Citations

Abstract Purpose: Data on laparoscopic totally extraperitoneal inguinal hernia repairs (TEP-IHRs) suggest that approximately 250 operations are needed to gain mastery, but the annual volume required to maintain high-quality outcomes is unknown. Materials and Methods: A retrospective review was performed of every patient undergoing a TEP-IHR at the Mayo Clinic (Rochester, MN) from 1995 to 2011. Analysis focused on the annual volume of 21 staff surgeons and their specific patient outcomes broken up into three groups: Group 1 (G1) ( n = 1 surgeon) performed >30 repairs per year; Group 2 (G2) ( n = 3 surgeons), 15–30 repairs; and Group 3 (G3) ( n = 17), <15 repairs. Results: In total, 1601 patients underwent 2410 TEP-IHRs, with no significant patient demographic differences among groups. Greater annual surgeon volume (G1 > G2 > G3) was associated with improved outcomes as shown by the respective rates for intra- (1%, 2.6%, and 5.6%) and postoperative (13%, 27%, and 36%) complications, need for overnight stay (17%, 23%, and 29%), and hernia recurrence (1%, 4%, and 4.3%) (all P < .05). Surgeons with greater annual operative volumes were more likely to operate on patients with bilateral and recurrent hernias. Surgeons performing at least 15 repairs per year (G1 and G2) showed improvements in quality metrics over time. Conclusions: Annual operative volumes of >30 repairs per year are associated with the highest quality outcomes for TEP-IHR. Operative volumes of at least 15 repairs per year are associated with improvements in quality metrics over time. Mentorship and operative assistance of low-volume TEP-IHR surgeons may be useful in improving patient outcomes.

AbstractBackgroundExposure to aeroallergens induces eosinophilic airway inflammation in patients with asthma and allergic airway diseases. The circulating number of eosinophils in peripheral blood is relatively small, leading us to hypothesize that bone marrow needs to be engaged quickly to meet the demands of the tissues.MethodsTo investigate the communication between the lungs and bone marrow, we used acute allergen exposure and airway inflammation models in mice. Gene‐deficient mice and cytokine reporter mice as well as in vitro cell culture models were used to dissect the mechanisms.ResultsNaïve BALB/c mice produced increased numbers of eosinophil precursors and mature eosinophils in the bone marrow when their airways were exposed to a common fungal allergen, Alternaria alternata. Expression of IL‐5 and IL‐33 increased rapidly in the lungs, but not in the bone marrow. Sera from allergen‐exposed mice promoted eosinophilopoiesis in bone marrow cells from naïve mice, which was blocked by anti‐IL‐5 antibody. Mice deficient in the IL‐33 receptor ST2 (i.e., Il1rl1−/− mice) were unable to increase their serum levels of IL‐5 and allergen‐induced eosinophilopoiesis in the bone marrow after allergen exposure. Finally, group 2 innate lymphoid cells (ILC2s) in the lungs showed robust expression of IL‐5 after Alternaria exposure.ConclusionsThese finding suggests that lung IL‐33, through innate activation of ILC2s and their production of IL‐5, plays a key role in promoting acute reactive eosinophilopoiesis in the bone marrow when naïve animals are exposed to airborne allergens. Therefore, bone marrow eosinophilopoiesis may be affected by atmospheric environmental conditions.