Risk of bowel resection in incarcerated inguinal hernia: watch out for ASA score and hernia type.

PURPOSE: Incarcerated inguinal hernias can promote bowel ischemia. Emergent bowel resection is associated with increased postoperative morbidity. Risk factors for bowel resection might identify patients who benefit from elective inguinal hernia repair. METHODS: Sixty-five consecutive patients undergoing emergency inguinal hernia repair between 2012 and 2018 at our institution were entered in a prospective database. Data analysis was approved by the local ethics committee. Patient characteristics, surgery data, and postoperative outcomes were compared between patients with and without bowel resection. Risk factors for bowel resection were assessed with univariate and multivariate analysis. RESULTS: Patients requiring bowel resection were more often female (87%, P = 0.004) and presented in 67% with a femoral hernia. Postoperative complications occurred more often after hernia reduction and bowel resection compared to no resection (67% vs. 36%, P = 0.035). ASA score 3-4 and femoral herniation were independent predictors of bowel resection (P = 0,046 and P = 0,047, respectively). CONCLUSION: Highly comorbid patients can profit from early elective hernia repair to prevent bowel resection.

Perioperative omega-3 fatty acids fail to confer protection in liver surgery: Results of a multicentric, double-blind, randomized controlled trial.

BACKGROUND & AIMS: In a variety of animal models, omega-3 polyunsaturated fatty acids (Ω3-FAs) conferred strong protective effects, alleviating hepatic ischemia/reperfusion injury and steatosis, as well as enhancing regeneration after major tissue loss. Given these benefits along with its safety profile, we hypothesized that perioperative administration of Ω3-FAs in patients undergoing liver surgery may ameliorate the postoperative course. The aim of this study was to investigate the perioperative use of Ω3-FAs to reduce postoperative complications after liver surgery. METHODS: Between July 2013 and July 2018, we carried out a multicentric, double-blind, randomized, placebo-controlled trial designed to test whether 2 single intravenous infusions of Omegaven® (Ω3-FAs) vs. placebo may decrease morbidity. The primary endpoints were postoperative complications by severity (Clavien-Dindo classification) integrated within the comprehensive complication index (CCI). RESULTS: A total of 261 patients (132 in the Omegaven and 129 in the placebo groups) from 3 centers were included in the trial. Most cases (87%, n = 227) underwent open liver surgery and 56% (n = 105) were major resections (≥3 segments). In an intention-to-treat analysis including the dropout cases, the mortality rate was 4% and 2% in the Omegaven and placebo groups (odds ratio0.40;95% CI 0.04-2.51; p = 0.447), respectively. Any complications and major complications (Clavien-Dindo ≥ 3b) occurred in 46% vs. 43% (p = 0.709) and 12% vs. 10% (p = 0.69) in the Omegaven and placebo groups, respectively. The mean CCI was 17 (±23) vs.14 (±20) (p = 0.417). An analysis excluding the dropouts provided similar results. CONCLUSIONS: The routine perioperative use of 2 single doses of intravenous Ω3-FAs (100 ml Omegaven) cannot be recommended in patients undergoing liver surgery (Grade A recommendation). LAY SUMMARY: Despite strong evidence of omega-3 fatty acids having liver-directed, anti-inflammatory and pro-regenerative action in various rodent models, 2 single omega-3 fatty acid infusions given to patients before and during liver surgery failed to reduce complications. Because single omega-3 fatty acid infusions failed to confer liver protection in this trial, they cannot currently be recommended. TRIAL REGISTRATION: ClinicalTrial.gov: ID: NCT01884948; Institution Ethical Board Approval: KEK-ZH-Nr. 2010-0038; Swissmedic Notification: 2012DR3215.

The other explanation for dyspnea: giant paraesophageal hiatal hernia repair routinely improves pulmonary function.

