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Abdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction. All patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion. In 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75–43.8], P <.01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34–8.53], P <.01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention. Patients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk. [ABSTRACT FROM AUTHOR]

Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days. This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications. A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P =.12). Patient-reported outcomes were similar between groups at 30 days. Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk–benefit ratio. [ABSTRACT FROM AUTHOR]

Morbid obesity, with a body mass index 35 kg/m2, is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short-term wound morbidity, its effect on long-term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long-term outcomes. Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90-day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, inflammatory bowel disease, mesh weight, and mesh–to–hernia size ratio. A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14–1.77; P <.01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13–1.74; P <.01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08–1.82; P <.01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08–1.82; P =.01). Hernia recurrence rate at 1 year was lower for the body mass index ≥35 kg/m2 group (7% vs 12%; P =.02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02–1.74; P =.04) was associated with recurrence; body mass index was not (P =.11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year. Morbid obesity is associated with 90-day wound morbidity; however, short-term complications did not translate to higher reoperation or long-term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m2 should not be used to deny symptomatic patients abdominal wall reconstruction. [ABSTRACT FROM AUTHOR]

Telemedicine, Virtual visits, Carbon emissions, Sustainability, General surgery clinic Keywords: Telemedicine; Virtual visits; Carbon emissions; Sustainability; General surgery clinic EN Telemedicine Virtual visits Carbon emissions Sustainability General surgery clinic 2199 2201 3 10/18/23 20231001 NES 231001 Meeting Information: This project was presented at the Americas Hepato-Pancreato-Biliary Association (AHPBA) meeting on March 9-12, 2023, in Miami, Florida. [Extracted from the article]

Introduction: Delayed intracranial hemorrhage (ICH) after negative initial head cat scan (CT) is a recognized complication after blunt trauma. Due to theoretical increased risk in patients on direct oral anticoagulants (DOACs) and inability to monitor degree of anticoagulation, there is a lack of consensus regarding need for observation or repeat imaging. We hypothesized that patients on DOACs would have low risk of delayed ICH after blunt head trauma.Methods: In June 2020, an electronic literature search of MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library was performed by a medical librarian. Included studies reported outcomes on adult trauma patients taking anticoagulants that were observed after initial normal head CT. A meta-analysis was performed using random effects model.Results: Our electronic search returned 5719 papers with 12 meeting final inclusion/exclusion criteria. Overall, 5289 patients were studied including 1263 (23.9%) on DOAC and 1788 (33.8%) on warfarin. Sixty-nine patients suffered delayed ICH, 25 on DOAC and 44 on warfarin. The pooled weighted percentage for delayed ICH on DOAC was 2.43% (95% CI, 1.31 - 3.88%) compared to 2.31% (95% CI, 1.26 - 3.66%) on warfarin. The overall crude risk of death from delayed ICH while on DOAC or Warfarin was 0.36% (11/3051).Conclusions: The risk of delayed ICH following low energy blunt head trauma for patients on DOACs is low, and risk of clinically significant bleeding is even lower. The practice of routinely observing or systematically reimaging patients on DOACs after low energy blunt head trauma with initially negative head CT may not be warranted. [ABSTRACT FROM AUTHOR]