 2 groups: node positive and node negative.

Main Outcome Measures: The main outcome was nodal disease. The secondary outcome was overall survival.

Results: A total of 42,257 patients with stage II/III rectal cancer underwent chemoradiation therapy and radical resection; 4170 (9.9%) patients had ypT0 tumors and 395 (9.5%) were node positive. Of patients with clinically node-negative disease (ie, pretreatment imaging), 6.2% were node positive after chemoradiation therapy and resection. In multivariable analysis, factors predictive of nodal disease included increasing (pretreatment) clinical N-stage, high tumor grade (3/4), perineural invasion, and lymphovascular invasion. Higher clinical T-stage was inversely associated with residual nodal disease. Overall 5-year survival was significantly different between patients with ypN0, ypN1, and ypN2 disease (87.4%, 82.2%, and 62.5%, p = 0.002).

Limitations: This study was limited by the lack of clinical detail in the database and the inability to assess recurrence.

Conclusions: Ten percent of patients with ypT0 tumors had positive nodes after chemoradiation therapy and resection. Factors associated with residual nodal disease included clinical nodal disease at diagnosis and poor histologic features. Patients with any of these features should consider radical resection regardless of tumor response. Others could be suitable for "watchful waiting" strategies. See Video Abstract at http://links.lww.com/DCR/A458.
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http://dx.doi.org/10.1097/DCR.0000000000000947DOI Listing
December 2017

Commentary on "Perioperative hypothermia: turning up the heat on the conversation".

Transl Gastroenterol Hepatol 2016 16;1:17. Epub 2016 Mar 16.

Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

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http://dx.doi.org/10.21037/tgh.2016.03.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244756PMC
March 2016

Surgical Education and Health Care Reform: Defining the Role and Value of Trainees in an Evolving Medical Landscape.

Ann Surg 2017 03;265(3):459-460

*Duke University, Durham, NC †Barking, Havering and Redbridge University Hospital, Romford, Essex, UK ‡Vanderbilt University Medical Center, Nashville, TN §Massachussetts General Hospital, Boston, MA ¶VA MidSouth Health Care Network, Nashville, TN.

Objective: Health care reform and surgical education are often separated functionally. However, especially in surgery, where resident trainees often spend twice as much time in residency and fellowship than in undergraduate medical education, one must consider their contributions to health care.

Summary Background Data: In this short commentary, we briefly review the status of health care in the United States as well as some of the recent and current changes in graduate medical education that pertain to surgical trainees.

Methods: This is a perspective piece that draws on the interests and varied background of the multiinstitutional and international group of authors.

Results: The authors propose 3 main areas of focus for research and practice- (1) accurately quantifying the care provided currently by trainees, (2) determining impact to trainees and hospital systems of training parameters, focusing on long-term outcomes rather than short-term outcomes, and (3) determining practice models of education that work best for both health care delivery and trainees.

Conclusions: The authors propose that surgical education must align itself with rather than separate itself from overall health care reform measures and even individual hospital financial pressures. This should not be seen as additional burden of service, but rather practical education in training as to the pressures trainees will face as future employees. Rethinking the contributions and training of residents and fellows may also synergistically work to impress to hospital administrators that providing better, more focused and applicable education to residents and fellows may have long-term, strategic, positive impacts on institutions.
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http://dx.doi.org/10.1097/SLA.0000000000002021DOI Listing
March 2017

Cancer Survivorship: Defining the Incidence of Incisional Hernia After Resection for Intra-Abdominal Malignancy.

Ann Surg Oncol 2016 12 14;23(Suppl 5):764-771. Epub 2016 Oct 14.

Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: Cancer survivorship focuses largely on improving quality of life. We aimed to determine the rate of ventral incisional hernia (VIH) formation after cancer resection, with implications for survivorship.

Methods: Patients without prior VIH who underwent abdominal malignancy resections at a tertiary center were followed up to 2 years. Patients with a viewable preoperative computed tomography (CT) scan and CT within 2 years postoperatively were included. Primary outcome was postoperative VIH on CT, reviewed by a panel of surgeons uninvolved with the original operation. Factors associated with VIH were determined using Cox proportional hazards regression.

Results: 1847 CTs were reviewed among 491 patients (59 % men), with inter-rater reliability 0.85 for the panel. Mean age was 60 ± 12 years; mean follow-up time 13 ± 8 months. VIH occurred in 41 % and differed across diagnoses: urologic/gynecologic (30 %), colorectal (53 %), and all others (56 %) (p < 0.001). Factors associated with VIH (adjusting for stage, age, adjuvant therapy, smoking, and steroid use) included: incision location [flank (ref), midline, hazard ratio (HR) 6.89 (95 %CI 2.43-19.57); periumbilical, HR 6.24 (95 %CI 1.84-21.22); subcostal, HR 4.55 (95 %CI 1.51-13.70)], cancer type [urologic/gynecologic (ref), other {gastrointestinal, pancreatic, hepatobiliary, retroperitoneal, and others} HR 1.86 (95 %CI 1.26-2.73)], laparoscopic-assisted operation [laparoscopic (ref), HR 2.68 (95 %CI 1.44-4.98)], surgical site infection [HR 1.60 (95 %CI 1.08-2.37)], and body mass index [HR 1.06 (95 %CI 1.03-1.08)].

