Predictors of Robotic Versus Laparoscopic Inguinal Hernia Repair.

BACKGROUND: The advent of robotic-assisted surgery has added an additional decision point in the treatment of inguinal hernias. The goal of this study was to identify the patient, surgeon, and hospital demographic predictors of robotic inguinal hernia repair (IHR). METHODS: We conducted a retrospective analysis of 102,241 IHRs (1096 robotic and 101,145 laparoscopic) from 2010 through 2015 with data collected in the Premier Hospital Database. The adjusted odds ratio (OR) of receiving a robotic IHR was calculated for each of several demographic factors using multivariable logistic regression. RESULTS: The rate of robotic IHR increased from 2010 through 2015. Age <65 y and Charlson comorbidity index were not predictors of a robotic IHR. Females were more likely to receive a robotic IHR (OR 1.69, confidence interval [CI] 1.40-2.05, P < 0.0001). Compared with white patients, black patients were more likely (OR 1.33, CI 1.06-1.68, P = 0.0138), and other race patients were less likely (OR 0.47, CI 0.38-0.58, P < 0.0001) to receive a robotic IHR. Compared with Medicare insurance, patients with all other types of insurance were more likely to receive a robotic IHR (OR > 1.00, lower limit of CI > 1.00, P < 0.05). Higher volume surgeons were less likely to perform robotic IHR (OR < 1.00, upper limit of CI < 1.00, P < 0.05). Nonteaching (OR 1.81, CI 1.53-2.13, P < 0.0001), larger (OR > 1.00, lower limit of CI > 1.00, P < 0.05), and rural (OR 1.27, CI 1.03-1.57, P = 0.025) hospitals were more likely to perform robotic IHR. Significant regional variation in the rate of robotic IHR was identified (OR > 1.00, lower limit of CI > 1.00, P < 0.05). CONCLUSIONS: The rate of robotic IHR is increasing exponentially. This study found that female gender, black race, insurance other than Medicare, lower surgeon annual volume, larger hospital size, nonteaching hospital status, rural hospital location, and hospital region were predictors of robotic IHR.

Predictors of laparoscopic versus open inguinal hernia repair.

BACKGROUND: Inguinal hernia repair (IHR) is among the most common general surgery procedures. Multiple studies have examined costs and benefits of laparoscopic approach versus open repair. This study aimed to identify patient, surgeon, and hospital demographic predictors of laparoscopic versus open IHR. METHODS: We conducted a retrospective analysis of 342,814 IHRs (241,669 open; 101,145 laparoscopic) performed in adults (age ≥ 18) from 2010 to 2015 using the Premier Hospital Database. Multivariate logistic regression was used to estimate the adjusted odds ratio of an IHR being laparoscopic versus open with respect to several demographic variables. RESULTS: The odds of an IHR being laparoscopic increased from 2010 to 2015. A laparoscopic procedure was more likely in patients who were < age 65 (OR 1.29, CI 1.24-1.31, p < 0.0001), male (OR 1.31, CI 1.27-1.34, p < 0.0001), privately insured (OR 1.36, CI 1.33-1.40, p < 0.0001), and neither white, black, nor Hispanic (OR 1.11, CI 1.09-1.14, p < 0.0001). The likelihood of a procedure being laparoscopic decreased 13% with each one-unit increase in Charlson comorbidity index value (OR 0.88, CI 0.87-0.89, p < 0.0001). Surgeons were more likely to perform a laparoscopic procedure if they had larger annual IHR caseloads (≥ 45/year; OR 1.57, CI 1.53-1.60, p < 0.0001), and operated at large hospitals (> 500 beds; OR 1.36, CI 1.33-1.39, p < 0.0001) in New England (OR 2.38, CI 2.29-2.47, p < 0.0001). Non-predictors of a laparoscopic procedure included urban/rural hospital location (OR 1.02, CI 0.10-1.05, p = 0.06) and hospital teaching status (OR 1.01, CI 0.99-1.03, p = 0.2084). CONCLUSIONS: Use of laparoscopic IHR is increasing. Patient age, gender, race, and insurance type, as well as surgeon annual volume, hospital size, and hospital region were predictors of a laparoscopic procedure. Further studies are needed to explain and remedy underlying differences impacting these predictors.

Impact of minimally invasive surgery on healthcare utilization, cost, and workplace absenteeism in patients with Incisional/Ventral Hernia (IVH).

