Vol. 218, No. 5, May 2014
starting point for discussion between surgeons and patients to provide an estimate of risk and among surgeons about strategies to mitigate that risk. For example, the suggested operative techniques, such as the transversus abdominus release and retro-rectus repair, aim to avoid development of skin flaps, which, in our model, are an independent predictor of surgical site occurrence and infection. Although we agree that primary and incisional hernias differ in pathophysiology, operative approaches, and outcomes, all ventral hernias were included in the risk score to maximize efficiency and use. Additional analyses stratified by hernia type demonstrated that the VHRS had similar accuracy for predicting surgical site infections and still outperformed the Ventral Hernia Working Group grading system.2 The area under the curve was 0.70 vs 0.59 for primary ventral hernias and 0.68 vs 0.63 for incisional hernias when comparing VHRS with Ventral Hernia Working Group grade (Liang, unpublished data). In addition, this approach is consistent with that of the European Hernia Society, which recommends that primary and incisional ventral hernias be classified as one group.3 Matthews and colleagues inquired about the rate and consequences of deep surgical site infections in the model dataset. The rate of deep surgical site or mesh infections was 12.9%.1 Among 407 patients in whom mesh was placed, 28 (6.9%) required subsequent mesh explantation, which is similar to the 5.4% mesh explantation rate in a multicenter study by Hawn and colleagues.4,5 Patients underwent explantation during reoperation for multiple reasons, including hernia recurrence (19 of 28 [67.9%]) and deep surgical site infection (17 of 28 [60.7%]). Therefore, it is not surprising that Ventral Hernia Working Group grade is predictive of mesh explantation (area under the curve ¼ 0.67; 95% CI, 0.560.77),5 and additional analyses demonstrate that VHRS is similarly predictive (area under the curve ¼ 0.69; 95% CI, 0.600.79). Mesh type was not predictive, although the study might have been underpowered to identify a difference, given that multiple mesh types were used. Although promising results have been reported in the literature with lightweight macroporous synthetic meshes in contaminated ventral hernia repairs, the only published prospective, randomized controlled trial comparing lightweight with heavyweight mesh for ventral incisional hernias shows no difference in surgical site infections (18% vs 16%) and a nonstatistically significant increase in recurrence at 2 years (17% vs 7%).6 Additional trials are necessary to identify whether specific meshes, techniques, or combinations of the 2 can reduce the rates of infection and explantation. Whether or not surgical site occurrences or infections result in a dire consequence, in the current era of public
Letters
1077
reporting and pay for performance, valid models for risk adjustment and optimization of perioperative care are priorities for improving the quality of surgical care. We wholeheartedly agree with Matthews and colleagues that participation in a prospective quality collaborative with predefined definitions, audited data entry, and advanced statistical adjustment methodologies can improve outcomes in hernia care. In the meantime, the VHRS provides a starting point for identifying potential areas for improvement in patient selection, surgical techniques, and perioperative care. REFERENCES 1. Berger RL, Li LT, Hicks SC, et al. Development and validation of risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair. J Am Coll Surg 2013;217:974e982. 2. Ventral Hernia Working Group, Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010;148:544e558. 3. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia 2009; 13:407e414. 4. Hawn MT, Gray SH, Snyder CW, et al. Predictors of mesh explantation after incisional hernia repair. Am J Surg 2011; 202:28e33. 5. Liang MK, Li LT, Nguyen MT, et al. Abdominal reoperation and mesh explantation following open ventral hernia repair with mesh. Am J Surg in press. doi:10.1016/j.amjsurg.2013.10.024. 6. Conze J, Kingsnorth AN, Flament JB, et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg 2005;92:1488e1493.
Disclosure Information: Nothing to disclose.