Conclusions: The rate of VIH after abdominal cancer operations is high. VIH may impact cancer survivorship with pain and need for additional operations. Further studies assessing the impact on QOL and prevention efforts are needed.
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http://dx.doi.org/10.1245/s10434-016-5546-zDOI Listing
December 2016

Hidden Morbidity of Ventral Hernia Repair with Mesh: As Concerning as Common Bile Duct Injury?

J Am Coll Surg 2017 01 8;224(1):35-42. Epub 2016 Oct 8.

Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.

Background: Ventral hernia repair with mesh is increasingly common, but the incidence of long-term complications that necessitate mesh explantation is unknown. We aimed to determine the epidemiology of mesh explantation after ventral hernia repair and to compare this with common bile duct injury, a dreaded complication of laparoscopic cholecystectomy.

Study Design: We evaluated a retrospective cohort of patients undergoing ventral hernia repair by linking the all-payers State Inpatient Databases and State Ambulatory Surgery Databases for New York, California, and Florida. We followed patients longitudinally from 2005 to 2011 for the primary end point of mesh explantation, designated by concurrent procedure codes for ventral hernia repair and foreign body removal. We determined time to mesh explantation and calculated cumulative costs for surgical care, comparing these with historical data for common bile duct injury.

Results: During the study period, 619,751 patients underwent at least one ventral hernia repair (91% open, 9% laparoscopic). In a mean follow-up of 3 years, 438 patients (0.07%) had mesh removed at a median of 346 days after repair. Median cumulative cost for patients requiring mesh explantation was $21,889 vs $6,983 without (p < 0.01). Rates of mesh explantation and costs were on par with laparoscopic common bile duct injury, based on published data, but occurred later in the postoperative course.

Conclusions: By this conservative estimate, complications of ventral hernia repair with implantable mesh are comparably as frequent as for common bile duct injury, but occur later in a patient's experience. Long-term follow-up is critically necessary to fully understand the ramifications of implanted devices.
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http://dx.doi.org/10.1016/j.jamcollsurg.2016.09.016DOI Listing
January 2017

Abdomen and spinal cord segmentation with augmented active shape models.

J Med Imaging (Bellingham) 2016 Jul 26;3(3):036002. Epub 2016 Aug 26.

Vanderbilt University, Electrical Engineering, 2301 Vanderbilt Place, P.O. Box 351679 Station B, Nashville, Tennessee 37235, United States; Vanderbilt University, Institute of Imaging Science, 1161 21st Avenue South, AA-1105, Nashville, Tennessee 37232, United States; Vanderbilt University, Radiology and Radiological Science, 1161 21st Avenue South, Nashville, Tennessee 37203, United States.

Active shape models (ASMs) have been widely used for extracting human anatomies in medical images given their capability for shape regularization of topology preservation. However, sensitivity to model initialization and local correspondence search often undermines their performances, especially around highly variable contexts in computed-tomography (CT) and magnetic resonance (MR) images. In this study, we propose an augmented ASM (AASM) by integrating the multiatlas label fusion (MALF) and level set (LS) techniques into the traditional ASM framework. Using AASM, landmark updates are optimized globally via a region-based LS evolution applied on the probability map generated from MALF. This augmentation effectively extends the searching range of correspondent landmarks while reducing sensitivity to the image contexts and improves the segmentation robustness. We propose the AASM framework as a two-dimensional segmentation technique targeting structures with one axis of regularity. We apply AASM approach to abdomen CT and spinal cord (SC) MR segmentation challenges. On 20 CT scans, the AASM segmentation of the whole abdominal wall enables the subcutaneous/visceral fat measurement, with high correlation to the measurement derived from manual segmentation. On 28 3T MR scans, AASM yields better performances than other state-of-the-art approaches in segmenting white/gray matter in SC.
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http://dx.doi.org/10.1117/1.JMI.3.3.036002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999587PMC
July 2016

Current trends in the practice of endoscopy among surgeons in the USA.

Surg Endosc 2017 04 17;31(4):1675-1679. Epub 2016 Aug 17.

Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Medical Center North, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN, 37232-2730, USA.

Background: The diagnostic and therapeutic roles for endoscopic intervention are expanding. To continue emphasis on endoscopy in surgical training, The Society of American Gastrointestinal and Endoscopic Surgeons has developed the Fundamentals of Endoscopic Surgery (FES) course to standardize and assess endoscopy training. However, little demographic information exists about the current practice of endoscopy by general surgeons and how to best integrate endoscopic skills into surgical training.

Methods: A survey to collect data regarding the current practice patterns of endoscopy was sent to surgeons with a valid email address in the American Medical Association masterfile. Information regarding the type of training (academic vs. community general surgery residency) and current practice environment (academic medical center vs. community hospital) was collected. The respondents' current practice volume of upper endoscopy and colonoscopy over the prior year was stratified into three groups: rare (<1 per month), moderate (1-10 per month), and frequent (>10 per month). Pearson's Chi-squared test was used to analyze the data.

