Diagnostic techniques for diastasis recti.

Diastasis recti (DR) is an abnormality of the anterior abdominal wall, characterized by a separation of the rectus abdominis muscles along the linea alba. A thorough history and physical exam can diagnose most cases of diastasis recti. Classification schemes for diastasis recti have been created based on inter-rectus distance and location of the defect, which can help with management decisions. Imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can aid in the classification of diastasis recti and guide surgical planning. Planning is most important when contemplating the plan of care for the repair of hernias within a rectus diastasis.

Robotic iliopubic tract (r-IPT) repair: technique and preliminary outcomes of a minimally invasive tissue repair for inguinal hernia.

PURPOSE: The iliopubic tract repair was first introduced by Nyhus in 1959, as an open non-mesh posterior preperitoneal repair for inguinal hernia. We have adapted this repair using a robotic approach to offer a minimally invasive (MIS) non-mesh inguinal hernia repair, termed the robotic iliopubic tract (r-IPT) repair. The aim of this pilot study is to evaluate the safety and effectiveness of this new technique. METHODS: Starting in 2015, patients were enrolled in a Phase I trial of r-IPT repair. Inclusion criteria included low-risk patients with small inguinal hernias. Using a robotic TAPP approach, the direct and/or indirect defects were repaired by approximating the transversalis arch to the iliopubic tract. This trial was then expanded in Phase II to include a wider range of patients. Outcomes were collected prospectively. RESULTS: Twenty-four inguinal hernias were repaired in 13 patients via r-IPT as outpatients. Patients were followed for a mean of 24.9 months (range 2.7-55.3, median 24). There were no surgical site occurrences and no recurrences. One (7.7%) patient had acute post-operative genital branch neuralgia, which self-resolved. One (7.7%) patient has chronic pain. CONCLUSION: The Nyhus-inspired robotic iliopubic tract (r-IPT) repair is an MIS approach to provide a non-mesh repair in inguinal hernia. The repair is safe with acceptable preliminary outcomes in low-risk patients. We propose the r-IPT repair to be a MIS option for non-mesh inguinal hernia repair in low-risk patients.

Why we remove mesh.

PURPOSE: As more mesh is implanted for hernia repairs, mesh-related complications may increase, with some requiring mesh removal. We describe our experience as to indications and perioperative factors that surround hernia mesh removal. METHODS: All patients who underwent hernia mesh removal from the abdomen (ventral, flank) and pelvis (inguinal, femoral, obturator, perineal) were captured from a single hernia center database. RESULTS: Over 4.5 years, we removed 105 mesh. Most were in males (58%), average age 53 years, with average pain score 5/10. Males most commonly had mesh removed from the pelvis (65%), and females from the abdomen (63%, P = 0.009). Pain score was significantly higher prior to removal of hernia mesh from the pelvis (5.7 vs 4.5, P = 0.047). Type of mesh implanted and positioning of mesh showed no difference in pain (P > 0.05). Indications for hernia mesh removal significantly varied between the abdomen (infection, 43%) and the pelvis (pain, 91%, P < 0.0001). Mesh reaction became a more frequent indication for mesh removal in the pelvis, reaching 1/3 of patients by 2017. Most required general anesthesia (87%), with inpatient stay (53%, mode 1 day). Open technique decreased with time (82-17%), laparoscopic decreased (20-10%), and robotic increased (0-70%). CONCLUSIONS: This is the largest and most comprehensive study detailing why we remove mesh. We provide awareness of indications and operative options to help guide physicians as they encounter patients who may require hernia mesh removal.

Criteria for definition of a complex abdominal wall hernia.