Transcystic Access Cannot Be a Good Choice for Bile Leakage Test after Major Liver Resections Cuneyt Kayaalp, Malatya, Turkey
MD, PhD
I read with interest the article titled “Systematic Use of an Intraoperative Air Leak Test at the Time of Major Liver Resection Reduces the Rate of Postoperative Biliary Complications,” published in the Journal of the American College of Surgeons (December 2013) by Zimmitti and colleagues.1 They reported satisfactory results at reducing postoperative bile leaks after major liver resections by leak test. During the test, they used transcystic air injection under the guidance of liver ultrasound. While injecting the air through the ductus cysticus, they filled the upper
1078
J Am Coll Surg
Letters
abdomen with normal saline and occluded the distal common bile duct by finger compression. In our practice, for bile leakage test, it is not always possible to inject the test material (ie, air, normal saline, or dye) through the ductus cysticus when the distal common bile duct was occluded. This can be explained simply by the anatomic variations of level of ductus cysticus confluences. Occluding the common bile duct by fingers at the level of supraduodenal part (as shown in Figure 2 of the article) results, not uncommonly, in failure. I would like to ask some questions and make a comment. Did the authors have any experience with failure of injecting air through the ductus cysticus when the distal common bile duct was occluded? What was its success rate? If it failed, what did they do? If they injected the air easily with distal occlusion, what was the rationale of checking the air by ultrasound? It seems to me that the authors needed routine ultrasound because they could not be sure that they occluded the distal bile duct appropriately in every case. If there is inadequate distal occlusion, escape of the test material through the sphincter of Oddi makes it impossible to create a certain pressure in the biliary tree. To overcome these drawbacks, we usually prefer injection directly through the common bile duct (Fig. 1). The test involves passing a 22-G venous catheter through the anterior wall of the common bile duct. After occluding the distal part of the common bile duct with a sling, normal saline is injected into the intrahepatic bile ducts slowly with a syringe (Fig. 1). Any biliary orifices visualized are sutured with 3-0 polyglycolic acid sutures. The catheter is removed from the common bile duct, and the orifice that it has been inserted through is sutured with 6-0 polyglycolic acid fiber. We have used this technique in >25 cases without any major problem and with a very high success rate.2
Figure 1. Test through the common bile duct.
Preference of common bile duct for leakage test has the following advantages over the transcystic route: 1. Anatomic variation of cystic duct confluence does not matter anymore. Distal common bile duct occlusion ratio is always 100% and this provides a standard testing method. 2. There is no need for ultrasound control for distribution of the intrabiliary test material. 3. There is no need for cholecystectomy because the ductus cysticus is not necessary for the test. REFERENCES 1. Zimmitti G, Vauthey JN, Shindoh J, et al. Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. J Am Coll Surg 2013;217:1028e1037. 2. Kayaalp C, Aydin C, Olmez A, et al. Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery. Clinics (Sao Paulo) 2011;66:421e424.
Disclosure Information: Nothing to disclose.
