Reconstruction of the abdominal wall for the repair of ventral herniae or other abdominal wall defects is an area of continued progress and innovation in the fields of general and plastic surgery. With novel operative techniques and advances in materials science, surgical options for the repair of larger and more complex lesions have become increasingly available; however, there remains a relatively high risk of hernia recurrence and other complications, which are often associated with patient comorbidities and number of previous abdominal operations. Thus, additional investigation is needed in determining prognostic factors that can aid in preoperative planning and risk stratification. Although a patient’s overall clinical context is paramount to surgical decision-making in general, there has been a push for delineating more objective markers for preoperative risk assessment. This is exemplified by the landmark findings from the National Veterans Affairs Surgical Risk Study, a multi-institutional study of 87,078 patients undergoing surgery at 44 Veterans Affairs Medical Centers across the United States. This study identified a number of markers (e.g., serum albumin, American Society of Anesthesia class, emergency operations, age, and platelet count) as important predictors of 30-day morbidity and mortality after surgery across eight surgical subspecialties.1, 2 Of these variables, serum albumin was ranked as the most predictive. These results have been replicated in the literature to show increased complications in patients with lower serum albumin levels undergoing GI, hepatopancreaticobiliary, cardiac, spine, urologic, and plastic surgery. Because of its utility in risk stratification, albumin has been incorporated into tools predicting operative outcomes, including the multidimensional frailty score3 and proposals for being added as a parameter in the ACS-NSQIP Surgical Risk Calculator. Despite the robust literature behind serum albumin as a marker for operative results, to our knowledge there is no data that analyze this in the context of complex abdominal wall reconstruction (CAWR). Our study focuses on 1) whether hypoalbuminemia is predictive of CAWR outcomes and 2) how preoperative management might be risk-adjusted to decrease postoperative morbidity and mortality. With the approval of the Institutional Review Board, we performed a retrospective analysis of a prospectively maintained database of all patients who underwent CAWR at Emory University Hospital by a single surgeon (AL) between October 2002 and June 2016. Subject data included age, gender, comorbidities/risk factors, BMI, diagnosis of hypertension and/or diabetes, smoking status, preoperative diagnosis, and complications/outcomes. Preoperative albumin within 30 days of surgery was also recorded, and patients were divided into two cohorts: hypoalbuminemia (defined as albumin < 3.0 g/dL) and normal albumin (albumin $ 3.0 g/dL). Major complications included unanticipated return to the operating room, admission for intravenous antibiotics, fistula formation, and hernia recurrence. All other complications were documented as minor. Patients were excluded because of patient death within two weeks of surgery, undocumented preoperative serum albumin within 30 days of surgery, inadequate follow-up time (less than 30 days following surgery), or if they were lost to follow-up. The Mann-Whitney U test, Pearson x2 test, Fisher’s exact test, and student’s t test were used as appropriate to compare outcomes between albumin groups. In addition to albumin level, baseline characteristics were assessed to determine if and when to perform Address correspondence and reprint requests to Albert Losken, M.D., Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, 550 Peachtree Street NE, Suite 9000, Atlanta GA 30308. E-mail: alosken@emory.edu. Author contribution: All of the aforementioned authors were involved in the acquisition, analysis and/or interpretation of data, drafting and/or revision of the manuscript; gave final approval for submission of the manuscript; and agreed to be accountable for the data presented in the submitted manuscript.

Background: Ventral hernias are often repaired after planned or unplanned bowel procedures. Biologic materials are thought to better tolerate gastrointestinal contamination than synthetic alternatives. The purpose of this review was to evaluate the impact of intestinal contamination on ventral hernia repair with biologic material.Methods: This is a retrospective review of all patients who underwent ventral hernia repair with biologic material between 2003 and 2012. Groups were defined based on performance of concomitant bowel surgery. Data were collected on patient demographics, risk factors, concomitant procedures, mesh type, and outcomes.Results: Of 82 patients included in this series, 32 (39%) had concomitant bowel surgery. Ventral hernia repair was performed predominantly with Alloderm and Strattice. There was no difference in hernia recurrence (contaminated group-28% vs. non-contaminated group-34%, P = 0.58), surgical site infections (contaminated-28% vs. non-contaminated-20%, P = 0.40), or other complications when patients with and without concomitant bowel surgery were compared.Conclusions: Biologic materials have made it such that ventral hernias can be safely repaired after bowel surgery without increased risk of complications.

