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VIDEO: Wedge resection offers higher survival for NSCLC
BOSTON – High quality wedge resection results in higher survival for patients with early stage non–small cell lung cancer when compared with stereotactic body radiation therapy, according to new research.
The analysis, reported at the annual meeting of the American Association for Thoracic Surgery, evaluated the treatment of 7,337 patients in the National Cancer Database with clinical T1-T2, N0, M0 non–small cell lung cancer who were treated with either wedge resection or stereotactic body radiation therapy from 2005 to 2012.
In this video, Varun Puri, MD, of Washington University, St. Louis, discusses the study and the significance of the findings.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – High quality wedge resection results in higher survival for patients with early stage non–small cell lung cancer when compared with stereotactic body radiation therapy, according to new research.
The analysis, reported at the annual meeting of the American Association for Thoracic Surgery, evaluated the treatment of 7,337 patients in the National Cancer Database with clinical T1-T2, N0, M0 non–small cell lung cancer who were treated with either wedge resection or stereotactic body radiation therapy from 2005 to 2012.
In this video, Varun Puri, MD, of Washington University, St. Louis, discusses the study and the significance of the findings.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – High quality wedge resection results in higher survival for patients with early stage non–small cell lung cancer when compared with stereotactic body radiation therapy, according to new research.
The analysis, reported at the annual meeting of the American Association for Thoracic Surgery, evaluated the treatment of 7,337 patients in the National Cancer Database with clinical T1-T2, N0, M0 non–small cell lung cancer who were treated with either wedge resection or stereotactic body radiation therapy from 2005 to 2012.
In this video, Varun Puri, MD, of Washington University, St. Louis, discusses the study and the significance of the findings.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
AT THE AATS ANNUAL MEETING
VIDEO: Lack of heart teams impact prevalence of PCI
BOSTON – Data show a marked bias in referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team.
More patients underwent percutaneous coronary intervention (PCI) in hospitals without on-site cardiac surgery than patients at hospitals with on-site cardiac surgery, according to the analysis presented at the annual meeting of the American Association for Thoracic Surgery. The multivariate logistic regression analysis showed that the absence of on-site cardiac surgery and a heart team was an independent predictor for PCI.
In this video, Ehud Raanani, MD, of Tel Aviv University in Israel discusses referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team and how this phenomenon could affect patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – Data show a marked bias in referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team.
More patients underwent percutaneous coronary intervention (PCI) in hospitals without on-site cardiac surgery than patients at hospitals with on-site cardiac surgery, according to the analysis presented at the annual meeting of the American Association for Thoracic Surgery. The multivariate logistic regression analysis showed that the absence of on-site cardiac surgery and a heart team was an independent predictor for PCI.
In this video, Ehud Raanani, MD, of Tel Aviv University in Israel discusses referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team and how this phenomenon could affect patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – Data show a marked bias in referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team.
More patients underwent percutaneous coronary intervention (PCI) in hospitals without on-site cardiac surgery than patients at hospitals with on-site cardiac surgery, according to the analysis presented at the annual meeting of the American Association for Thoracic Surgery. The multivariate logistic regression analysis showed that the absence of on-site cardiac surgery and a heart team was an independent predictor for PCI.
In this video, Ehud Raanani, MD, of Tel Aviv University in Israel discusses referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team and how this phenomenon could affect patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
AT THE AATS ANNUAL MEETING
Trump administration loosens up HealthCare.gov
Patients buying health insurance through an Affordable Care Act health insurance exchange will no longer have to complete the transaction via HealthCare.gov.
The move is intended to help bring stability to the health insurance market, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a statement.
“It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage,” she said. “It is time to get the federal government out of the way and give patients the best tools to make their own health care decision.”
The change will take effect with the open enrollment period for the 2018 coverage year.
Since the beginning of the health insurance exchanges, patients were required to complete their coverage applications via HealthCare.gov. Feedback from users indicated that “the process was confusing and made it harder to complete the application,” Ms. Verma said in a statement.
The move comes as the Republican-led Congress and the Trump Administration seek to repeal and replace the ACA. This move would deemphasize the government’s role in providing coverage as consumers could potentially avoid contact with HealthCare.gov altogether if they are using a third party to purchase coverage.
Patients buying health insurance through an Affordable Care Act health insurance exchange will no longer have to complete the transaction via HealthCare.gov.
The move is intended to help bring stability to the health insurance market, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a statement.
“It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage,” she said. “It is time to get the federal government out of the way and give patients the best tools to make their own health care decision.”
The change will take effect with the open enrollment period for the 2018 coverage year.
Since the beginning of the health insurance exchanges, patients were required to complete their coverage applications via HealthCare.gov. Feedback from users indicated that “the process was confusing and made it harder to complete the application,” Ms. Verma said in a statement.
The move comes as the Republican-led Congress and the Trump Administration seek to repeal and replace the ACA. This move would deemphasize the government’s role in providing coverage as consumers could potentially avoid contact with HealthCare.gov altogether if they are using a third party to purchase coverage.
Patients buying health insurance through an Affordable Care Act health insurance exchange will no longer have to complete the transaction via HealthCare.gov.