Reply: Air Leak Test, Two Hands Are Better Than None Thomas A Aloia, MD, FACS, Jean-Nicolas Vauthey, MD, FACS Houston, TX We thank Dr Kayaalp for his insightful comments about the relative advantages and disadvantages to methods of biliary access for intraoperative bile leak testing. In his letter, Dr Kayaalp advocates for direct puncture of the common hepatic duct with a rigid, narrow-bore catheter and tourniquet occlusion of the common bile duct, with subsequent suture repair of the choledochotomy. We would argue that the air leak test (ALT) includes specific technical features, mainly related to the ability to carefully monitor the intrabiliary pressure, that enhance its safety and effectiveness and result in a considerable reduction in bile leak rates at our institution.1 Dr Kayaalp proposes that the direct puncture technique is superior to our transcystic approach based on 2 features. First, he contends that the technical success rate (ability to apply pressure to the possible leak site) could be higher using the direct puncture technique. However, we maintain that with the direct puncture technique, only minimal and insufficient pressure can be applied to the plunger of the injection syringe without leakage from around the common duct entry site. As an example of this problem, we have experienced air leaks from around cholangiogram catheters inserted in the
starting point for discussion between surgeons and patients to provide an estimate of risk and among surgeons about strategies to mitigate that risk. For example, the suggested operative techniques, such as the transversus abdominus release and retro-rectus repair, aim to avoid development of skin flaps, which, in our model, are an independent predictor of surgical site occurrence and infection. Although we agree that primary and incisional hernias differ in pathophysiology, operative approaches, and outcomes, all ventral hernias were included in the risk score to maximize efficiency and use. Additional analyses stratified by hernia type demonstrated that the VHRS had similar accuracy for predicting surgical site infections and still outperformed the Ventral Hernia Working Group grading system.2 The area under the curve was 0.70 vs 0.59 for primary ventral hernias and 0.68 vs 0.63 for incisional hernias when comparing VHRS with Ventral Hernia Working Group grade (Liang, unpublished data). In addition, this approach is consistent with that of the European Hernia Society, which recommends that primary and incisional ventral hernias be classified as one group.3 Matthews and colleagues inquired about the rate and consequences of deep surgical site infections in the model dataset. The rate of deep surgical site or mesh infections was 12.9%.1 Among 407 patients in whom mesh was placed, 28 (6.9%) required subsequent mesh explantation, which is similar to the 5.4% mesh explantation rate in a multicenter study by Hawn and colleagues.4,5 Patients underwent explantation during reoperation for multiple reasons, including hernia recurrence (19 of 28 [67.9%]) and deep surgical site infection (17 of 28 [60.7%]). Therefore, it is not surprising that Ventral Hernia Working Group grade is predictive of mesh explantation (area under the curve ¼ 0.67; 95% CI, 0.560.77),5 and additional analyses demonstrate that VHRS is similarly predictive (area under the curve ¼ 0.69; 95% CI, 0.600.79). Mesh type was not predictive, although the study might have been underpowered to identify a difference, given that multiple mesh types were used. Although promising results have been reported in the literature with lightweight macroporous synthetic meshes in contaminated ventral hernia repairs, the only published prospective, randomized controlled trial comparing lightweight with heavyweight mesh for ventral incisional hernias shows no difference in surgical site infections (18% vs 16%) and a nonstatistically significant increase in recurrence at 2 years (17% vs 7%).6 Additional trials are necessary to identify whether specific meshes, techniques, or combinations of the 2 can reduce the rates of infection and explantation. Whether or not surgical site occurrences or infections result in a dire consequence, in the current era of public
Letters
1077
reporting and pay for performance, valid models for risk adjustment and optimization of perioperative care are priorities for improving the quality of surgical care. We wholeheartedly agree with Matthews and colleagues that participation in a prospective quality collaborative with predefined definitions, audited data entry, and advanced statistical adjustment methodologies can improve outcomes in hernia care. In the meantime, the VHRS provides a starting point for identifying potential areas for improvement in patient selection, surgical techniques, and perioperative care. REFERENCES 1. Berger RL, Li LT, Hicks SC, et al. Development and validation of risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair. J Am Coll Surg 2013;217:974e982. 2. Ventral Hernia Working Group, Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010;148:544e558. 3. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia 2009; 13:407e414. 4. Hawn MT, Gray SH, Snyder CW, et al. Predictors of mesh explantation after incisional hernia repair. Am J Surg 2011; 202:28e33. 5. Liang MK, Li LT, Nguyen MT, et al. Abdominal reoperation and mesh explantation following open ventral hernia repair with mesh. Am J Surg in press. doi:10.1016/j.amjsurg.2013.10.024. 6. Conze J, Kingsnorth AN, Flament JB, et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg 2005;92:1488e1493.
Disclosure Information: Nothing to disclose.
