Transition from Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair to Robotic Transabdominal Preperitoneal Inguinal Hernia Repair: A Retrospective Review of a Single Surgeon's Experience.

BACKGROUND: There is a paucity of literature comparing laparoscopic to robotic inguinal hernia repair. We present a single surgeon's transition from laparoscopic totally extraperitoneal (L-TEP) to robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair and compare outcomes from the two approaches. METHODS: This retrospective review and analysis of prospectively collected data compare outcomes during the transition from L-TEP to R-TAPP inguinal hernia repair by a single surgeon at one institution. Operating times and surgical outcomes and complications are analyzed. All consecutive L-TEP cases from November 2012 to August 2014 and all consecutive R-TAPP cases from March 2013 to October 2015 were included in the analysis. RESULTS: A total of 157 and 118 patients underwent L-TEP and R-TAPP inguinal hernia repair, respectively. The groups were similar regarding demographics and ASA class. A significantly higher number of complex cases were performed in the R-TAPP group compared to L-TEP group (n = 11 vs. n = 1, p = 0.0001). Mean surgical times were nearly identical (69.12 ± 35.13 min, R-TAPP; 69.05 ± 26.31, L-TEP) as were intraoperative and postoperative complication rates-despite the significantly higher number of complex cases in the R-TAPP group. CONCLUSIONS: This is the largest study in the literature comparing a single surgeon's experience transitioning from L-TEP to R-TAPP inguinal hernia repair. Results from the R-TAPP cases were similar to those achieved from laparoscopic cases. The robotic platform may have facilitated the execution of complex hernia cases during the proficiency phase.

A novel pleckstrin homology domain-containing protein enhances insulin-stimulated Akt phosphorylation and GLUT4 translocation in adipocytes.

Protein kinase B/Akt protein kinases control an array of diverse functions, including cell growth, survival, proliferation, and metabolism. We report here the identification of pleckstrin homology-like domain family B member 1 (PHLDB1) as an insulin-responsive protein that enhances Akt activation. PHLDB1 contains a pleckstrin homology domain, which we show binds phosphatidylinositol PI(3,4)P(2), PI(3,5)P(2), and PI(3,4,5)P(3), as well as a Forkhead-associated domain and coiled coil regions. PHLDB1 expression is increased during adipocyte differentiation, and it is abundant in many mouse tissues. Both endogenous and HA- or GFP-tagged PHLDB1 displayed a cytoplasmic disposition in unstimulated cultured adipocytes but translocated to the plasma membrane in response to insulin. Depletion of PHLDB1 by siRNA inhibited insulin stimulation of Akt phosphorylation but not tyrosine phosphorylation of IRS-1. RNAi-based silencing of PHLDB1 in cultured adipocytes also attenuated insulin-stimulated deoxyglucose transport and Myc-GLUT4-EGFP translocation to the plasma membrane, whereas knockdown of the PHLDB1 isoform PHLDB2 failed to attenuate insulin-stimulated deoxyglucose transport. Furthermore, adenovirus-mediated expression of PHLDB1 in adipocytes enhanced insulin-stimulated Akt and p70 S6 kinase phosphorylation, as well as GLUT4 translocation. These results indicate that PHLDB1 is a novel modulator of Akt protein kinase activation by insulin.

T cell receptor engagement leads to phosphorylation of clathrin heavy chain during receptor internalization.

T cell receptor (TCR) internalization by clathrin-coated vesicles after encounter with antigen has been implicated in the regulation of T cell responses. We demonstrate that TCR internalization after receptor engagement and TCR signaling involves inducible phosphorylation of clathrin heavy chain (CHC) in both CD4+ and CD8+ human T cells. Studies with mutant Jurkat T cells implicate the Src family kinase Lck as the responsible enzyme and its activity in this process is influenced by the functional integrity of the downstream signaling molecule ZAP-70. CHC phosphorylation positively correlates with ligand-induced TCR internalization in both CD4+ and CD8+ T cells, and CHC phosphorylation as a result of basal Lck activity is also implicated in constitutive TCR endocytosis by CD4+ T cells. Remarkably, irreversible CHC phosphorylation in the presence of pervanadate reduced both constitutive and ligand-induced TCR internalization in CD4+ T cells, and immunofluorescence studies revealed that this inhibition affected the early stages of TCR endocytosis from the plasma membrane. Thus, we propose that CHC phosphorylation and dephosphorylation are involved in TCR internalization and that this is a regulatory mechanism linking TCR signaling to endocytosis.

IBD: A Growing and Vulnerable Cohort of Hospitalized Patients with Clostridium difficile Infection.