The move is intended to help bring stability to the health insurance market, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a statement.
“It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage,” she said. “It is time to get the federal government out of the way and give patients the best tools to make their own health care decision.”
The change will take effect with the open enrollment period for the 2018 coverage year.
Since the beginning of the health insurance exchanges, patients were required to complete their coverage applications via HealthCare.gov. Feedback from users indicated that “the process was confusing and made it harder to complete the application,” Ms. Verma said in a statement.
The move comes as the Republican-led Congress and the Trump Administration seek to repeal and replace the ACA. This move would deemphasize the government’s role in providing coverage as consumers could potentially avoid contact with HealthCare.gov altogether if they are using a third party to purchase coverage.
More telemedicine shifts to system-wide models
As telemedicine gains momentum, more health providers are moving from stand-alone programs to system-wide approaches.
In a survey of 436 U.S. health care executives, physicians, nurses, hospitals, and other health professionals, 25% of respondents with a telemedicine program began with a departmental approach but are now shifting to an enterprise system, 39% had an established enterprise system, and 36% remain with a departmental basis.
The survey of health care professionals’ priorities, objectives, challenges, and telemedicine models of care was conducted between December 2016 and January 2017 for REACH Health, a telemedicine software company.
Fifty-one percent of respondents reported that telemedicine is a top priority or high priority, a decrease from last year’s survey in which 66% of respondents said so. This shift could be linked to a continuing evolution and maturation of telemedicine as more programs move from ad-hoc project status to mainstream service, according to the report.
The telemedicine features most valuable to health providers were clinical documentation, the ability to send documentation to/from the electronic medical record, and the ability to analyze consult data. For the second year, health providers rated their top three telemedicine objectives as: improving patient outcomes, improving patient convenience, and increasing patient engagement.
Overall, health providers responded that the possible repeal and replacement of the Affordable Care Act would be positive for telemedicine. Forty-one percent of respondents said that patient adoption and the use of telemedicine would increase with ACA repeal/replace and 40% of health providers said that internal adoption and use of telemedicine would rise with replacement of the health law.
Just under half (47%) said they were uncertain how health care law changes would impact telemedicine parity laws, and 45% were unsure how repeal and replace would affect Medicare and Medicaid reimbursement for telemedicine services.
[email protected]
On Twitter @legal_med
As telemedicine gains momentum, more health providers are moving from stand-alone programs to system-wide approaches.
In a survey of 436 U.S. health care executives, physicians, nurses, hospitals, and other health professionals, 25% of respondents with a telemedicine program began with a departmental approach but are now shifting to an enterprise system, 39% had an established enterprise system, and 36% remain with a departmental basis.
The survey of health care professionals’ priorities, objectives, challenges, and telemedicine models of care was conducted between December 2016 and January 2017 for REACH Health, a telemedicine software company.
Fifty-one percent of respondents reported that telemedicine is a top priority or high priority, a decrease from last year’s survey in which 66% of respondents said so. This shift could be linked to a continuing evolution and maturation of telemedicine as more programs move from ad-hoc project status to mainstream service, according to the report.
The telemedicine features most valuable to health providers were clinical documentation, the ability to send documentation to/from the electronic medical record, and the ability to analyze consult data. For the second year, health providers rated their top three telemedicine objectives as: improving patient outcomes, improving patient convenience, and increasing patient engagement.
Overall, health providers responded that the possible repeal and replacement of the Affordable Care Act would be positive for telemedicine. Forty-one percent of respondents said that patient adoption and the use of telemedicine would increase with ACA repeal/replace and 40% of health providers said that internal adoption and use of telemedicine would rise with replacement of the health law.
Just under half (47%) said they were uncertain how health care law changes would impact telemedicine parity laws, and 45% were unsure how repeal and replace would affect Medicare and Medicaid reimbursement for telemedicine services.
[email protected]
On Twitter @legal_med
As telemedicine gains momentum, more health providers are moving from stand-alone programs to system-wide approaches.
In a survey of 436 U.S. health care executives, physicians, nurses, hospitals, and other health professionals, 25% of respondents with a telemedicine program began with a departmental approach but are now shifting to an enterprise system, 39% had an established enterprise system, and 36% remain with a departmental basis.
The survey of health care professionals’ priorities, objectives, challenges, and telemedicine models of care was conducted between December 2016 and January 2017 for REACH Health, a telemedicine software company.
Fifty-one percent of respondents reported that telemedicine is a top priority or high priority, a decrease from last year’s survey in which 66% of respondents said so. This shift could be linked to a continuing evolution and maturation of telemedicine as more programs move from ad-hoc project status to mainstream service, according to the report.
The telemedicine features most valuable to health providers were clinical documentation, the ability to send documentation to/from the electronic medical record, and the ability to analyze consult data. For the second year, health providers rated their top three telemedicine objectives as: improving patient outcomes, improving patient convenience, and increasing patient engagement.
Overall, health providers responded that the possible repeal and replacement of the Affordable Care Act would be positive for telemedicine. Forty-one percent of respondents said that patient adoption and the use of telemedicine would increase with ACA repeal/replace and 40% of health providers said that internal adoption and use of telemedicine would rise with replacement of the health law.
