Response to botulinum toxin may predict response to peroral pyloromyotomy in patients with gastroparesis.

BACKGROUND : Patients with gastroparesis who have undergone prior intrapyloric botulinum toxin injection (BTI) may seek an opinion regarding peroral pyloromyotomy (POP). There are only two small reports assessing the role of BTI as a predictor for successful treatment with POP. METHODS: We performed a retrospective cohort study to assess whether symptomatic improvement after BTI predicts a response to POP. We included 119 patients who had undergone both BTI and POP at Cleveland Clinic Ohio or Cleveland Clinic Florida from January 2016 to September 2019. RESULTS: 65.5 % of patients had symptomatic improvement after BTI. Gastroparesis Cardinal Symptom Index (GCSI) scores were available for 74 patients, with 64 % achieving a response to POP, defined as a decrease in mean GCSI ≥ 1. In multivariable analysis, response to BTI (odds ratio [OR] 7.7 [95 %CI 2.2-26.1]) and higher pre-POP GCSI score (OR 2.3 [95 %CI 1.2-4.6]) were independent predictors of response to POP. CONCLUSIONS: Clinical improvement after BTI is a predictor of response to POP in patients with gastroparesis. This information may aid in improving patient selection for POP.

Role of laparoscopic hernia repair in men with a previous negative inguinal exploration for a cryptorchid testicle.

OBJECTIVES: To evaluate the role of laparoscopy in adults presenting with indirect inguinal hernias with a previous negative inguinal exploration for nonpalpable testes in childhood who were diagnosed with a vanishing testis. MATERIALS AND METHODS: We present a case report of an individual who underwent a negative inguinal exploration in childhood for a nonpalpable testis. During laparoscopic repair of the defect, an intra-abdominal testicle was discovered. This was the basis for a literature search for the role of laparoscopy in adults with nonpalpable testes. A MEDLINE and PubMed online literature search was performed from 1980 to present. Search words such as adult nonpalpable testis, cryptorchidism, vanishing testis, and laparoscopy were used. RESULTS: Ten articles were found detailing the role of laparoscopy in the management of undescended testes in adult patients. CONCLUSIONS: When a patient presents with an indirect hernia and a history of inguinal exploration for an impalpable testicle and there is no clear prior negative inguinal exploration for a nonpalpable testis, laparoscopy has an important role in further evaluation of the patient. Owing to the risk of malignancy in the undescended testis and risk for subfertility, patients evaluated during the prelaparoscopic era need to have the diagnosis of an absent testis confirmed or refuted. Laparoscopy is a safe, effective, and sensitive procedure for evaluating and treating nonpalpable testes in adults.

Objective analysis of the accuracy and efficacy of a novel fascial closure device.

Abdominal fascial closure after midline laparotomy can be time-consuming and inaccurate and is a common time for needle-stick injuries. The SuturTek 360 degrees Fascial Closure Device (FCD) is designed to provide a secure fascial closure while reducing the risk of needle-stick injury. To date, the accuracy and efficacy of the fascial closure obtained with this device have never been objectively determined. Ten pigs averaging 18 kg were killed and underwent a midline laparotomy. Idealized suture locations were premarked through the fascia. The animals were then randomly assigned to either a traditional suture closure or the FCD for fascial closure. Surgeons were instructed to place sutures through the idealized markers. Surgeons were then evaluated based on the time to close fascia and distance from the markers. Abdominal bursting pressures were obtained using a manometric balloon. Accuracy was also tested on an ex vivo model on which the participants were again asked to place stitches as close as possible to idealized marks, and absolute distance from the idealized location was calculated. The FCD resulted in a faster closure time when compared with traditional closure (5.9 +/- 0.6 vs 7.7 +/- 1.0 minute, P = .012), with a similar accuracy of placement from the idealized markers (1.5 +/- 1.4 mm vs 0.8 +/- 1.1 mm). Bursting pressures were similar between the 2 groups: 470 +/- 71 mm Hg for FCD versus 453 +/- 94 mm Hg for traditional closure ( P = .76). The FCD resulted in a faster fascial closure with similar accuracy and strength when compared with traditional open techniques. The potential reduction in serious needle-stick injuries warrants prospective trials.