Results: The survey was sent to 9902 general surgeons. There were 767 who provided answers regarding their current practice of endoscopy. Mean time in practice was 18 ± 10 years, 87 % were male, and 83 % practiced in a metropolitan area. Respondents who trained at academic general surgery programs were less likely than those at community programs to frequently perform colonoscopy (17.3 vs. 27.9 %, p < 0.05) and upper endoscopy (11.8 vs. 17.1 %, p < 0.05). Those who currently practice in academic medical centers were also less likely to be frequent performers of colonoscopy (5.6 vs. 24.7 %, p < 0.05) and upper endoscopy (9.8 vs. 14.8 %, p < 0.05) than those who practice at community hospitals.

Conclusions: The type of residency training and current practice setting of general surgeons has a significant influence on the volume of endoscopic procedures performed. This study identifies areas where more emphasis on endoscopic skills training is needed, such as FES.
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http://dx.doi.org/10.1007/s00464-016-5157-6DOI Listing
April 2017

Whole Abdominal Wall Segmentation using Augmented Active Shape Models (AASM) with Multi-Atlas Label Fusion and Level Set.

Proc SPIE Int Soc Opt Eng 2016 Feb 21;9784. Epub 2016 Mar 21.

Electrical Engineering, Vanderbilt University, Nashville, TN, USA 37235; Radiology and Radiological Science, Vanderbilt University, Nashville, TN, USA 37235.

The abdominal wall is an important structure differentiating subcutaneous and visceral compartments and intimately involved with maintaining abdominal structure. Segmentation of the whole abdominal wall on routinely acquired computed tomography (CT) scans remains challenging due to variations and complexities of the wall and surrounding tissues. In this study, we propose a slice-wise augmented active shape model (AASM) approach to robustly segment both the outer and inner surfaces of the abdominal wall. Multi-atlas label fusion (MALF) and level set (LS) techniques are integrated into the traditional ASM framework. The AASM approach globally optimizes the landmark updates in the presence of complicated underlying local anatomical contexts. The proposed approach was validated on 184 axial slices of 20 CT scans. The Hausdorff distance against the manual segmentation was significantly reduced using proposed approach compared to that using ASM, MALF, and LS individually. Our segmentation of the whole abdominal wall enables the subcutaneous and visceral fat measurement, with high correlation to the measurement derived from manual segmentation. This study presents the first generic algorithm that combines ASM, MALF, and LS, and demonstrates practical application for automatically capturing visceral and subcutaneous fat volumes.
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http://dx.doi.org/10.1117/12.2216841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4845968PMC
February 2016

Evaluation of Body-Wise and Organ-Wise Registrations For Abdominal Organs.

Proc SPIE Int Soc Opt Eng 2016 Feb 21;9784. Epub 2016 Mar 21.

Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, USA 37235; Biomedical Engineering, Vanderbilt University, Nashville, TN, USA 37235; Radiology and Radiological Science, Vanderbilt University, Nashville, TN 37235.

Identifying cross-sectional and longitudinal correspondence in the abdomen on computed tomography (CT) scans is necessary for quantitatively tracking change and understanding population characteristics, yet abdominal image registration is a challenging problem. The key difficulty in solving this problem is huge variations in organ dimensions and shapes across subjects. The current standard registration method uses the global or body-wise registration technique, which is based on the global topology for alignment. This method (although producing decent results) has substantial influence of outliers, thus leaving room for significant improvement. Here, we study a new image registration approach using local (organ-wise registration) by first creating organ-specific bounding boxes and then using these regions of interest (ROIs) for aligning references to target. Based on Dice Similarity Coefficient (DSC), Mean Surface Distance (MSD) and Hausdorff Distance (HD), the organ-wise approach is demonstrated to have significantly better results by minimizing the distorting effects of organ variations. This paper compares exclusively the two registration methods by providing novel quantitative and qualitative comparison data and is a subset of the more comprehensive problem of improving the multi-atlas segmentation by using organ normalization.
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http://dx.doi.org/10.1117/12.2217082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4845963PMC
February 2016

Quantitative CT Imaging of Ventral Hernias: Preliminary Validation of an Anatomical Labeling Protocol.

PLoS One 2015 28;10(10):e0141671. Epub 2015 Oct 28.

Electrical Engineering, Vanderbilt University, Nashville, Tennessee, United States of America; Radiology and Radiological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America.

Objective: We described and validated a quantitative anatomical labeling protocol for extracting clinically relevant quantitative parameters for ventral hernias (VH) from routine computed tomography (CT) scans. This information was then used to predict the need for mesh bridge closure during ventral hernia repair (VHR).

Methods: A detailed anatomical labeling protocol was proposed to enable quantitative description of VH including shape, location, and surrounding environment (61 scans). Intra- and inter-rater reproducibilities were calculated for labeling on 18 and 10 clinically acquired CT scans, respectively. Preliminary clinical validation was performed by correlating 20 quantitative parameters derived from anatomical labeling with the requirement for mesh bridge closure at surgery (26 scans). Prediction of this clinical endpoint was compared with similar models fit on metrics from the semi-quantitative European Hernia Society Classification for Ventral Hernia (EHSCVH).