Just under half (47%) said they were uncertain how health care law changes would impact telemedicine parity laws, and 45% were unsure how repeal and replace would affect Medicare and Medicaid reimbursement for telemedicine services.
[email protected]
On Twitter @legal_med
VIDEO: Surgeon case volume linked to mitral valve repair outcomes
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
AT THE AATS ANNUAL MEETING
Hot Threads in ACS Communities
Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.) 
- Texas SB 1148 The MOC Bill
- Low back pain (Women Surgeons)
- Domestic volunteerism
- Hour limits for staff/attending surgeons?
- Health Care Reform
- A day on Capitol Hill
- Reactions to the “Replacement” of our Surgeon General?
- Any input on this article?
- Another tough case
- Rectal prolapse (Colon and Rectal Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.)
- Texas SB 1148 The MOC Bill
- Low back pain (Women Surgeons)
- Domestic volunteerism
- Hour limits for staff/attending surgeons?
- Health Care Reform
- A day on Capitol Hill
- Reactions to the “Replacement” of our Surgeon General?
- Any input on this article?
- Another tough case
- Rectal prolapse (Colon and Rectal Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.)
- Texas SB 1148 The MOC Bill
- Low back pain (Women Surgeons)
- Domestic volunteerism
- Hour limits for staff/attending surgeons?
- Health Care Reform
- A day on Capitol Hill
- Reactions to the “Replacement” of our Surgeon General?
- Any input on this article?
- Another tough case
- Rectal prolapse (Colon and Rectal Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Bariatric patients can conquer obesity, but few achieve BMI < 25
Around one-quarter of obese individuals who undergo Roux-en-Y gastric bypass had sustained, long-term remission of obesity, but far fewer achieved body mass index of under 25 kg/m2 or maintained it over 5 years, new research suggests.
Researchers reported on the outcomes of a retrospective cohort study of 219 patients who underwent Roux-en-Y gastric bypass surgery at a single center between 2008 and 2010 and were followed for up to 7 years after the procedure.
Only 16.9% of female patients achieved a BMI of under 25 kg/m2 – during the study period, and only 2.7% reached this BMI by year 2 and sustained it at least to year 5 of follow-up.
Two males in the study achieved BMI of under 25 during follow-up. One was recorded as having maintained this weight at year 1 and the other at year 4, but no further measurements were available for either.
“Given the low number of patients achieving BMI of less than 25 kg/m2, we also wanted to focus on another important clinical goal of obesity remission (BMI less than 30),” wrote Corey J. Lager, MD, of the University of Michigan, Brehm Center for Diabetes, Ann Arbor, and his coauthors. “Taking into account that the mean BMI prior to surgery in our cohort was 47.1 kg/m2, this target is associated with significant estimated health benefits and likely brings a mortality benefit for patients undergoing gastric bypass.”
The authors said that a conservative estimate of the probability of achieving and sustaining BMI 25 or less after Roux-en-Y gastric bypass was just 2.3%. However, they offered a more liberal estimate – based on the number of patients who were at BMI 25 or under at the last available data point – of 6.8%.
Achieving weight loss to a BMI less than 30 was significantly influenced by age. The group who achieved this weight were on average 3 years younger at baseline than those who did not.
Similarly, initial BMI played a role in outcomes. The women who achieved a BMI below 30 had an initial mean BMI of 43.5, compared with 50.4 in the women who did not achieve this weight (P less than .0001). In males, the mean baseline BMI in those who got their weight below 30 was 44.6, compared with 48.1 in those who did not (P = .18).
Roux-en-Y gastric bypass was also associated with significant and sustained decreases in both systolic and diastolic blood pressure that was similar for both sexes. The maximum mean decrease of 14 ± 7 mm Hg was achieved at 1 year after surgery, and, at 5 years, the mean decrease was 11 ± 3 mm Hg.
The authors commented that, despite “excellent” weight loss being achieved by a majority of patients, the findings show the challenge of weight loss and maintenance in patients with a very high BMI. However, they also pointed to the encouragingly low rates of significant weight regain and the fact that fewer than 1% of patients returned to a weight greater than their preoperative weight. Higher preoperative BMI was correlated with greater weight loss but also negatively correlated with achieving BMI under 30.
The authors concluded with two takeaway messages. First, realistic goals should be set for patients undergoing gastric bypass surgery, with an emphasis on remission of obesity and with a reduced expectation of achievement of BMI under 25 over the long run. In addition, because the higher the initial BMI, the less likely that weight loss will not be maintained, “we should also carefully examine the option of pursuing surgery at lower BMI cutoffs, at which point patients have a greater likelihood of obesity remission.”
The study was supported by the University of Michigan Health System, the National Institutes of Health, and the Nutrition Obesity Research Centers. One author declared grant support and advisory positions with pharmaceutical companies and intellectual property unrelated to the study. Another author is an investigator on a sponsored clinical study. No other conflicts of interest were declared.
Around one-quarter of obese individuals who undergo Roux-en-Y gastric bypass had sustained, long-term remission of obesity, but far fewer achieved body mass index of under 25 kg/m2 or maintained it over 5 years, new research suggests.