Paraesophageal hiatal hernias (PEHs) are most commonly associated with gastrointestinal symptoms; less widely appreciated is their potentially important influence on respiratory function. We hypothesize that surgical repair of PEH will significantly improve not only gastrointestinal symptoms, but also preoperative dyspnea and spirometry scores. A prospective Institutional Review Board-approved database was used to review all patients undergoing PEH repair from 2000 to 2016. Patients with pre- and postoperative pulmonary function tests assessed by spirometry were included. Postoperative changes in spirometry measurements were compared to PEH size as reflected by the percentage of intrathoracic stomach observed on preoperative contrast studies. Patients were stratified according to improvement in forced expiratory volume in 1 second (FEV1). Patients with >12% ('significant') improvement in FEV1 after surgery were compared to the remaining patient population. In total, 299 patients met the inclusion criteria. Symptomatic improvement in respiratory function was noted in all patients after PEH repair. Age, gender, BMI, presenting symptoms, Charlson comorbidity index as well as preoperative comorbidities did not significantly impact the functional outcome. Spirometry results improved in 80% of the patients, 21% of whom showed an improvement of >20% compared to the preoperative level. 'Significant' improvement in respiratory function was seen in 122 of 299 (41%) patients. Patients presenting with moderate and severe preoperative pulmonary obstruction demonstrated 'significant' improvement in FEV1 in 48% and 40% of cases, respectively. Large PEHs, characterized by a percentage of intrathoracic stomach >75%, was strongly associated with 'significant' improvement in FEV1 (P = 0.001). PEHs can impact subjective and objective respiratory status and surgical repair can result in a significant improvement in dyspnea and pulmonary function score that is independent of preoperative pulmonary disease. Gastric herniation of more than 75% was associated with higher possibility for improvement of pulmonary function tests. Patients with persistent and unexplained dyspnea and coexistent PEH should be assessed by an experienced surgeon for consideration of elective repair.

Intravoxel incoherent motion analysis of abdominal organs: computation of reference parameters in a large cohort of C57Bl/6 mice and correlation to microvessel density.

OBJECTIVE: Diffusion-weighted magnetic resonance imaging (DW-MRI) combined with intravoxel incoherent motion (IVIM) analysis may be applied for assessment of organ lesions, diffuse parenchymal pathologies, and therapy monitoring. The aim of this study was to determine IVIM reference parameters of abdominal organs for translational research in a large cohort of C57Bl/6 laboratory mice. MATERIALS AND METHODS: Anesthetized mice (n = 29) were measured in a 4.7 T small-animal MR scanner with a diffusion-weighted echo-planar imaging sequence at the [Formula: see text]-values 0, 13, 24, 55, 107, 260, 514, 767, 1020 s/mm(2). IVIM analysis was conducted on the liver, spleen, renal medulla and cortex, pancreas, and small bowel with computation of the true tissue diffusion coefficient [Formula: see text], the perfusion fraction [Formula: see text], and the pseudodiffusion coefficient [Formula: see text]. Microvessel density (MVD) was assessed by immunohistochemistry (IHC) against panendothelial cell antigen CD31. RESULTS: Mean values of the different organs [[Formula: see text] (10(-3) mm(2)/s); [Formula: see text] (%); [Formula: see text] (10(-3) mm(2)/s); MVD (MV/mm(2))]: liver 1.15 ± 0.14; 14.77 ± 6.15; 50.28 ± 33.21, 2008.48 ± 419.43, spleen 0.55 ± 0.12; 9.89 ± 5.69; 24.46 ± 17.31; n.d., renal medulla 1.50 ± 0.20; 14.63 ± 4.07; 35.50 ± 18.01; 1231.88 ± 290.61, renal cortex 1.34 ± 0.18; 10.83 ± 3.70; 16.74 ± 6.74; 810.09 ± 193.50, pancreas 1.23 ± 0.22; 20.12 ± 7.46; 29.35 ± 17.82, 591.15 ± 86.25 and small bowel 1.06 ± 0.13; 16.48 ± 3.63; 15.31 ± 7.00; 420.50 ± 168.42. Unlike [Formula: see text] and [Formula: see text], [Formula: see text] correlates significantly with MVD (r = 0.90, p = 0.037). CONCLUSION: This systematic evaluation of murine abdominal organs with IVIM and MVD analysis allowed to establish reference parameters for future DW-MRI translational research studies on small-animal disease models.

"A randomized, double-blind study of the effects of omega-3 fatty acids (Omegaven) on outcome after major liver resection".