Results: High labeling reproducibilities were achieved for abdominal walls (±2 mm in mean surface distance), key anatomical landmarks (±5 mm in point distance), and hernia volumes (0.8 in Cohen's kappa). 9 out of 20 individual quantitative parameters of hernia properties were significantly different between patients who required mesh bridge closure versus those in whom fascial closure was achieved at the time of VHR (p<0.05). Regression models constructed by two to five metrics presented a prediction with 84.6% accuracy for bridge requirement with cross-validation; similar models constructed by EHSCVH variables yielded 76.9% accuracy.

Significance: Reproducibility was acceptable for this first formal presentation of a quantitative image labeling protocol for VH on abdominal CT. Labeling-derived metrics presented better prediction of the need for mesh bridge closure than the EHSCVH metrics. This effort is intended as the foundation for future outcomes studies attempting to optimize choice of surgical technique across different anatomical types of VH.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0141671PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4624799PMC
June 2016

Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery.

J Am Coll Surg 2015 Dec 23;221(6):1057-66. Epub 2015 Sep 23.

Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.

Background: Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations.

Study Design: A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times.

Results: Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01).

Conclusions: In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.
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http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4662904PMC
December 2015

Patient reported outcomes after incisional hernia repair-establishing the ventral hernia recurrence inventory.

Am J Surg 2016 Jul 31;212(1):81-8. Epub 2015 Jul 31.

Department of Surgery, Vanderbilt University Medical Center, Nashville, 1161 Medical Center Drive, D-5203 Medical Center North, TN 37232, USA.

Background: Assessing incisional hernia recurrence typically requires a clinical encounter. We sought to determine if patient-reported outcomes (PROs) could detect long-term recurrence.

Methods: Adult patients 1 to 5 years after incisional hernia repair were prospectively asked about recurrence, bulge, and pain at the original repair site. Using dynamic abdominal sonography for hernia to detect recurrence, performance of each PRO was determined. Multivariable regression was used to evaluate PRO association with recurrence.

Results: Fifty-two patients enrolled with follow-up time 46 ± 13 months. A patient-reported bulge was 85% sensitive, and 81% specific to detect recurrence. Patients reporting no bulge and no pain had 0% chance of recurrence. In multivariable analysis, patients reporting a bulge were 18 times more likely to have a recurrence than those without (95% confidence interval, 3.7 to 90.0; P < .001).

Conclusions: This preliminary study demonstrates that PROs offer a promising means of detecting long-term recurrence after incisional hernia repair, which can help facilitate quality improvement and research efforts.
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http://dx.doi.org/10.1016/j.amjsurg.2015.06.007DOI Listing
July 2016

Previous Methicillin-Resistant Staphylococcus aureus Infection Independent of Body Site Increases Odds of Surgical Site Infection after Ventral Hernia Repair.

J Am Coll Surg 2015 Aug 1;221(2):470-7. Epub 2015 May 1.

Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.

Background: Methicillin-resistant Staphylococcus aureus infections can be difficult to manage in ventral hernia repair (VHR). We aimed to determine whether a history of preoperative MRSA infection, regardless of site, confers increased odds of 30-day surgical site infection (SSI) after VHR.

Study Design: A retrospective cohort study of patients undergoing VHR with class I to III wounds between 2005 and 2012 was performed using Vanderbilt University Medical Center's Perioperative Data Warehouse. Preoperative MRSA status, site of infection, and 30-day SSI were determined. Univariate and multivariate analyses adjusting for confounding factors were performed to determine whether a history of MRSA infection was independently associated with SSIs.

Results: A total of 768 VHR patients met inclusion criteria, of which 46% were women. There were 54 (7%) preoperative MRSA infections (MRSA positive); 15 (28%) soft tissue, 9 (17%) bloodstream, 4 (7%) pulmonary, 3 (6%) urinary, and 5 (9%) other. Overall SSI rate was 10% (n = 80), SSI rate in the MRSA-positive group was 33% (n = 18), compared with 9% (n = 62) in controls (p < 0.001). Multivariate analysis demonstrated that a history of MRSA infection significantly increased odds of 30-day SSI after VHR by 2.3 times (95% CI, 1.1-4.8; p = 0.035). Other factors associated with postoperative SSI were performance of myofascial release, increasing BMI, length of operation, open repair, and clean-contaminated wound classification.

Conclusions: A history of site-independent MRSA infection confers significantly increased odds of 30-day SSI after VHR. Additional investigation is needed to determine perioperative treatment regimens that might decrease odds of SSI in VHR, and optimal prosthetic types and techniques for this population.
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http://dx.doi.org/10.1016/j.jamcollsurg.2015.04.023DOI Listing
August 2015

Incisional Hernia Classification Predicts Wound Complications Two Years after Repair.