Researchers reported on the outcomes of a retrospective cohort study of 219 patients who underwent Roux-en-Y gastric bypass surgery at a single center between 2008 and 2010 and were followed for up to 7 years after the procedure.
Only 16.9% of female patients achieved a BMI of under 25 kg/m2 – during the study period, and only 2.7% reached this BMI by year 2 and sustained it at least to year 5 of follow-up.
Two males in the study achieved BMI of under 25 during follow-up. One was recorded as having maintained this weight at year 1 and the other at year 4, but no further measurements were available for either.
“Given the low number of patients achieving BMI of less than 25 kg/m2, we also wanted to focus on another important clinical goal of obesity remission (BMI less than 30),” wrote Corey J. Lager, MD, of the University of Michigan, Brehm Center for Diabetes, Ann Arbor, and his coauthors. “Taking into account that the mean BMI prior to surgery in our cohort was 47.1 kg/m2, this target is associated with significant estimated health benefits and likely brings a mortality benefit for patients undergoing gastric bypass.”
The authors said that a conservative estimate of the probability of achieving and sustaining BMI 25 or less after Roux-en-Y gastric bypass was just 2.3%. However, they offered a more liberal estimate – based on the number of patients who were at BMI 25 or under at the last available data point – of 6.8%.
Achieving weight loss to a BMI less than 30 was significantly influenced by age. The group who achieved this weight were on average 3 years younger at baseline than those who did not.
Similarly, initial BMI played a role in outcomes. The women who achieved a BMI below 30 had an initial mean BMI of 43.5, compared with 50.4 in the women who did not achieve this weight (P less than .0001). In males, the mean baseline BMI in those who got their weight below 30 was 44.6, compared with 48.1 in those who did not (P = .18).
Roux-en-Y gastric bypass was also associated with significant and sustained decreases in both systolic and diastolic blood pressure that was similar for both sexes. The maximum mean decrease of 14 ± 7 mm Hg was achieved at 1 year after surgery, and, at 5 years, the mean decrease was 11 ± 3 mm Hg.
The authors commented that, despite “excellent” weight loss being achieved by a majority of patients, the findings show the challenge of weight loss and maintenance in patients with a very high BMI. However, they also pointed to the encouragingly low rates of significant weight regain and the fact that fewer than 1% of patients returned to a weight greater than their preoperative weight. Higher preoperative BMI was correlated with greater weight loss but also negatively correlated with achieving BMI under 30.
The authors concluded with two takeaway messages. First, realistic goals should be set for patients undergoing gastric bypass surgery, with an emphasis on remission of obesity and with a reduced expectation of achievement of BMI under 25 over the long run. In addition, because the higher the initial BMI, the less likely that weight loss will not be maintained, “we should also carefully examine the option of pursuing surgery at lower BMI cutoffs, at which point patients have a greater likelihood of obesity remission.”
The study was supported by the University of Michigan Health System, the National Institutes of Health, and the Nutrition Obesity Research Centers. One author declared grant support and advisory positions with pharmaceutical companies and intellectual property unrelated to the study. Another author is an investigator on a sponsored clinical study. No other conflicts of interest were declared.
Around one-quarter of obese individuals who undergo Roux-en-Y gastric bypass had sustained, long-term remission of obesity, but far fewer achieved body mass index of under 25 kg/m2 or maintained it over 5 years, new research suggests.
Researchers reported on the outcomes of a retrospective cohort study of 219 patients who underwent Roux-en-Y gastric bypass surgery at a single center between 2008 and 2010 and were followed for up to 7 years after the procedure.
Only 16.9% of female patients achieved a BMI of under 25 kg/m2 – during the study period, and only 2.7% reached this BMI by year 2 and sustained it at least to year 5 of follow-up.
Two males in the study achieved BMI of under 25 during follow-up. One was recorded as having maintained this weight at year 1 and the other at year 4, but no further measurements were available for either.
“Given the low number of patients achieving BMI of less than 25 kg/m2, we also wanted to focus on another important clinical goal of obesity remission (BMI less than 30),” wrote Corey J. Lager, MD, of the University of Michigan, Brehm Center for Diabetes, Ann Arbor, and his coauthors. “Taking into account that the mean BMI prior to surgery in our cohort was 47.1 kg/m2, this target is associated with significant estimated health benefits and likely brings a mortality benefit for patients undergoing gastric bypass.”
The authors said that a conservative estimate of the probability of achieving and sustaining BMI 25 or less after Roux-en-Y gastric bypass was just 2.3%. However, they offered a more liberal estimate – based on the number of patients who were at BMI 25 or under at the last available data point – of 6.8%.
Achieving weight loss to a BMI less than 30 was significantly influenced by age. The group who achieved this weight were on average 3 years younger at baseline than those who did not.
Similarly, initial BMI played a role in outcomes. The women who achieved a BMI below 30 had an initial mean BMI of 43.5, compared with 50.4 in the women who did not achieve this weight (P less than .0001). In males, the mean baseline BMI in those who got their weight below 30 was 44.6, compared with 48.1 in those who did not (P = .18).