Background. Intrapyloric botulinum toxin injection has emerged as a possible alternative to standard pyloric drainage procedures. Possible advantages include decreased operative time and less postoperative dumping and bile reflux symptoms. However, data are lacking to show its effectiveness versus standard drainage procedures. The purpose of this review is to compare the results in a prospective cohort of patients who received pyloric botulinum injection versus patients who received pyloromyotomy or pyloroplasty with esophagectomy.Methods. We performed a retrospective review of a prospective database of all patients who underwent an open esophageal resection at a single institution from 2005 through 2010. Three hundred twenty- two patients were divided into 3 groups for analysis: botulinum injection (n = 78), pyloromyotomy (n = 45), and pyloroplasty (n = 199). We compared these groups with respect to duration of the procedure, presence of delayed gastric emptying on postoperative swallow studies, requirement of anastomotic dilation, requirement of pyloric dilation, use of postoperative promotility agents, and patient experience of postoperative symptoms of reflux or dumping, or both.Results. Patients receiving botulinum injections experienced similar delayed gastric emptying on postoperative radiologic evaluation as did patients undergoing pyloromyotomy and pyloroplasty (16% versus 5% and 13%, respectively; p = 0.14). Mean operative time was significantly shorter for the patients receiving botulinum as expected (239 minutes versus 312 minutes and 373 minutes, respectively; p < 0.001). However, more patients receiving botulinum and pyloric dilation (22% versus 4% and 2%, respectively; p < 0.001) experienced postoperative reflux symptoms (32% versus 12% and 13%, respectively; p= 0.001) and used postoperative promotility agents (22% versus 5% and 15%, respectively; p = 0.04). There was no statistical difference between the groups regarding postoperative dumping.Conclusions. Use of intrapyloric botulinum injection significantly decreased operative time. However, the patients receiving botulinum experienced more postoperative reflux symptoms, had increased use of promotility agents as well as a requirement for postoperative endoscopic interventions, and postoperative dumping was not reduced by the reversible procedure. Intrapyloric botulinum injection should not be used as an alternative to standard drainage procedures. Pyloromyotomy appears to be the drainage procedure of choice to accompany an esophagectomy. (C) 2014 by The Society of Thoracic Surgeons

BACKGROUND:Nipple reconstruction is often used as a marker for completion of the breast reconstructive process. The purpose of this study was to determine the average time to nipple reconstruction and the factors that influence this process.METHODS:All patients who underwent postmastectomy breast reconstruction at Emory University between 2005 and 2011 were reviewed. Only those who had completed nipple reconstruction were included. Variables recorded were body mass index, age, smoking history, surgeon, presence of preoperative or postoperative chemotherapy or radiation therapy, type of reconstruction, timing of reconstruction, unilateral or bilateral reconstruction, and complication history. Time to completion of nipple reconstruction was calculated and comparisons were made.RESULTS:A total of 451 patients completed nipple reconstruction (128 implant reconstructions, 120 latissimus plus implant reconstructions, 23 latissimus only reconstructions, and 180 transverse rectus abdominus myocutaneous flap [TRAM] or deep inferior epigastric perforator flap [DIEP] reconstructions). Average time to nipple reconstruction was 12.25 months. Patients who underwent TRAM or DIEP flaps completed reconstruction on average earlier than implant-based reconstruction and latissimus-only reconstruction (8.67 vs 11.2 and 11.3 months, respectively, P = 0.0016). Patients who underwent postoperative chemotherapy or radiation therapy were delayed compared to those that did not (11.3 vs 9.33 and 13.87 vs 9.87 months, P = 0.0315 and P = 0.0052). Timing of completion was also dependent on attending surgeon (9.8 and 11.43 months for the 2 senior surgeons, P = 0.0135) and presence of complications (10.3 compared to 9.77 months for patients without complications, P = 0.0334). Body mass index, smoking history, preoperative chemotherapy or radiation therapy, timing of reconstruction, and unilateral versus bilateral reconstruction did not affect time to nipple reconstruction.CONCLUSIONS:Type of reconstruction, surgeon, presence of complications, and need for postoperative chemotherapy or radiation therapy all affect timing to completion of breast reconstruction. Patients should be counseled as to these factors at the initial consultation to set appropriate expectations.