Am Surg 2015 Jul;81(7):679-86

Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Classification of ventral hernias (VHs) into categories that impact surgical outcome is not well defined. The European Hernia Society (EHS) classification divides ventral incisional hernias by midline or lateral location. This study aimed to determine whether EHS classification is associated with wound complications after VH repair, indicated by surgical site occurrences (SSOs). A retrospective cohort study of patients who underwent VH repair at a tertiary referral center between July 1, 2005 and May 30, 2012, was performed. EHS classification, comorbidities, and operative details were determined. Primary outcome was SSO within two years, defined as an infection, wound dehiscence, seroma, or enterocutaneous fistula. There were 538 patients included, and 51.5 per cent were female, with a mean age of 54.2 ± 12.4 years and a mean body mass index of 32.4 ± 8.6 kg/m(2). Most patients had midline hernias (87.0%, n = 468). There were 47 patients (8.7%) who had a lateral hernia, and 23 patients (4.3%) whose repair included both midline and lateral components. Overall rate of SSO was 39 per cent (n = 211) within two years. The rate of SSO by VH location was: 39 per cent (n = 183) for midline, 23 per cent (n = 11) for lateral, and 74 per cent (n = 17) for VHs with midline and lateral components (P = <0.001). Patients whose midline hernia spanned more than one EHS category also had a higher rate of SSOs (P = 0.001). VHs are often described by transverse dimension alone, but a more descriptive classification system offers a richness that correlates with outcomes.
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July 2015

Surgeons, ERCP, and laparoscopic common bile duct exploration: do we need a standard approach for common bile duct stones?

Surg Endosc 2016 Feb 20;30(2):414-423. Epub 2015 Jun 20.

Department of Surgery, Vanderbilt University Medical Center, D-5203 MCN, VUMC, 1161 Medical Center Drive, Nashville, TN, 37232, USA.

Background: Variation exists in the management of choledocholithiasis (CDL). This study evaluated associations between demographic and practice-related characteristics and CDL management.

Methods: A 22-item, web-based survey was administered to US general surgeons. Respondents were classified into metropolitan or nonmetropolitan groups by zip code. Univariate tests and multivariable logistic regression were used to determine factors associated with CDL management preferences.

Results: The survey was sent to 32,932 surgeons; 9902 performed laparoscopic cholecystectomy within the last year; 750 of 771 respondents had a valid US zip code and were included in the analysis. Mean practice time was 18 ± 10 years, 87% were male, and 83% practiced in a metropolitan area. For preoperatively known CDL, 86% chose preoperative endoscopic retrograde cholangiopancreatography (ERCP). Those in metropolitan areas were more likely to select preoperative ERCP than those in nonmetropolitan areas (88 vs. 79%, p < 0.001). For CDL discovered intraoperatively, 30% selected laparoscopic common bile duct exploration (LCBDE) as their preferred method of management with no difference between metropolitan and nonmetropolitan areas (30 vs. 26%, p = 0.335). The top reasons for not performing LCBDE were: having a reliable ERCP proceduralist available, lack of equipment, and lack of comfort performing LCBDE. Factors associated with preoperative ERCP were: metropolitan status, selective intraoperative cholangiography (IOC), and availability of a reliable ERCP proceduralist. Those who perform selective IOC were 70% less likely to prefer LCBDE (OR 0.32, 95% CI 0.18-0.57, p < 0.001). Those with a reliable ERCP proceduralist available were 90% less likely to prefer LCBDE (OR 0.10, 95% CI 0.04-0.26, p < 0.001).

Conclusions: The majority of respondents preferred ERCP for the management of CDL. Having a reliable ERCP proceduralist available, use of selective IOC, and metropolitan status were independently associated with preoperative ERCP. Postoperative ERCP was preferred for managing intraoperatively discovered CDL. Many surgeons are uncomfortable performing LCBDE, and increased training may be needed.
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http://dx.doi.org/10.1007/s00464-015-4273-zDOI Listing
February 2016

Efficient multi-atlas abdominal segmentation on clinically acquired CT with SIMPLE context learning.

Med Image Anal 2015 Aug 21;24(1):18-27. Epub 2015 May 21.

Electrical Engineering, Vanderbilt University, Nashville, TN 37235, USA; Biomedical Engineering, Vanderbilt University, Nashville, TN 37235, USA; General Surgery, Vanderbilt University, Nashville, TN 37235, USA; Radiology and Radiological Science, Vanderbilt University, Nashville, TN 37235, USA.

Abdominal segmentation on clinically acquired computed tomography (CT) has been a challenging problem given the inter-subject variance of human abdomens and complex 3-D relationships among organs. Multi-atlas segmentation (MAS) provides a potentially robust solution by leveraging label atlases via image registration and statistical fusion. We posit that the efficiency of atlas selection requires further exploration in the context of substantial registration errors. The selective and iterative method for performance level estimation (SIMPLE) method is a MAS technique integrating atlas selection and label fusion that has proven effective for prostate radiotherapy planning. Herein, we revisit atlas selection and fusion techniques for segmenting 12 abdominal structures using clinically acquired CT. Using a re-derived SIMPLE algorithm, we show that performance on multi-organ classification can be improved by accounting for exogenous information through Bayesian priors (so called context learning). These innovations are integrated with the joint label fusion (JLF) approach to reduce the impact of correlated errors among selected atlases for each organ, and a graph cut technique is used to regularize the combined segmentation. In a study of 100 subjects, the proposed method outperformed other comparable MAS approaches, including majority vote, SIMPLE, JLF, and the Wolz locally weighted vote technique. The proposed technique provides consistent improvement over state-of-the-art approaches (median improvement of 7.0% and 16.2% in DSC over JLF and Wolz, respectively) and moves toward efficient segmentation of large-scale clinically acquired CT data for biomarker screening, surgical navigation, and data mining.
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http://dx.doi.org/10.1016/j.media.2015.05.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4532551PMC
August 2015

Multi-Atlas Segmentation for Abdominal Organs with Gaussian Mixture Models.