Roux-en-Y gastric bypass was also associated with significant and sustained decreases in both systolic and diastolic blood pressure that was similar for both sexes. The maximum mean decrease of 14 ± 7 mm Hg was achieved at 1 year after surgery, and, at 5 years, the mean decrease was 11 ± 3 mm Hg.
The authors commented that, despite “excellent” weight loss being achieved by a majority of patients, the findings show the challenge of weight loss and maintenance in patients with a very high BMI. However, they also pointed to the encouragingly low rates of significant weight regain and the fact that fewer than 1% of patients returned to a weight greater than their preoperative weight. Higher preoperative BMI was correlated with greater weight loss but also negatively correlated with achieving BMI under 30.
The authors concluded with two takeaway messages. First, realistic goals should be set for patients undergoing gastric bypass surgery, with an emphasis on remission of obesity and with a reduced expectation of achievement of BMI under 25 over the long run. In addition, because the higher the initial BMI, the less likely that weight loss will not be maintained, “we should also carefully examine the option of pursuing surgery at lower BMI cutoffs, at which point patients have a greater likelihood of obesity remission.”
The study was supported by the University of Michigan Health System, the National Institutes of Health, and the Nutrition Obesity Research Centers. One author declared grant support and advisory positions with pharmaceutical companies and intellectual property unrelated to the study. Another author is an investigator on a sponsored clinical study. No other conflicts of interest were declared.
FROM OBESITY SURGERY
Key clinical point: Roux-en-Y gastric bypass is associated with sustained, long-term remission of obesity in around one-quarter of patients.
Major finding: Nearly one-quarter of patients who underwent Roux-en-Y gastric bypass achieved a BMI below 30 kg/m2 that was sustained at their last follow-up, but healthy weight was sustained at 5 years’ follow-up in far fewer patients.
Data source: Retrospective cohort study of 219 patients.
Disclosures: The study was supported by the University of Michigan Health System, the National Institutes of Health, and the Nutrition Obesity Research Centers. One author declared grant support and advisory positions with pharmaceutical companies and intellectual property unrelated to the study. Another author is an investigator on a sponsored clinical study. No other conflicts of interest were declared.
Physician-created APMs: Early recommendations offer insight
Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.
Proposals are routed through the Physician-focused Payment Model Technical Advisory Committee (PTAC), comprising physicians and experts in value-based health care systems. Commissioners are appointed by the Comptroller General of the United States.
Each proposals was assigned to three commissioners, including at least one physician, for review against 10 criteria:
- Scope of proposed PFPM (high priority)
- Quality and cost (high priority)
- Payment methodology (high priority)
- Value over volume
- Flexibility
- Ability to be evaluated
- Integration and care coordination
- Patient choice
- Patient safety
- Health information technology
While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”
The two models that got the limited recommendation were
- Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
- APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model.
“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.
Proposals are routed through the Physician-focused Payment Model Technical Advisory Committee (PTAC), comprising physicians and experts in value-based health care systems. Commissioners are appointed by the Comptroller General of the United States.
Each proposals was assigned to three commissioners, including at least one physician, for review against 10 criteria:
- Scope of proposed PFPM (high priority)
- Quality and cost (high priority)
- Payment methodology (high priority)
- Value over volume
- Flexibility
- Ability to be evaluated
- Integration and care coordination
- Patient choice
- Patient safety
- Health information technology
While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”
The two models that got the limited recommendation were
- Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
- APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model.
“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.
Proposals are routed through the Physician-focused Payment Model Technical Advisory Committee (PTAC), comprising physicians and experts in value-based health care systems. Commissioners are appointed by the Comptroller General of the United States.
Each proposals was assigned to three commissioners, including at least one physician, for review against 10 criteria:
- Scope of proposed PFPM (high priority)
- Quality and cost (high priority)
- Payment methodology (high priority)
- Value over volume
- Flexibility
- Ability to be evaluated
- Integration and care coordination
- Patient choice
- Patient safety
- Health information technology
While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”
The two models that got the limited recommendation were
- Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
- APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model.
“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Skin cancer risk similar for liver and kidney transplant recipients
SYDNEY – The risk of developing nonmelanoma skin cancer among liver transplant recipients is similar to that among kidney transplant recipients, but the former tend to have more skin cancer risk factors at baseline, according to a longitudinal cohort study reported at the annual meeting of the Australasian College of Dermatologists.
Liver transplant recipients have been thought to be at a lower risk of developing nonmelanoma skin cancers than are other solid organ transplant recipients, said Ludi Ge, MD, of the department of dermatology at the University of Sydney and Royal Prince Alfred Hospital, Sydney. However, data from a longitudinal cohort study of 230 kidney or liver transplant patients suggest the risk of nonmelanoma skin cancer is similar – if not greater – among liver transplant recipients, compared with kidney transplant recipients.
Over a 5-year period, 47% of liver transplant recipients developed at least one nonmelanoma skin cancer, compared with 33% of renal transplant recipients, representing a 78% greater risk among liver transplant recipients. However, Dr. Ge said the confidence intervals were wide, and the difference lost statistical significance in the multivariate analysis.