PURPOSE: A clear definition of "complex (abdominal wall) hernia" is missing, though the term is often used. Practically all "complex hernia" literature is retrospective and lacks proper description of the population. There is need for clarification and classification to improve patient care and allow comparison of different surgical approaches. The aim of this study was to reach consensus on criteria used to define a patient with "complex" hernia. METHODS: Three consensus meetings were convened by surgeons with expertise in complex abdominal wall hernias, aimed at laying down criteria that can be used to define "complex hernia" patients, and to divide patients in severity classes. To aid discussion, literature review was performed to identify hernia classification systems, and to find evidence for patient and hernia variables that influence treatment and/or prognosis. RESULTS: Consensus was reached on 22 patient and hernia variables for "complex" hernia criteria inclusion which were grouped under four categories: "Size and location", "Contamination/soft tissue condition", "Patient history/risk factors", and "Clinical scenario". These variables were further divided in three patient severity classes ('Minor', 'Moderate', and 'Major') to provide guidance for peri-operative planning and measures, the risk of a complicated post-operative course, and the extent of financial costs associated with treatment of these hernia patients. CONCLUSION: Common criteria that can be used in defining and describing "complex" (abdominal wall) hernia patients have been identified and divided under four categories and three severity classes. Next step would be to create and validate treatment algorithms to guide the choice of surgical technique including mesh type for the various complex hernias.

A multicentre, open-label, randomized comparative study of tigecycline versus ceftriaxone sodium plus metronidazole for the treatment of hospitalized subjects with complicated intra-abdominal infections.

Tigecycline (TGC) has demonstrated clinical efficacy and safety, in comparison with imipenem/cilastatin in phase 3 clinical trials, for complicated intra-abdominal infection (cIAI). The present study comprised a multicentre, open-label, randomized study of TGC vs. ceftriaxone plus metronidazole (CTX/MET) for the treatment of patients with cIAI. Eligible subjects were randomized (1:1) to receive either an initial dose of TGC (100 mg) followed by 50 mg every 12 h or CTX (2 g once daily) plus MET (1-2 g daily), for 4-14 days. The primary endpoint was the clinical response in the clinically evaluable (CE) population at the test of cure (TOC) assessment. Of 473 randomized subjects, 376 were CE. Among these, clinical cure rates were 70.4% (133/189) with TGC vs. 74.3% (139/187) with CTX/MET (95% CI -13.1 to 5.1; p 0.009 for non-inferiority). Clinical cure rates for subjects with Acute Physiological and Chronic Health Evaluation II scores > or =10 were 56.8% (21/37) with TGC vs. 58.3% (21/36) with CTX/MET. The microbiologic response was similar between the two treatment arms, with microbiological eradication at TOC achieved in 68.1% (94/138) of TGC-treated subjects and 71.5% (98/137) of CTX/MET-treated subjects. (The most frequently reported adverse events (AEs) for both treatment arms were nausea (TGC, 38.6% vs CTX/MET, 27.7%) and vomiting (TGC, 23.3% vs CTX/MET, 17.7%). Overall discontinuation rates as a result of an AE were 8.9% and 4.8% in TGC- and comparator-treated subjects, respectively. The results obtained in the present study demonstrate that TGC monotherapy is non-inferior to a combination regimen of CTX/MET with respect to treating subjects with cIAI.

Obesity should not influence the management of appendicitis.

BACKGROUND: Obesity implies an adverse effect on outcome after appendectomy. This study aimed to determine whether obese patients with appendicitis should be managed differently than nonobese patients. METHODS: After appendectomy, all patients were enrolled in a prospective clinical pathway and followed from initial presentation to full outpatient recovery. RESULTS: In 1 year, 272 adults underwent appendectomy, 55 (22%) of whom were obese. The obese patients were slightly older (35 vs 33 years; p < 0.001). The time to diagnosis (8.5 vs 8.6 h), and the need for computed tomography (CT) scanning (40% vs 49%) was similar in both populations. The obese patients had similar rates of perforation (35% vs 35%) and laparoscopy (47% vs 41%). The median hospital length of stay (LOS) (2 days) and complications, including wound complications (9.1% vs 10.9%) and intraabdominal abscesses (3.6% vs 3.1%), were similar. Subgroup analysis showed a longer LOS for the obese patients with perforation than for the nonobese patients (6 vs 5.5 days; p = 0.036). CONCLUSION: Obese patients had no greater delay in diagnosis, had no greater need for CT scan, gained no additional benefit from laparoscopy, and did not incur significantly worse outcomes after appendectomy except for an increased LOS among those with perforation.

Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis.

INTRODUCTION: Though ruptured appendicitis is not a contraindication to laparoscopic appendectomy (LA), most surgeons have not embraced LA as the first-line approach to ruptured appendicitis. In fact, in 2002, the Cochrane Database Review concluded: 1) the clinical effects of LA are "small and of limited clinical relevance," and 2) the effects of LA in perforated appendicitis require further study. OBJECTIVE: To study the effects of LA vs open appendectomy (OA) among adults with appendicitis. METHODS: In 2003, 272 adults underwent appendectomy at a large County hospital, and were enrolled in a prospective clinical pathway that detailed their hospital course from time of diagnosis to discharge. Data included patient demographics, time elapse from diagnosis to surgery, surgical technique (LA vs. OA), operative diagnosis (acute vs perforated appendicitis) and post-operative length of stay (LOS). RESULTS: Complete data was obtained for 264 (97%) patients. Patient demographics were similar in the LA and OA groups (p > 0.05). Patients with LA had a significantly shorter LOS than OA by 1.6 days (p < 0.05). This LOS was significantly shorter among those with ruptured appendicitis vs. non-ruptured appendicitis (2.0 days vs. 0.3 day reduction, p = 0.0357). Rank-order multiple regression analysis, controlling for all other factors, showed laparoscopy to have a significant effect on postoperative LOS in all appendicitis cases, especially ruptured appendicitis. CONCLUSIONS: The two-day reduction in LOS among those with ruptured appendicitis who underwent LA was significant enough to overcome the smaller benefit of LA in acute appendicitis. From a hospital utilization point of view, LA should be considered as the first-line approach for all patients with appendicitis.

Porcelain gallbladder is not associated with gallbladder carcinoma.

The surgical management of porcelain gallbladder is based on studies performed in 1931 and 1962, which indicated a correlation between porcelain gallbladder and carcinoma. We sought to evaluate the characteristics of patients with porcelain gallbladder and the risk for gallbladder carcinoma. The medical records of 10,741 cholecystectomies performed between 1955 and 1998 were reviewed and recorded. The pathology slides were evaluated for evidence of calcification and gallbladder carcinoma. Fifteen (0.14%) of 10,741 specimens were porcelain gallbladders. Ten patients (67%) had symptoms suggestive of biliary colic or cholecystitis. Five (33%) were asymptomatic and diagnosed incidentally. All specimens demonstrated chronic cholecystitis and partial calcification of the gallbladder wall. Nine (60%) had cholelithiasis. None had gallbladder carcinoma by recent review of pathologic material. During this same period 88 (0.82%) patients had gallbladder carcinoma, none of which showed calcification of the wall. This report represents the largest modern review of porcelain gallbladders. No carcinoma was identified among patients with porcelain gallbladder. In addition no patient with gallbladder carcinoma had calcified gallbladder. With a better understanding of the natural history of the porcelain gallbladder the current management of these patients may change.

Peptide YY and vitamin E inhibit hormone-sensitive and -insensitive breast cancer cells.

We have shown that peptide YY, an endogenous gut hormone, and vitamin E succinate (VES) inhibit pancreatic cancer cell growth in vitro. We hypothesized that PYY and VES would inhibit breast cancer cell viability regardless of the hormone receptor status. Human breast ZR-75 ductal carcinoma (estrogen receptor negative) and MCF-7 adenocarcinoma (estrogen receptor positive) cells were cultured and exposed to VES (10 pg/ml), PYY (500 pmol), or both agents together. MTT assay was performed at 24, 48, and 72 h to evaluate cell viability. At every time interval, PYY and VES significantly inhibited cell growth compared to control. The effects of PYY were similar in magnitude to those of VES. Combining the agents resulted in a significant additive inhibition of growth with the greatest effect seen at 72 h. We have shown that PYY and vitamin E inhibit in vitro growth of breast cancer cells with variable hormone receptor status. When used in combination, the agents have a significant increase in effect. Further studies are ongoing to define the mechanism of action of these agents and to translate the experiments to an in vivo model.