Proc SPIE Int Soc Opt Eng 2015 Mar;9417

Biomedical Engineering, Vanderbilt University, Nashville, TN, USA 37235 ; Electrical Engineering, Vanderbilt University, Nashville, TN, USA 37235 ; Computer Science, Vanderbilt University, Nashville, TN, USA 37235 ; Radiology and Radiological Science, Vanderbilt University, Nashville, TN, USA 37235.

Abdominal organ segmentation with clinically acquired computed tomography (CT) is drawing increasing interest in the medical imaging community. Gaussian mixture models (GMM) have been extensively used through medical segmentation, most notably in the brain for cerebrospinal fluid/gray matter/white matter differentiation. Because abdominal CT exhibit strong localized intensity characteristics, GMM have recently been incorporated in multi-stage abdominal segmentation algorithms. In the context of variable abdominal anatomy and rich algorithms, it is difficult to assess the marginal contribution of GMM. Herein, we characterize the efficacy of an framework that integrates GMM of organ-wise intensity likelihood with spatial priors from multiple target-specific registered labels. In our study, we first manually labeled 100 CT images. Then, we assigned 40 images to use as training data for constructing target-specific spatial priors and intensity likelihoods. The remaining 60 images were evaluated as test targets for segmenting 12 abdominal organs. The overlap between the true and the automatic segmentations was measured by Dice similarity coefficient (DSC). A median improvement of 145% was achieved by integrating the GMM intensity likelihood against the specific spatial prior. The proposed framework opens the opportunities for abdominal organ segmentation by efficiently using both the spatial and appearance information from the atlases, and creates a benchmark for large-scale automatic abdominal segmentation.
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http://dx.doi.org/10.1117/12.2081061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405670PMC
March 2015

Efficient Abdominal Segmentation on Clinically Acquired CT with SIMPLE Context Learning.

Proc SPIE Int Soc Opt Eng 2015 Mar;9413

Electrical Engineering, Vanderbilt University, Nashville, TN, USA 37235 ; Biomedical Engineering, Vanderbilt University, Nashville, TN, USA 37235 ; Computer Science, Vanderbilt University, Nashville, TN, USA 37235 ; Radiology and Radiological Science, Vanderbilt University, Nashville, TN, USA 37235.

Abdominal segmentation on clinically acquired computed tomography (CT) has been a challenging problem given the inter-subject variance of human abdomens and complex 3-D relationships among organs. Multi-atlas segmentation (MAS) provides a potentially robust solution by leveraging label atlases via image registration and statistical fusion. We posit that the efficiency of atlas selection requires further exploration in the context of substantial registration errors. The selective and iterative method for performance level estimation (SIMPLE) method is a MAS technique integrating atlas selection and label fusion that has proven effective for prostate radiotherapy planning. Herein, we revisit atlas selection and fusion techniques for segmenting 12 abdominal structures using clinically acquired CT. Using a re-derived SIMPLE algorithm, we show that performance on multi-organ classification can be improved by accounting for exogenous information through Bayesian priors (so called context learning). These innovations are integrated with the joint label fusion (JLF) approach to reduce the impact of correlated errors among selected atlases for each organ, and a graph cut technique is used to regularize the combined segmentation. In a study of 100 subjects, the proposed method outperformed other comparable MAS approaches, including majority vote, SIMPLE, JLF, and the Wolz locally weighted vote technique. The proposed technique provides consistent improvement over state-of-the-art approaches (median improvement of 7.0% and 16.2% in DSC over JLF and Wolz, respectively) and moves toward efficient segmentation of large-scale clinically acquired CT data for biomarker screening, surgical navigation, and data mining.
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http://dx.doi.org/10.1117/12.2081012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405802PMC
March 2015

Evaluation of Five Image Registration Tools for Abdominal CT: Pitfalls and Opportunities with Soft Anatomy.

Proc SPIE Int Soc Opt Eng 2015 Mar;9413

Computer Science, Vanderbilt University, Nashville, TN, USA 37235 ; Electrical Engineering, Vanderbilt University, Nashville, TN, USA 37235 ; Biomedical Engineering, Vanderbilt University, Nashville, TN, USA 37235 ; Radiology and Radiological Science, Vanderbilt University, Nashville, TN, USA 37235.