The researchers also noted that the liver transplant recipients in the study tended to be older at baseline, with a history of more sun exposure and more previous skin cancers, and were more likely to have a high risk skin type that sunburns easily.
In an interview, Dr. Ge said the findings had implications for the screening and follow-up of liver transplant recipients.
“Previously, we always thought that liver transplant recipients were at lower risk, and, possibly, they’re not screened as much so not followed up as much,” she said. “I think they really should be thought ... as high risk as renal transplant patients and the heart and lung transplant patients.”
The study showed that, while the renal transplant patients developed fewer skin cancers, they developed 1.9 lesions per year on average, compared with liver transplant patients, who developed 1.4 lesions per year.
The majority of skin cancers in both groups were squamous cell carcinomas and basal cell carcinomas, with a small number of keratoacanthomas. There was a similar ratio of squamous cell carcinomas to basal cell carcinomas between the two groups of transplant recipients – 1.7:1 in renal transplant recipients and 1.6:1 in liver recipients – which differed from the previously reported ratios of about 3:1, Dr. Ge said at the meeting.
She noted that this may have been because not every squamous cell carcinoma in situ was biopsied because of the sheer number of tumors, so many were treated empirically and, therefore, not entered into the clinic database.
Dr. Ge also pointed out that the evidence for the 3:1 ratio was around 10 years old.
“I think there’s been quite a change in the immunosuppressants that are used by transplant physicians, so, more and more, we’re seeing the use of sirolimus and everolimus, which are antiangiogenic,” she said.
Dr. Ge also strongly recommended that dermatology clinics specifically manage organ transplant recipients and commented that this could revolutionize the management of these patients, who tend to get lost to follow-up in standard dermatology clinics. “They’re very difficult to look after, they develop innumerable skin cancers that can result in death, and you need to intervene quite early,” she said in the interview.
No conflicts of interest were declared.
SYDNEY – The risk of developing nonmelanoma skin cancer among liver transplant recipients is similar to that among kidney transplant recipients, but the former tend to have more skin cancer risk factors at baseline, according to a longitudinal cohort study reported at the annual meeting of the Australasian College of Dermatologists.
Liver transplant recipients have been thought to be at a lower risk of developing nonmelanoma skin cancers than are other solid organ transplant recipients, said Ludi Ge, MD, of the department of dermatology at the University of Sydney and Royal Prince Alfred Hospital, Sydney. However, data from a longitudinal cohort study of 230 kidney or liver transplant patients suggest the risk of nonmelanoma skin cancer is similar – if not greater – among liver transplant recipients, compared with kidney transplant recipients.
Over a 5-year period, 47% of liver transplant recipients developed at least one nonmelanoma skin cancer, compared with 33% of renal transplant recipients, representing a 78% greater risk among liver transplant recipients. However, Dr. Ge said the confidence intervals were wide, and the difference lost statistical significance in the multivariate analysis.
The researchers also noted that the liver transplant recipients in the study tended to be older at baseline, with a history of more sun exposure and more previous skin cancers, and were more likely to have a high risk skin type that sunburns easily.
In an interview, Dr. Ge said the findings had implications for the screening and follow-up of liver transplant recipients.
“Previously, we always thought that liver transplant recipients were at lower risk, and, possibly, they’re not screened as much so not followed up as much,” she said. “I think they really should be thought ... as high risk as renal transplant patients and the heart and lung transplant patients.”
The study showed that, while the renal transplant patients developed fewer skin cancers, they developed 1.9 lesions per year on average, compared with liver transplant patients, who developed 1.4 lesions per year.
The majority of skin cancers in both groups were squamous cell carcinomas and basal cell carcinomas, with a small number of keratoacanthomas. There was a similar ratio of squamous cell carcinomas to basal cell carcinomas between the two groups of transplant recipients – 1.7:1 in renal transplant recipients and 1.6:1 in liver recipients – which differed from the previously reported ratios of about 3:1, Dr. Ge said at the meeting.
She noted that this may have been because not every squamous cell carcinoma in situ was biopsied because of the sheer number of tumors, so many were treated empirically and, therefore, not entered into the clinic database.
Dr. Ge also pointed out that the evidence for the 3:1 ratio was around 10 years old.
“I think there’s been quite a change in the immunosuppressants that are used by transplant physicians, so, more and more, we’re seeing the use of sirolimus and everolimus, which are antiangiogenic,” she said.
Dr. Ge also strongly recommended that dermatology clinics specifically manage organ transplant recipients and commented that this could revolutionize the management of these patients, who tend to get lost to follow-up in standard dermatology clinics. “They’re very difficult to look after, they develop innumerable skin cancers that can result in death, and you need to intervene quite early,” she said in the interview.
No conflicts of interest were declared.
SYDNEY – The risk of developing nonmelanoma skin cancer among liver transplant recipients is similar to that among kidney transplant recipients, but the former tend to have more skin cancer risk factors at baseline, according to a longitudinal cohort study reported at the annual meeting of the Australasian College of Dermatologists.