Transcystic Access Cannot Be a Good Choice for Bile Leakage Test after Major Liver Resections Cuneyt Kayaalp, Malatya, Turkey
MD, PhD
I read with interest the article titled “Systematic Use of an Intraoperative Air Leak Test at the Time of Major Liver Resection Reduces the Rate of Postoperative Biliary Complications,” published in the Journal of the American College of Surgeons (December 2013) by Zimmitti and colleagues.1 They reported satisfactory results at reducing postoperative bile leaks after major liver resections by leak test. During the test, they used transcystic air injection under the guidance of liver ultrasound. While injecting the air through the ductus cysticus, they filled the upper
1078
J Am Coll Surg
Letters
abdomen with normal saline and occluded the distal common bile duct by finger compression. In our practice, for bile leakage test, it is not always possible to inject the test material (ie, air, normal saline, or dye) through the ductus cysticus when the distal common bile duct was occluded. This can be explained simply by the anatomic variations of level of ductus cysticus confluences. Occluding the common bile duct by fingers at the level of supraduodenal part (as shown in Figure 2 of the article) results, not uncommonly, in failure. I would like to ask some questions and make a comment. Did the authors have any experience with failure of injecting air through the ductus cysticus when the distal common bile duct was occluded? What was its success rate? If it failed, what did they do? If they injected the air easily with distal occlusion, what was the rationale of checking the air by ultrasound? It seems to me that the authors needed routine ultrasound because they could not be sure that they occluded the distal bile duct appropriately in every case. If there is inadequate distal occlusion, escape of the test material through the sphincter of Oddi makes it impossible to create a certain pressure in the biliary tree. To overcome these drawbacks, we usually prefer injection directly through the common bile duct (Fig. 1). The test involves passing a 22-G venous catheter through the anterior wall of the common bile duct. After occluding the distal part of the common bile duct with a sling, normal saline is injected into the intrahepatic bile ducts slowly with a syringe (Fig. 1). Any biliary orifices visualized are sutured with 3-0 polyglycolic acid sutures. The catheter is removed from the common bile duct, and the orifice that it has been inserted through is sutured with 6-0 polyglycolic acid fiber. We have used this technique in >25 cases without any major problem and with a very high success rate.2
Figure 1. Test through the common bile duct.
Preference of common bile duct for leakage test has the following advantages over the transcystic route: 1. Anatomic variation of cystic duct confluence does not matter anymore. Distal common bile duct occlusion ratio is always 100% and this provides a standard testing method. 2. There is no need for ultrasound control for distribution of the intrabiliary test material. 3. There is no need for cholecystectomy because the ductus cysticus is not necessary for the test. REFERENCES 1. Zimmitti G, Vauthey JN, Shindoh J, et al. Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. J Am Coll Surg 2013;217:1028e1037. 2. Kayaalp C, Aydin C, Olmez A, et al. Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery. Clinics (Sao Paulo) 2011;66:421e424.
Disclosure Information: Nothing to disclose.
Reply: Air Leak Test, Two Hands Are Better Than None Thomas A Aloia, MD, FACS, Jean-Nicolas Vauthey, MD, FACS Houston, TX We thank Dr Kayaalp for his insightful comments about the relative advantages and disadvantages to methods of biliary access for intraoperative bile leak testing. In his letter, Dr Kayaalp advocates for direct puncture of the common hepatic duct with a rigid, narrow-bore catheter and tourniquet occlusion of the common bile duct, with subsequent suture repair of the choledochotomy. We would argue that the air leak test (ALT) includes specific technical features, mainly related to the ability to carefully monitor the intrabiliary pressure, that enhance its safety and effectiveness and result in a considerable reduction in bile leak rates at our institution.1 Dr Kayaalp proposes that the direct puncture technique is superior to our transcystic approach based on 2 features. First, he contends that the technical success rate (ability to apply pressure to the possible leak site) could be higher using the direct puncture technique. However, we maintain that with the direct puncture technique, only minimal and insufficient pressure can be applied to the plunger of the injection syringe without leakage from around the common duct entry site. As an example of this problem, we have experienced air leaks from around cholangiogram catheters inserted in the