Image registration has become an essential image processing technique to compare data across time and individuals. With the successes in volumetric brain registration, general-purpose software tools are beginning to be applied to abdominal computed tomography (CT) scans. Herein, we evaluate five current tools for registering clinically acquired abdominal CT scans. Twelve abdominal organs were labeled on a set of 20 atlases to enable assessment of correspondence. The 20 atlases were pairwise registered based on only intensity information with five registration tools (affine IRTK, FNIRT, Non-Rigid IRTK, NiftyReg, and ANTs). Following the brain literature, the Dice similarity coefficient (DSC), mean surface distance, and Hausdorff distance were calculated on the registered organs individually. However, interpretation was confounded due to a significant proportion of outliers. Examining the retrospectively selected top 1 and 5 atlases for each target revealed that there was a substantive performance difference between methods. To further our understanding, we constructed majority vote segmentation with the top 5 DSC values for each organ and target. The results illustrated a median improvement of 85% in DSC between the raw results and majority vote. These experiments show that some images may be well registered to some targets using the available software tools, but there is significant room for improvement and reveals the need for innovation and research in the field of registration in abdominal CTs. If image registration is to be used for local interpretation of abdominal CT, great care must be taken to account for outliers (e.g., atlas selection in statistical fusion).
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http://dx.doi.org/10.1117/12.2081045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405654PMC
March 2015

Smoking as dominant risk factor for anastomotic leak after left colon resection.

Am J Surg 2015 Jul 28;210(1):1-5. Epub 2015 Mar 28.

Division of General Surgery, Vanderbilt University Medical Center, D-5203 Medical Center North, 1161 Medical Center Drive, Nashville, TN 37232, USA.

Background: Some risk factors for anastomotic leak have been identified, but the effect of smoking is unknown.

Methods: This study aimed to evaluate the effect of smoking on clinical leak after left-sided anastomoses. Adult patients who underwent elective left colectomy between January 1, 2008 and December 31, 2012 were included. Those with stomas and inflammatory bowel diseases were excluded. Primary outcome was anastomotic leak requiring percutaneous drainage or operative intervention within 30 days.

Results: There were 246 patients included; 56% were female. Most had a diagnosis of diverticular disease (53%) or cancer (37%). Anastomotic leak rate was 6.5% (n = 16). The rate in smokers was 17% versus 5% in nonsmokers (P = .01). Smokers had over 4 times greater chance of leak (odds ratio 4.2, 95% confidence interval 1.3 to 13.5, P = .02).

Conclusion: Smoking is a risk factor for leak after left colectomy. Consideration should be given to delaying elective left colectomy until smoking cessation is achieved.
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http://dx.doi.org/10.1016/j.amjsurg.2014.10.033DOI Listing
July 2015

Association of Perioperative Hypothermia During Colectomy With Surgical Site Infection.

JAMA Surg 2015 Jun;150(6):570-5

Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: Maintaining perioperative normothermia has been shown to decrease the rate of surgical site infection (SSI) after segmental colectomy and is part of the World Health Organization's Guidelines for Safe Surgery. However, strong evidence supporting this association is lacking, and an exact definition of normothermia has not been described.

Objective: To determine whether intraoperative hypothermia in patients who undergo segmental colectomy is associated with postoperative SSI.

Design, Setting, And Participants: In a retrospective cohort study at a single tertiary-referral hospital, 296 adult patients who underwent elective segmental colectomy from January 1, 2005, through December 31, 2009, were included. Exclusion criteria included postoperative stoma, emergent or urgent operation, and diagnosis of inflammatory bowel disease.

Exposures: Perioperative temperature was measured continuously, and 4 possible definitions of hypothermia were explored, including temperature nadir, mean intraoperative temperature, percentage of time at the temperature nadir, and percentage of time with a temperature of less than 36.0°C.

Main Outcomes And Measures: The primary outcome measure was 30-day SSI. Secondary outcome measures included clinical leak, return to the operating room, and nasogastric tube placement (a surrogate for ileus).

Results: The mean (SD) findings were as follows: intraoperative temperature, 35.9°C (0.6°C); temperature nadir, 34.3°C (2.8°C); percentage of time at the nadir, 4.7% (10.8%); and percentage of time with a temperature of less than 36.0°C, 49.9% (42.0%). The rate of SSI was 12.2% (n = 36). There was no statistically significant difference in temperature measurements between the patients who developed an SSI and those who did not. Logistic regression models evaluated each exposure measure and its effect on SSI, adjusting for body mass index, smoking status, and sex. The adjusted analyses revealed no association between intraoperative hypothermia and 30-day SSI (odds ratio, 1.17; 95% CI, 0.76-1.81; P = .48). Increased body mass index (odds ratio, 1.39; 95% CI, 1.10-1.76; P = .007) was significantly associated with SSI in all 4 logistic regression models.

Conclusions And Relevance: Patients who underwent segmental colectomy and sustained a period of intraoperative hypothermia were no more likely to develop an SSI than those who were normothermic.
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http://dx.doi.org/10.1001/jamasurg.2015.77DOI Listing
June 2015

The importance of surgeon-reviewed computed tomography for incisional hernia detection: a prospective study.