BACKGROUND: The body is dependent on the exogenous supply of omega-3 polyunsaturated fatty acids (n3-PUFA). These essential fatty acids are key players in regulating metabolic signaling but also exert anti-inflammatory and anti-carcinogenic properties. The liver is a major metabolic organ involved in fatty acid metabolism. Under experimental conditions, n3-PUFA exert beneficial effect on hepatic steatosis, regeneration and inflammatory insults such as ischemic injury after surgery. Some of these effects have also been observed in human subjects. However, it is unclear whether perioperative administration of n3-PUFA is sufficient to protect the liver from ischemic injury. Therefore, we designed a randomized controlled trial (RCT) assessing n3-PUFA (pre-) conditioning strategies in patients scheduled for liver surgery. METHODS/DESIGN: The Omegaven trial is a multi-centric, double-blind, randomized, placebo- controlled trial applying two single doses of Omegaven or placebo on 258 patients undergoing major liver resection. Primary endpoints are morbidity and mortality one month after hospital discharge, defined by the Clavien- Dindo classification of surgical complications (Ann Surg 240(2):205-13, 2004) as well as the Comprehensive Complication Index (CCI) (Ann Surg 258(1):1-7, 2013). Secondary outcome variables include length of Intensive Care Unit (ICU) and hospital stay, postoperative liver function tests, fatty acid and eicosanoid concentration, inflammatory markers in serum and in liver tissue. An interim analysis is scheduled after the first 30 patients per randomization group. DISCUSSION: Long-term administration of n3-PUFA have a beneficial effect on metabolism and hepatic injury. Patients often require surgery without much delay, thus long-term n3-PUFA uptake is not possible. Also, lack of compliance may lead to incomplete n3-PUFA substitution. Hence, perioperative Omegaven™ may provide an easy and controllable way to ensure hepaative application of tic protection. TRIAL REGISTRATION: ClinicalTrial.gov: ID: NCT01884948 , registered June 14, 2013; Institution Ethical Board Approval: KEK-ZH-Nr. 2010-0038; Swissmedic Notification: 2012DR3215.

Achalasia Treatment in Patients over 80 Years of Age: A Multicenter Survey.

Background and Aims: Laparoscopic Heller's myotomy (LHM), per oral endoscopic myotomy, and pneumatic dilatation are well-established methods to treat achalasia. The ideal treatment algorithm in elderly patients is, however, still elusive. This multicenter study aims to evaluate outcomes and changes in routine therapeutic options in patients >80 years of age. Methods: Worldwide high-volume centers for the treatment of achalasia were surveyed. Therapeutic options and outcomes in patients >80 years of age were reviewed. Results: Eighty-five (54% men, mean age 84 ± 4 years) patients were studied. Primary treatment was endoscopic in 43 (51%) patients, surgical in 39 (46%) patients (30 LHM, 9 cardioplasty + gastrectomy), and medical in 3 (4%) patients. Four centers tailored treatment based on age (14% of the patients). Secondary treatment was necessary in 34 (40%) patients: 30 of them with endoscopic treatment as primary treatment. LHM was performed in 20 patients and endoscopic treatment in 14 patients. A total of 11 (13%) patients had complications after LHM. Seven had LHM or cardioplasty + gastrectomy as primary treatment. Four had LHM as secondary treatment. The mean time of hospitalization was 4 ± 2 days for those who did not have complications, and 7 ± 6 days for those who had complications. Conclusions: Most specialized centers do not tailor treatment based on advanced age. Treatment of the oldest-old patients should be based solely on their physiologic and mental health, not their age. Endoscopic treatment has a high rate of recurrence and gastrectomy a high rate of complications in his population. LHM seems to be a safe option with good outcomes in this population.

Endoscopic therapy and surveillance versus esophagectomy for early esophageal adenocarcinoma: A review of early outcomes and cost analysis.

BACKGROUND: Endoscopic therapy is considered to be comparable to esophagectomy with respect to oncologic outcomes in early (cT1) esophageal adenocarcinoma (EC). The current study aims to compare early outcomes and financial costs, associated with endoscopic versus surgical therapy for early esophageal adenocarcinoma. METHODS: Retrospective review of patients undergoing either endoscopic or surgical therapy for cT1 EC between 2010 and 2015. RESULTS: Age, BMI, and Charlson Comorbidity Scores were similar in patients undergoing endoscopic therapy (N = 20) and esophagectomy (N = 23). For patients undergoing endoscopic therapy a median of 6 endoscopic interventions, were performed per patient (range 2-18). Esophagectomy was associated with a median hospital stay of 9 (8-13) days and greater procedure specific morbidity compared to endoscopic therapy. Costs related to endoscopic therapy were significantly lower compared to esophagectomy ($22,640 vs. $53,849, P < 0.001). CONCLUSIONS: Endoscopic treatment is associated with decreased morbidity and financial costs when compared to esophagectomy.

Comparison of costs and short-term clinical outcomes of per-oral endoscopic myotomy and laparoscopic Heller myotomy.