Liver transplant recipients have been thought to be at a lower risk of developing nonmelanoma skin cancers than are other solid organ transplant recipients, said Ludi Ge, MD, of the department of dermatology at the University of Sydney and Royal Prince Alfred Hospital, Sydney. However, data from a longitudinal cohort study of 230 kidney or liver transplant patients suggest the risk of nonmelanoma skin cancer is similar – if not greater – among liver transplant recipients, compared with kidney transplant recipients.
Over a 5-year period, 47% of liver transplant recipients developed at least one nonmelanoma skin cancer, compared with 33% of renal transplant recipients, representing a 78% greater risk among liver transplant recipients. However, Dr. Ge said the confidence intervals were wide, and the difference lost statistical significance in the multivariate analysis.
The researchers also noted that the liver transplant recipients in the study tended to be older at baseline, with a history of more sun exposure and more previous skin cancers, and were more likely to have a high risk skin type that sunburns easily.
In an interview, Dr. Ge said the findings had implications for the screening and follow-up of liver transplant recipients.
“Previously, we always thought that liver transplant recipients were at lower risk, and, possibly, they’re not screened as much so not followed up as much,” she said. “I think they really should be thought ... as high risk as renal transplant patients and the heart and lung transplant patients.”
The study showed that, while the renal transplant patients developed fewer skin cancers, they developed 1.9 lesions per year on average, compared with liver transplant patients, who developed 1.4 lesions per year.
The majority of skin cancers in both groups were squamous cell carcinomas and basal cell carcinomas, with a small number of keratoacanthomas. There was a similar ratio of squamous cell carcinomas to basal cell carcinomas between the two groups of transplant recipients – 1.7:1 in renal transplant recipients and 1.6:1 in liver recipients – which differed from the previously reported ratios of about 3:1, Dr. Ge said at the meeting.
She noted that this may have been because not every squamous cell carcinoma in situ was biopsied because of the sheer number of tumors, so many were treated empirically and, therefore, not entered into the clinic database.
Dr. Ge also pointed out that the evidence for the 3:1 ratio was around 10 years old.
“I think there’s been quite a change in the immunosuppressants that are used by transplant physicians, so, more and more, we’re seeing the use of sirolimus and everolimus, which are antiangiogenic,” she said.
Dr. Ge also strongly recommended that dermatology clinics specifically manage organ transplant recipients and commented that this could revolutionize the management of these patients, who tend to get lost to follow-up in standard dermatology clinics. “They’re very difficult to look after, they develop innumerable skin cancers that can result in death, and you need to intervene quite early,” she said in the interview.
No conflicts of interest were declared.
AT ACDASM 2017
Key clinical point: Liver transplant recipients should be screened and followed for the development of nonmelanoma skin cancers as closely as are kidney transplant recipients.
Major finding: Over 5 years, 47% of liver transplant recipients developed at least one nonmelanoma skin cancer, compared with 33% of renal transplant recipients, a difference that was not statistically significant after a multivariate analysis was done.
Data source: A longitudinal cohort study of 230 kidney or liver transplant recipients attending a dermatology clinic affiliated with an organ transplant unit.
Disclosures: No conflicts of interest were disclosed.
Pregnancy boosts risk of ventral hernia recurrence
Pregnancy is associated with a significant increase in the risk of ventral hernia recurrence after repair, according to a population-based cohort study published online in the American Journal of Surgery.
Analysis of registry data from 3,578 Danish women of reproductive age who had previously undergone ventral hernia repair showed that subsequent pregnancy was associated with a 56% higher risk of recurrence (95% confidence interval, 1.09-2.25; P = .016), compared with women who did not get pregnant (Am J Surg. 2017 April 5. doi: 10.1016/j.amjsurg.2017.03.044).
They noted that few studies have directly reported on the rate of ventral hernia recurrence after pregnancy, and the results that do exist are conflicting.
The overall rate of ventral hernia recurrence in the cohort was 12.5%, 67.9% of whom subsequently underwent reoperation to repair. The median time from hernia repair to pregnancy was 1.1 years, and median follow-up was 3.1 years.
Umbilical and incisional hernia repair were independently associated with a higher risk of recurrence (hazard ratio, 1.55 and 3.30, respectively) than epigastric repair, while larger hernia defects also increased the risk of recurrence.
“According to Laplace’s law, both the abdominal wall stretch and the raised intra-abdominal pressure theoretically strain the repaired ventral hernia site and are likely involved in the associated increased risk of recurrence,” the authors wrote. “Furthermore, prolonged duration of the second stage of labor and the use of manual fundal pressure might increase the risk of ventral hernia recurrence.”
The authors pointed out that inadequate fixation and lateral detachment of the mesh material were the most commonly reported mechanisms involved in ventral hernia recurrence after mesh repair. The fact that most mesh materials are far less elastic than the abdominal wall could account for the association between pregnancy and recurrence.
Based on the findings, they suggested that elective surgery for incisional or umbilical hernia repair be postponed until after the last planned pregnancy and that female patients of reproductive age be counseled on the increased risk of recurrence with pregnancy should they choose to undergo ventral hernia repair. They also noted that the natural course of an untreated ventral hernia, how it responds to pregnancy, and the risk of emergency repair during pregnancy need further investigation.