The most recent nationwide data show a rising incidence of Clostridium difficile infection in hospitalized patients with ulcerative colitis (UC). We describe recent national trends with regard to incidence, mortality, and the rate of total colectomy. The Nationwide Inpatient Sample database identified patients admitted to hospitals in the United States with diagnoses of C. difficile and inflammatory bowel disease (IBD) during the study years 2007 to 2013. We analyzed incidence of C. difficile, mortality, and colectomy rates. From 2007 to 2013, incidence of patients with IBD admitted with the primary diagnosis of C. difficile rose faster than the non-IBD population (1.24% to 2.14% vs 0.26% to 0.30%, P < 0.0001) and specifically in the UC population rose from 2.36 to 3.48 per cent (P < 0.001). The mortality of non-IBD patients with C. difficile decreased 47 per cent (3.76% to 1.99%, P = 0.003), whereas mortality of IBD patients with C. difficile decreased 54 per cent (6.08% to 2.79%, P = 0.003). For UC patients with primary diagnosis C. difficile, the percentage undergoing total colectomy decreased by 38 per cent (2.47% vs 1.51%, P = 0.049). The incidence of C. difficile continues to rise in the both the IBD and non-IBD population. Our study shows decreasing mortality for IBD and non-IBD patients with C. difficile but a greater decrease in mortality for IBD patients.

Stenting for obstructing colon cancer: fewer complications and colostomies.

BACKGROUND AND OBJECTIVES: Colonic stenting has been used in the setting of malignant obstruction to avoid an emergent colectomy. We sought to determine whether preoperative placement of a colonic stent decreases morbidity and the rate of colostomy formation. METHODS: Cases of obstructing sigmoid, rectosigmoid, and rectal cancer from January 1, 2010, to December 31, 2011, were identified in the Nationwide Inpatient Sample (NIS) database. All patients were treated at hospitals in the United States, and the database generated national estimates. Postoperative complications, mortality, and the rate of colostomy formation were analyzed. RESULTS: Of the estimated 7891 patients who presented with obstructing sigmoid, rectosigmoid, or rectal cancer necessitating intervention, 12.1% (n = 956) underwent placement of a colonic stent, and the remainder underwent surgery without stent placement. Of the patients who underwent stenting, 19.9% went on to have colon resection or stoma creation during the same admission. Patients who underwent preoperative colonic stent placement had a lower rate of total postoperative complications (10.5% vs 21.7%; P < .01). There was no significant difference in mortality (4.7% vs 4.2%; P = .69). The rate of colostomy formation was more than 2-fold higher in patients who did not undergo preoperative stenting (42.5% vs 19.5%; P < .01). Preoperative stenting was associated with increased use of laparoscopy (32.6% vs 9.7%; P < .01). CONCLUSIONS: Our study characterizes the national incidence of preoperative placement of a colonic stent in the setting of malignant obstruction. Preoperative stent placement is associated with lower postoperative complications and a lower rate of colostomy formation. The results support the hypothesis that stenting as a bridge to surgery may benefit patients by converting an emergent surgery into an elective one.

Laparoscopic vs open ventral hernia repair in the era of obesity.

IMPORTANCE: This study analyzes a role of laparoscopy in obese patients with ventral hernia. OBJECTIVE: To evaluate the outcomes of laparoscopic compared with open ventral hernia repair (VHR) in obese patients. DESIGN: Retrospective cohort analysis. SETTING: Nationwide hospital survey. PARTICIPANTS: Obese patients undergoing VHR from 2008 through 2009 were selected from the Nationwide Inpatient Sample database. MAIN OUTCOMES AND MEASURES: Data analysis included intraoperative and postoperative complications, length of stay, and total hospital charges. Additional patient demographics, including insurance, median income, and locations, were analyzed. RESULTS: Of the 47,661 obese patients who underwent VHR during the study period, laparoscopic VHR increased more than 4-fold, from 1547 of 23,917 (6.5%) to 6629 of 23,704 (28.0%) (P < .001). Laparoscopic VHR was associated with a lower overall complication rate (6.3% vs 13.7%; P < .001), shorter median length of stay (3 vs 4 days; P < .001), and lower mean total hospital charges ($40,387 vs $48,513; P < .001). Multivariable logistic regression analysis identified a predictive variable for laparoscopic VHR: private insurance (odds ratio, 1.20; 95% CI, 1.15-1.27; P < .001). Ventral hernias with a gangrenous bowel were less likely to undergo laparoscopic VHR (odds ratio, 0.14; 95% CI, 0.06-0.34; P < .001). CONCLUSIONS AND RELEVANCE: In the era of laparoscopy, the overall use of laparoscopic VHR in obese patients has increased significantly and appears to be safe, with a shorter stay and a lower cost of care.