OBJECTIVE: Per-Oral Endoscopic Myotomy (POEM) has seen increasing application and comparisons to laparoscopic Heller myotomy (LHM). The aim of the present study was to compare perioperative and short-term outcomes, and costs between the two procedures at a single institution. METHODS: Fifty-one consecutive patients documented in a prospective IRB approved database from January 2014 to December 2017 were included. Perioperative data, pre-operative and 3-month postoperative Eckardt Scores, and cost data were compared. RESULTS: Median hospital stay was comparable between POEM and LHM (1 day each). Complications were minor (Clavien-Dindo 1, 2) and rare in both groups. Median Eckardt scores improved significantly after POEM (5 to 0) and LHM (5 to 0). Normalized median costs were comparable: 14 201 USD (POEM) vs. 13 328 USD (LHM) p = 0.45. CONCLUSIONS: POEM demonstrates comparable clinical outcomes and costs to LHM. Long-term issues related to GERD require ongoing assessment in POEM patients. SUMMARY: In patients with achalasia, extended myotomy of the lower esophageal sphincter offers excellent palliation of symptoms. In the last decades, laparoscopic Heller myotomy (LHM) has been the gold standard. Over the past decade, per-oral endoscopic myotomy (POEM) has seen wide application in specialized centers worldwide. In our patient cohort, we demonstrate, that POEM can be introduced with similar outcomes and costs compared to LHM.

Transient steatosis assessed by magnetic resonance imaging predicts outcome after extended hepatectomy in mice.

RATIONALE AND OBJECTIVES: Posthepatectomy liver failure (PHLF) remains challenging to diagnose and difficult to treat. The extent of transient regeneration-associated steatosis (TRAS) differs between successful liver regeneration and PHLF. This study aims to quantify TRAS by magnetic resonance imaging (MRI) after hepatectomy in mice. MATERIALS AND METHODS: Mice (C57BL/6) underwent either extended hepatectomy (EH) or standard hepatectomy (SH). Serial MRI on postoperative days 1-7 was used to compare TRAS and liver remnant growth between groups. Survival was also assessed. RESULTS: EH was associated with decreased survival and impaired proliferation when compared to SH (p = 0.02 and p = 0.03). MRI showed increased TRAS 48 h after EH compared to SH (11.8 ±â€¯6% vs. 4.3 ±â€¯2%, p < 0.001). Compared to EH survivors, death after EH was associated with increased TRAS 48 h postoperatively (16.4 ±â€¯6% vs. 9.2 ±â€¯5%, p = 0.02). CONCLUSIONS: EH is associated with increased TRAS and inferior outcomes when compared to SH. MRI may help to predict PHLF after hepatectomy.

Abnormal High-Resolution Manometry Findings and Outcomes after Paraesophageal Hernia Repair.

BACKGROUND: Abnormal esophageal peristalsis diagnosed by high-resolution manometry is frequently found as part of the preoperative evaluation of patients with paraesophageal hernia (PEH). Currently, the clinical relevance of these findings is largely unknown. STUDY DESIGN: From 2013 to 2016, two hundred and twelve patients undergoing PEH repair were prospectively recorded in an IRB-approved database. Preoperative high-resolution manometry was available for reanalysis according to the latest Chicago Classification (version 3.0) in 200 patients. Outcomes in patients with abnormal motility (AM) were compared with patients with normal motility (NM). RESULTS: Abnormal motility was documented in 106 (53%) patients. Abnormal motility was associated with older age (72 vs 69 years) and increased age-adjusted Charlson Comorbidity Index (both, p = 0.04). Compared with preoperative symptoms, postoperative retrosternal pain in AM vs NM patients went from 79% to 5% vs 75% to 2%, regurgitation from 52% to 2% vs 59% to 0%, and dysphagia from 56% to 7% vs 67% to 7%. An esophagogram was performed at a median of 4 months and 3.5 months postoperatively. Postoperative reflux in AM vs NM went from 54% to 21% vs 57% to 16%, and abnormal esophageal motility, visually assessed during the esophagogram, was stable (52% to 56% vs 41% to 48% for AM vs NM, respectively). CONCLUSIONS: Patients found to have AM according to the Chicago classification before surgical repair of PEH demonstrated similar symptomatic improvement compared with patients with NM. Selective motility disorders diagnosed by preoperative high-resolution manometry should not preclude surgical repair of giant PEHs.

Acute Vs. Elective Paraesophageal Hernia Repair: Endoscopic Gastric Decompression Allows Semi-Elective Surgery in a Majority of Acute Patients.