The study was supported by grants from Edgar Schnohr, MD, Dr MSc & Wife Gilberte Schnohr’s Foundation, and Bispebjerg Hospital. No conflicts of interest were declared.
Pregnancy is associated with a significant increase in the risk of ventral hernia recurrence after repair, according to a population-based cohort study published online in the American Journal of Surgery.
Analysis of registry data from 3,578 Danish women of reproductive age who had previously undergone ventral hernia repair showed that subsequent pregnancy was associated with a 56% higher risk of recurrence (95% confidence interval, 1.09-2.25; P = .016), compared with women who did not get pregnant (Am J Surg. 2017 April 5. doi: 10.1016/j.amjsurg.2017.03.044).
They noted that few studies have directly reported on the rate of ventral hernia recurrence after pregnancy, and the results that do exist are conflicting.
The overall rate of ventral hernia recurrence in the cohort was 12.5%, 67.9% of whom subsequently underwent reoperation to repair. The median time from hernia repair to pregnancy was 1.1 years, and median follow-up was 3.1 years.
Umbilical and incisional hernia repair were independently associated with a higher risk of recurrence (hazard ratio, 1.55 and 3.30, respectively) than epigastric repair, while larger hernia defects also increased the risk of recurrence.
“According to Laplace’s law, both the abdominal wall stretch and the raised intra-abdominal pressure theoretically strain the repaired ventral hernia site and are likely involved in the associated increased risk of recurrence,” the authors wrote. “Furthermore, prolonged duration of the second stage of labor and the use of manual fundal pressure might increase the risk of ventral hernia recurrence.”
The authors pointed out that inadequate fixation and lateral detachment of the mesh material were the most commonly reported mechanisms involved in ventral hernia recurrence after mesh repair. The fact that most mesh materials are far less elastic than the abdominal wall could account for the association between pregnancy and recurrence.
Based on the findings, they suggested that elective surgery for incisional or umbilical hernia repair be postponed until after the last planned pregnancy and that female patients of reproductive age be counseled on the increased risk of recurrence with pregnancy should they choose to undergo ventral hernia repair. They also noted that the natural course of an untreated ventral hernia, how it responds to pregnancy, and the risk of emergency repair during pregnancy need further investigation.
The study was supported by grants from Edgar Schnohr, MD, Dr MSc & Wife Gilberte Schnohr’s Foundation, and Bispebjerg Hospital. No conflicts of interest were declared.
Pregnancy is associated with a significant increase in the risk of ventral hernia recurrence after repair, according to a population-based cohort study published online in the American Journal of Surgery.
Analysis of registry data from 3,578 Danish women of reproductive age who had previously undergone ventral hernia repair showed that subsequent pregnancy was associated with a 56% higher risk of recurrence (95% confidence interval, 1.09-2.25; P = .016), compared with women who did not get pregnant (Am J Surg. 2017 April 5. doi: 10.1016/j.amjsurg.2017.03.044).
They noted that few studies have directly reported on the rate of ventral hernia recurrence after pregnancy, and the results that do exist are conflicting.
The overall rate of ventral hernia recurrence in the cohort was 12.5%, 67.9% of whom subsequently underwent reoperation to repair. The median time from hernia repair to pregnancy was 1.1 years, and median follow-up was 3.1 years.
Umbilical and incisional hernia repair were independently associated with a higher risk of recurrence (hazard ratio, 1.55 and 3.30, respectively) than epigastric repair, while larger hernia defects also increased the risk of recurrence.
“According to Laplace’s law, both the abdominal wall stretch and the raised intra-abdominal pressure theoretically strain the repaired ventral hernia site and are likely involved in the associated increased risk of recurrence,” the authors wrote. “Furthermore, prolonged duration of the second stage of labor and the use of manual fundal pressure might increase the risk of ventral hernia recurrence.”
The authors pointed out that inadequate fixation and lateral detachment of the mesh material were the most commonly reported mechanisms involved in ventral hernia recurrence after mesh repair. The fact that most mesh materials are far less elastic than the abdominal wall could account for the association between pregnancy and recurrence.
Based on the findings, they suggested that elective surgery for incisional or umbilical hernia repair be postponed until after the last planned pregnancy and that female patients of reproductive age be counseled on the increased risk of recurrence with pregnancy should they choose to undergo ventral hernia repair. They also noted that the natural course of an untreated ventral hernia, how it responds to pregnancy, and the risk of emergency repair during pregnancy need further investigation.
The study was supported by grants from Edgar Schnohr, MD, Dr MSc & Wife Gilberte Schnohr’s Foundation, and Bispebjerg Hospital. No conflicts of interest were declared.
FROM THE AMERICAN JOURNAL OF SURGERY
Key clinical point: Pregnancy after ventral hernia repair can significantly increase the risk of recurrence.
Major finding: Pregnancy is associated with a 56% increase in the risk of recurrence of ventral hernia after repair.
Data source: A population-based cohort study of 3,578 women of reproductive age who underwent ventral hernia repair.
Disclosures: The study was supported by grants from Edgar Schnohr MD, Dr MSc & Wife Gilberte Schnohr’s Foundation, and Bispebjerg Hospital. No conflicts of interest were declared.