Am Surg 2014 Jul;80(7):720-2

Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Patients with incisional hernias or abdominal pain are frequently referred with abdominal computed tomography (CT) scans. The purpose of this study was to determine the sensitivity and specificity of a CT radiology report for the detection of incisional hernias. General surgery patients with a history of an abdominal operation and a recent viewable abdominal CT scan were enrolled prospectively. Patients with a stoma, fistula, or soft tissue infection were excluded. The results of the radiology reports were compared with blinded, surgeon-interpreted CT for each patient. Testing characteristics including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. One hundred eighty-one patients were enrolled with a mean age of 54 years. Sixty-eight per cent were women. Hernia prevalence was 55 per cent, and mean hernia width was 5.2 cm. The radiology report had a sensitivity and specificity of 79 per cent and 94 per cent, respectively, for hernia diagnosis. The PPV and NPV were 94 and 79 per cent, respectively. Reliance on the CT report alone underestimates the presence of incisional hernia. Referring physicians should not use CT as a screening modality for detection of hernias. Referral to a surgeon for evaluation before imaging may provide more accurate diagnosis and potentially decrease the cost of caring for this population.
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July 2014

Comparative Evaluation of Dynamic Abdominal Sonography for Hernia and Computed Tomography for Characterization of Incisional Hernia.

JAMA Surg 2014 Jun;149(6):591-6

Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: Previous work has demonstrated that dynamic abdominal sonography for hernia (DASH) is accurate for the diagnosis of incisional hernia. The usefulness of DASH for characterization of incisional hernia is unknown.

Objective: To determine whether DASH can be objectively used to characterize incisional hernias by measurement of mean surface area (MSA).

Design, Setting, And Participants: A prospective cohort study was conducted. A total of 109 adults with incisional hernia were enrolled between July 1, 2010, and March 1, 2012. Patients with a stoma, fistula, or soft-tissue infection were excluded.

Interventions: DASH was performed by a surgeon to determine the maximal transverse and craniocaudal dimensions of the incisional hernia. A separate surgeon, blinded to the DASH results, performed the same measurements using computed tomography (CT).

Main Outcomes And Measures: The MSA was calculated, and the difference in MSA by DASH and CT was compared using the Wilcoxon signed rank test. Subset analysis was performed with patients stratified into nonobese, obese, and morbidly obese groups. We hypothesized that there was no significant difference between MSA as measured by DASH compared with CT.

Results: A total of 109 patients were enrolled (mean age, 56 years; mean body mass index, 32.2 [calculated as weight in kilograms divided by height in meters squared]; and 67.0% women). The mean (SD) MSA measurements were similar between the modalities: DASH, 41.8 (67.5) cm2 and CT, 44.6 (78.4) cm2 (P = .82). The MSA measurements determined by DASH and CT were also similar for all groups when stratified by body mass index. There were 15 patients who had a hernia 10 cm or larger in transverse dimension. The mean body mass index of this group was 39.2, and the MSA measurements by DASH and CT were similar (P = .26).

Conclusions And Relevance: DASH can be used to objectively characterize hernias by MSA, with accuracy demonstrated in the obese population and in patients whose hernias were very large (≥10 cm in diameter). DASH offers the advantages of real-time imaging and no ionizing radiation and may obviate the need for the patient to schedule additional imaging appointments.
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http://dx.doi.org/10.1001/jamasurg.2014.36DOI Listing
June 2014

Defining intraoperative hypothermia in ventral hernia repair.

J Surg Res 2014 Jul 4;190(1):385-90. Epub 2014 Feb 4.

Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Intraoperative normothermia, a single measurement of core body temperature≥36°C, is an important quality metric outlined by the World Health Organization for the reduction of surgical site infections (SSIs). Hypothermia has been linked to SSI in colorectal and trauma patients, but the effect in ventral hernia repair (VHR) is unknown.

Materials And Methods: Patients who underwent VHR at a single institution between 2005 and 2012 were included. Temperature data were matched with National Surgical Quality Improvement Program SSI data. Novel definitions of hypothermia were explored: patient temperature nadir, percentage of time spent at the nadir, mean temperature, and time spent <36°C. Multivariable regression models were performed.

Results: Five hundred fifty-three patients were included with temperature recorded every 8-15 min. Mean temperature nadir was 35.7°C (±1.3°C [standard deviation]) and was not associated with SSI (odds ratio [OR], 0.938; 95% confidence interval, 0.778-1.131). The percentage of readings spent at the nadir was 31% (±31%) and was not predictive of SSI (OR, 1.471; 95% CI, 0.983-2.203). As mean temperature increased, the risk of SSI increased (OR, 1.115; 95% CI, 0.559-2.225). Percentage of temperature readings<36°C was 29% (±38%) and was not associated with SSI (OR, 1.062; 95% CI, 0.628-1.796). In all models, body mass index, smoking, and length of surgery were predictive of SSI.

Conclusions: Our results demonstrate no association between temperature and SSI in VHR. Efforts to reduce SSI should focus on factors such as smoking cessation, weight loss, and length of surgery. Our study suggests that maintenance of perioperative normothermia may only decrease SSIs in certain at-risk populations.
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http://dx.doi.org/10.1016/j.jss.2014.01.059DOI Listing
July 2014