BACKGROUND: Historically, patients presenting acutely with paraesophageal hernia and requiring urgent operation demonstrated inferior outcomes compared to patients undergoing elective repair. METHODS: A prospective IRB-approved database was used to retrospectively review 570 consecutive patients undergoing paraesophageal hernia repair between 2000 and 2016. RESULTS: Thirty-eight patients presented acutely (6.7%) and 532 electively. Acute presentation was associated with increased age (74 vs. 69 years) but similar age-adjusted Charlson comorbidity scores. A history of chest pain, intrathoracic stomach ≥75%, and mesoaxial rotation were more common in acute presentations. Emergency surgery was required in three patients (8%), and 35 patients were managed in a staged approach with guided decompression prior to semi-elective surgery. Acute presentation was associated with an increased hospital stay (5 (2-13) days vs. 4 (1-27) days, p = 0.001). There was no difference in postoperative Clavien-Dindo severity scores. One patient in the elective group died, and the overall mortality was 0.2%. CONCLUSION: Our findings suggest that a majority of patients presenting with acute paraesophageal hernia can undergo a staged approach instead of urgent surgery with comparable outcomes to elective operations in high-volume centers. We suggest elective repair for patients presenting with a history of chest pain, intrathoracic stomach ≥75%, and a mesoaxial rotation.

Prediction of small for size syndrome after extended hepatectomy: Tissue characterization by relaxometry, diffusion weighted magnetic resonance imaging and magnetization transfer.

This study aimed to monitor the course of liver regeneration by multiparametric magnetic-resonance imaging (MRI) after partial liver resection characterizing Small-for-Size Syndrome (SFSS), which frequently leads to fatal post-hepatectomy liver failure (PLF). Twenty-two C57BL/6 mice underwent either conventional 70% partial hepatectomy (cPH), extended 86% partial hepatectomy (ePH) or SHAM operation. Subsequent MRI scans on days 0, 1, 2, 3, 5 and 7 in a 4.7T MR Scanner quantified longitudinal and transverse relaxation times, apparent diffusion coefficient (ADC) and the magnetization-transfer ratio (MTR) of the regenerating liver parenchyma. Histological examination was performed by hematoxylin-eosin staining. After hepatectomy, an increase of T1 time was detected being larger for ePH on day 1: 18% for cPH vs. 40% for ePH and on day 2: 24% for cPH vs. 49% for ePH. An increase in T2 time, again greater in ePH was most pronounced on day 5: 21% for cPH vs. 41% for ePH. ADC and MTR showed a decrease on day 1: 21% for ePH vs. 13% for cPH for ADC, 15% for ePH vs. 11% for cPH for MTR. Subsequently, all MR parameters converged towards initial values in surviving animals. Dying PLF animals exhibited the strongest increase of T1 relaxation time and most prominent decreases of ADC and MTR. The retrieved MRI biomarkers indicate SFSS and potentially developing PLF at an early stage, likely reflecting cellular hypertrophy with extended water content and concomitantly diluted cellular components as features of liver regeneration, appearing more intense in ePH as compared to cPH.

Temporary portal vein embolization is as efficient as permanent portal vein embolization in mice.

BACKGROUND: Temporary portal vein embolization may be a safe alternative to permanent portal vein embolization. Such a new approach could be applied in living-related liver transplantation to increase graft volume before procurement. The impact of temporary portal vein embolization on occluded liver after recanalization, however, has never been assessed. Using a mouse model of temporary portal vein embolization, we investigated (1) the efficiency of temporary portal vein embolization in inducing nonoccluded liver hypertrophy and (2) the regeneration potential and functional recovery of embolized liver after recanalization. METHODS: Selected portal vein branches were occluded using gelfoam powder (temporary portal vein embolization) or embospheres (permanent portal vein embolization), n = 5/group. Magnetic resonance volumetry and angiography were used to determine volumes of the liver lobe and portal vein branch recanalization. In order to assess the functional and regenerative capacity of occluded liver lobes, nonoccluded lobes were resected 14 days (timespan of complete portal vein recanalization) after temporary portal vein embolization or permanent portal vein embolization. Subsequently, RNA sequencing was performed to compare the signaling pathways of early liver regeneration among the groups. RESULTS: Hypertrophy of nonoccluded lobes 30 days after temporary portal vein embolization and permanent portal vein embolization was similar (103 ± 26% and 129 ± 13%, P = .11). Temporary occluded lobes increased their volumes after nonoccluded lobes resection, reaching similar liver-to-body-weight ratios and similar functional capacity after 7 days compared with partial hepatectomy controls (4 ± 1% vs 4 ± 1%, P = .22). Partial hepatectomy activated similar signaling pathways in temporary occluded and native liver. CONCLUSION: Temporary portal vein embolization induces hypertrophy of contralateral liver lobes similarly to permanent portal vein embolization in mice. This experimental work suggests that temporary portal vein embolization may be considered as a possibility in living liver donation, because regenerative and functional capacities are preserved in the embolized liver after recanalization in mice.