Peptide YY augments gross inhibition by vitamin E succinate of human pancreatic cancer cell growth.

BACKGROUND: Vitamin E succinate (VES) significantly inhibits cell growth in vitro in breast, prostate, and skin cancer cell lines. Our study demonstrated similar inhibitory effects on Mia PaCa-2 pancreatic cancer cells at the same concentration of VES (10 pg/ml). Peptide YY (PYY) also inhibits pancreatic cancer cell growth in vitro. We observed a significant additive effect on growth inhibition in Mia PaCa cells treated with both VES and PYY. METHODS: Human pancreatic ductal adenocarcinoma Mia PaCa-2 cells were cultured and treated once with either 10 pg/ml of VES or 500 pmols of PYY or with both agents together. The control group received an equivalent volume of solvents. MTT assay was performed at 24, 48, and 72 h to evaluate cell viability. RESULTS: Pancreatic cancer cell growth was reduced in all groups treated with PYY and VES. Student's t test was used to analyze the data for each treatment group. At 72 h, both PYY and vitamin E significantly inhibited cell growth compared to control. Combining the agents resulted in a dramatic additive inhibition of growth. CONCLUSION: PYY and vitamin E both inhibit growth of pancreatic cancer cells in vitro with a significant increase in effect when used in combination.

Intestinal ischemia and the gut-liver axis: an in vitro model.

BACKGROUND: Sustained intestinal ischemic injury often leads to shock and multiorgan failure, mediated in part by a cytokine cascade. Animal models have also identified a central role of Kupffer cells in amplification of cytokines following intestinal ischemia. To better understand this gut-liver axis, we developed an in vitro model. MATERIALS AND METHODS: Kupffer cells were isolated from rat livers by arabinogalactan gradient ultracentrifugation and adherence purification. Cells were grown in RPMI medium in 5% CO(2). Rat intestinal epithelial cells, IEC-6, were cultured under normoxic or anoxic (90% N(2), 10% CO(2)) conditions for 2, 12, and 24 h. Kupffer cells were then grown in the conditioned medium of the IEC-6 cultures. After 24 h, the medium was replaced with fresh medium. This final Kupffer cell supernatant was tested for tumor necrosis factor alpha and interleukin-6 production by ELISA. Trypan blue exclusion was performed to assess cell viability. RESULTS: Intestinal and Kupffer cells remained viable during the experimental time. Production of both tumor necrosis factor alpha and interleukin-6 by Kupffer cells increased with increasing ischemia time of the intestinal cells. CONCLUSIONS: Consistent with animal studies of intestinal ischemia, this study found an increase in cytokine production by Kupffer cells following hypoxia of intestinal cells. This in vitro model offers a new tool to study the expression of cytokines, proteins, and messengers involved in the cascade of events that follow intestinal ischemia.

Two decades of cervical esophagostomy: indications and outcomes.

Diverting cervical esophagostomy is a surgical procedure generally reserved for extremely ill patients as a life-saving maneuver. However, it is also a procedure that is infrequently performed, such that most centers have limited experience with the operation. To investigate the indications and outcomes of cervical esophagostomy, we reviewed the use of this operation at UCLA Medical Center over the last 20 years as employed for esophageal leaks. Eighteen patients underwent this procedure for the following indications: leak with malignant tracheoesophageal fistula (11%), anastomotic leak (44%), endoscopic injury (18%), gunshot wound (5.5%), operative injury (11%), corrosive ingestion (11%), and spontaneous rupture (5.5%). Overall mortality directly attributable to sepsis was 33 per cent. Of the surviving patients, 67 per cent later underwent reconstruction. Seventy-two per cent of patients had end esophagostomies, and the remainder had loop diversions. The primary indication for operation in these patients was persistent sepsis after initial surgical management of esophageal spillage into the mediastinum or neck. This series suggests that cervical esophagostomy, when applied to the appropriate patient population, can decrease mortality and allow subsequent alimentary reconstruction.