Single-center ventral hernia repair with porcine dermis collagen implant.

INTRODUCTION: This study aims to evaluate the outcomes and utilization of porcine acellular dermal collagen implant (PADCI) during VHR at a large tertiary referral center. METHODS: Records of 5485 patients who underwent VIHR from June 1995 to August 2014 were retrospectively reviewed to identify patients >18 years of age who had VIHR with PADCI reinforcement. Use of multiple mesh reinforcement products, inguinal hernias, and hiatal hernias were exclusion criteria. The primary outcome was hernia recurrence, and secondary outcomes were early complications and surgical site occurrences (SSOs). Uni- and multivariate analyses assessed risk factors for recurrence after PADCI reinforced VIHR. RESULTS: There were 361 patients identified (54.5% female, mean age of 56.7 ± 12.5 years, and mean body mass index (BMI) of 33.0 ± 9.9 kg/m2). Hypertension (49.5%), diabetes (24.3%), and coronary artery disease (14.4%) were the most common comorbidities, as was active smoking (20.7%). Most were classified as American Association of Anesthesiologists (ASA) Class 3 (61.7%). Hernias were distributed across all grades of the ventral hernia working group (VHWG) grading system: grade I 93 (25.7%), grade II 51 (14.1%), grade III 113 (31.3%), and grade IV 6 (1.6%). Most VIHR were performed from an open approach (96.1%), and were frequently combined with concomitant surgical procedures (47.9%). Early postoperative complications (first 30 days) were reported in 39.0%, with 71 being SSO. Of the 19.7% of patients with SSO, there were 31 who required procedural intervention. After a mean follow-up of 71.5 ± 20.5 months, hernia recurrence was documented in 34.9% of patients. Age and male gender were predictors of recurrence on multivariate analysis. CONCLUSION: To the best of our knowledge, this is the largest retrospective single institutional study evaluating PADCI to date. Hernias repaired with PADCI were frequently in patients undergoing concomitant operations. Reinforcement with PADCI may be considered a temporary closure, with a relatively high recurrence rate, especially among patients who are older, male, and undergo multiple explorations in a short perioperative period.

Outcomes of concomitant ventral hernia repair performed during bariatric surgery.

BACKGROUND: Currently there is no consensus on management of ventral hernias encountered during bariatric surgery (BS). This study aims to evaluate the incidence and outcomes of concomitant ventral hernia repair (VHR) during BS at our institution. METHODS: Patients who had concomitant VHR during BS from 2004 to 2015 were identified. Data collected included baseline demographics, comorbidities, perioperative parameters, surgical approach and postoperative outcomes. RESULTS: A total of 159 patients underwent concomitant VHR during the study period at the time of BS. One hundred and one (64 %) patients were female; median age was 53 years (IQR 45.0-60.3) and median BMI was 48.2 kg/m2 (IQR 41.6-54.1). Comorbidities included: hypertension (n = 124, 78 %), type 2 diabetes (n = 103, 65 %), hyperlipidemia (n = 100, 63 %), obstructive sleep apnea (n = 98, 62 %) and reflux disease (n = 54, 34 %). Out of 159 patients, 41 patients (26 %) had a prior VHR. Out of 103 patients, 69 patients (67 %) had a previous abdominal surgery. Of the concomitant VHR, 144 (91 %) were completed laparoscopically, 12 (7 %) patients were converted to open surgery and 3 (2 %) patients underwent primary open procedures. Technique included primary suture closure in 115 (72 %) and mesh repair in 44. Early postoperative complications (<30 days) were reported in 16 (10 %) patients, with superficial wound infection (n = 9), bowel obstruction (n = 2), marginal ulcer (n = 2), DVT (n = 1) and pneumonia (n = 1). Hernia recurrence was reported in 3 patients (2 %) in the early post-op period and in 40 patients (25 %) as a late (>30 days) complication. Surgery for recurrent hernia was performed in 31/42 patients during follow-up. At 12-month follow-up, median BMI and % excess weight loss were 34.2 kg/m2 (IQR 29.5-40.9) and 59.6 % (IQR 44.9-74.8 %), respectively. CONCLUSION: Ventral hernia is a common finding in patients undergoing BS. Both primary suture repair and mesh repair result in acceptable results, both in terms of recurrence and perioperative complications.

Complete endoscopic/transgastric retrieval of eroded gastric band: description of a novel technique and review of the literature.

Complications of laparoscopic adjustable gastric banding (LAGB) include band slippage, material infection, and band erosion. Band erosion can lead to chronic infection, obstruction, delayed perforation, and ineffectiveness; therefore, removal is indicated. A myriad of approaches exist for band removal and many authors have described novel techniques. A minimally invasive approach, including laparoscopic or endoscopic assistance, is favored given the reduction of postoperative complications compared with laparotomy. We present a novel approach to band retrieval following partial erosion involving a complete endoscopic/transgastric technique. Perioperative management and a review of the literature also are described.

Laparoscopic gastric electrical stimulation for medically refractory diabetic and idiopathic gastroparesis.

BACKGROUND: Gastric electrical stimulator (GES) implantation is effective in certain patients with gastroparesis; however, laparotomy is often employed for placement. The aim of this study is to review outcomes of patients who underwent laparoscopic GES therapy for diabetic and idiopathic gastroparesis at a large referral center. METHODS: Patients who underwent GES (Enterra Therapy System; Medtronic, Minneapolis, MN) implantation with subsequent interrogation and programming between March 2001 and November 2011 were analyzed. RESULTS: A total of 113 patients underwent GES placement or revision during the study period. One hundred eleven patients underwent primary GES at our institution, while two patients underwent GES generator revision at our institution. Primary operations were completed laparoscopically in 110 of 111 cases, with one conversion to laparotomy due to severe adhesions. At a mean follow-up of 27 months (1-113), symptom improvement was achieved in 91 patients (80 %) and was similar for both the diabetic and idiopathic subgroups. Need for supplemental nutrition (enteral and/or parental) decreased in both groups. CONCLUSIONS: GES placement is feasible using a laparoscopic approach. Medical refractory gastroparesis in the diabetic and idiopathic groups had significant symptom improvement with no difference between the two groups. Need for supplemental nutrition is decreased following GES.

Post Roux-en-Y gastric bypass biliary dilation: natural process or significant entity?

BACKGROUND: Changes in the biliary system after gastric bypass are not well defined. Dilation may be normal or due to biliary tract pathology. The purpose of this study is to review patients who underwent imaging of their biliary system both before and after Roux-en-Y gastric bypass in an effort to elucidate the effect this operation has on hepatic duct diameter. METHODS: Patients with imaging both before and at least 3 months after gastric bypass were analyzed. Hepatic duct was measured at the level of the porta hepatis to determine interval changes. RESULTS: Thirty-three patients had postoperative imaging at least 3 months following gastric bypass. Mean hepatic duct diameter was 5.2 ± 2 and 7.1 ± 2.6 mm preoperatively and postoperatively, respectively (p < 0.01). Patients with prior cholecystectomy had hepatic duct diameters of 7.9 ± 1.3 and 9.5 ± 3.5 mm preoperatively and postoperatively, respectively (p = 0.3). Patients who had not previously undergone cholecystectomy had hepatic duct diameters of 4.3 ± 1.1 and 6.4 ± 1.8 mm preoperatively and postoperatively, respectively (p < 0.01). CONCLUSIONS: Hepatic duct diameter increases after Roux-en-Y gastric bypass. A better understanding of this phenomenon may limit the need for further work-up in patients with incidentally detected biliary dilation.

Percutaneous endoscopic gastrostomy (PEG) with T-fasteners obviates the need for emergent replacement after early tube dislodgement.

BACKGROUND: Despite technical refinements of percutaneous endoscopic gastrostomy (PEG) tube placement, complications such as early tube dislodgement remain relatively static. This study aimed to review the experience of a high-volume endoscopy center after the introduction of T-fastener placement in high-risk patients. METHODS: The authors retrospectively reviewed PEG placement from October 2010 to September 2011, when their group began to use T-fasteners selectively in high-risk patients. Patients deemed to have an increased risk for early tube dislodgement underwent T-fastener placement at the time of PEG placement. Patients with PEG alone were compared with patients who had PEG with T-fastener (PEG-T) placement. Statistical analysis was performed using SPSS version 18. RESULTS: During the study period, 195 patients underwent PEG placement. For 121 patients, PEG alone was performed, whereas PEG-T was performed for 74 patients. Six patients had tube dislodgement (five early, one late) in the PEG-T cohort versus none in the PEG-alone cohort (P = 0.003). The first patient underwent diagnostic laparoscopy with replacement gastrostomy 2 days after tube dislodgement and was noted to have no contamination, with direct apposition of the stomach to the abdominal wall from the T-fasteners. The subsequent four patients with early tube dislodgement underwent non-emergent PEG replacement in the endoscopy unit within 24 h after tube dislodgement. In the short-term follow-up period, no repeat dislodgements were noted. Early mortality in the entire cohort was experienced by 38 (19.5%) of the 195 patients. CONCLUSION: Placement of T-fasteners in high-risk patients may decrease overall morbidity if early tube dislodgement occurs. The findings show the safety of non-emergent endoscopic replacement of PEGs in certain patients. Early tube dislodgement may be a marker of overall mortality.

Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned?

BACKGROUND: The definition of marginal ulcer after Roux-en-Y gastric bypass (RYGB) is widely debated. This study reviewed findings of upper endoscopy in symptomatic patients at a quaternary bariatric referral center. Further investigation included symptom constellation, potential etiologies, and efficacy of treatment for patients found to have marginal ulcer. METHODS: Patients presenting for upper gastrointestinal endoscopy after Roux-en-Y gastric bypass were included in this study. An institutional review board-approved database was queried for the period 1 June 2010 to 31 August 2011. Subgroup analysis was performed for patients with marginal ulcer. Statistical analysis was performed using PASW version 18 for Windows. RESULTS: During the study period, 455 upper gastrointestinal endoscopies were performed for 328 consecutive symptomatic patients. Marginal ulcer, found in 112 patients (34 %), was diagnosed for 59 of the patients (53 %) within 12 months after surgery and for 53 of the patients (47 %) more than 12 months after surgery. In patients found to have marginal ulcer, the most common presenting symptoms were pain, dysphagia, nausea, and vomiting. All the patients with marginal ulcer underwent acid suppression and cytoprotective therapy. Using uni- and multivariate analyses for healing, nonhealing, and healing with recurrence, tobacco use was found to be the solitary significant risk factor for recurrence (p = 0.01). CONCLUSION: Patients with pain or dysphagia after gastric bypass warrant upper endoscopy given the high yield for abnormalities. Although the risk factors for the development of marginal ulcer remain multifactorial, a thorough investigation for potential etiologies including tobacco, alcohol, and nonsteroidal antiinflammatory drug (NSAID) usage should be determined and eliminated. The presence of multiple risk factors may pose a higher challenge in ulcer resolution, leading to increased recurrence. In the current series, prior or current tobacco use remained the sole independent risk factor for ulcer persistence.