BACKGROUND: Incisional hernia repair is one of the most common general surgery operations being performed today. With the advancement of laparoscopy since the 1990s, we have seen vast improvements in faster return to normal activity, shorter hospital stays and less post-operative narcotic use, to name a few. OBJECTIVE: The key aims of this review were to measure the impact of minimally invasive surgery versus open surgery on health care utilization, cost, and work place absenteeism in the patients undergoing inpatient incisional/ventral hernia (IVH) repair. METHODS: We analyzed data from the Truven Health Analytics MarketScan® Commercial Claims and Encounters Database. Total of 2557 patients were included in the analysis. RESULTS: Of the patient that underwent IVH surgery, 24.5% (n = 626) were done utilizing minimally invasive surgical (MIS) techniques and 75.5% (n = 1931) were done open. Ninety-day post-surgery outcomes were significantly lower in the MIS group compared to the open group for total payment ($19,288.97 vs. $21,708.12), inpatient length of stay (3.12 vs. 4.24 days), number of outpatient visit (5.48 vs. 7.35), and estimated days off (11.3 vs. 14.64), respectively. At 365 days post-surgery, the total payment ($27,497.96 vs. $30,157.29), inpatient length of stay (3.70 vs. 5.04 days), outpatient visits (19.75 vs. 23.42), and estimated days off (35.71 vs. 41.58) were significantly lower for MIS group versus the open group, respectively. CONCLUSION: When surgical repair of IVH is performed, there is a clear advantage in the MIS approach versus the open approach in regard to cost, length of stay, number of outpatient visits, and estimated days off.

Stray energy transfer during endoscopy.

INTRODUCTION: Endoscopy is the standard tool for the evaluation and treatment of gastrointestinal disorders. While the risk of complication is low, the use of energy devices can increase complications by 100-fold. The mechanism of increased injury and presence of stray energy is unknown. The purpose of the study was to determine if stray energy transfer occurs during endoscopy and if so, to define strategies to minimize the risk of energy complications. METHODS AND PROCEDURES: A gastroscope was introduced into the stomach of an anesthetized pig. A monopolar generator delivered energy for 5 s to a snare without contacting tissue or the endoscope itself. The endoscope tip orientation, energy device type, power level, energy mode, and generator type were varied to mimic in vivo use. The primary outcome (stray current) was quantified as the change in tissue temperature (°C) from baseline at the tissue closest to the tip of the endoscope. Data were reported as mean ± standard deviation. RESULTS: Using the 60 W coag mode while changing the orientation of the endoscope tip, tissue temperature increased by 12.1 ± 3.5 °C nearest the camera lens (p < 0.001 vs. all others), 2.1 ± 0.8 °C nearest the light lens, and 1.7 ± 0.4 °C nearest the working channel. Measuring temperature at the camera lens, reducing power to 30 W (9.5 ± 0.8 °C) and 15 W (8.0 ± 0.8 °C) decreased stray energy transfer (p = 0.04 and p = 0.002, respectively) as did utilizing the low-voltage cut mode (6.6 ± 0.5 °C, p < 0.001). An impedance-monitoring generator significantly decreased the energy transfer compared to a standard generator (1.5 ± 3.5 °C vs. 9.5 ± 0.8 °C, p < 0.001). CONCLUSION: Stray energy is transferred within the endoscope during the activation of common energy devices. This could result in post-polypectomy syndrome, bleeding, or perforation outside of the endoscopist's view. Decreasing the power, utilizing low-voltage modes and/or an impedance-monitoring generator can decrease the risk of complication.

Preoperative chemical component relaxation using Botulinum toxin A: enabling laparoscopic repair of complex ventral hernia.

BACKGROUND: Repair of complex ventral hernia can be very challenging for surgeons. Closure of large defects can have serious pathophysiological consequences. Botulinum toxin A (BTA) has recently been described to provide flaccid paralysis to abdominal muscles prior to surgery, facilitating closure and repair. METHODS: This was a prospective observational study of 32 patients who underwent ultrasound-guided injections of BTA to the lateral abdominal wall muscles prior to elective repair of complex ventral hernia between January 2013 and December 2015. Serial non-contrast abdominal CT imaging was performed to measure changes in fascial defect size, abdominal wall muscle length and thickness. All hernias were repaired laparoscopically or laparoscopic-assisted with placement of intra-peritoneal mesh. RESULTS: Thirty-two patients received BTA injections which were well tolerated with no complications. A comparison of baseline (preBTA) CT imaging with postBTA imaging demonstrated an increase in mean baseline abdominal wall length from 16.4 to 20.4 cm per side (p < 0.0001), which translates to a gain in mean transverse length of the unstretched anterolateral abdominal wall muscles of 4.0 cm/side (range 0-11.7 cm/side). Fascial closure was achieved in all cases, with no instances of raised intra-abdominal pressures or its sequelae, and there have been no hernia recurrences to date. CONCLUSIONS: Preoperative BTA injection to the muscles of the anterolateral abdominal wall is a safe and effective technique for the preoperative preparation of patients prior to laparoscopic mesh repair of complex ventral hernia. This technique elongates and thins the contracted and retracted musculature, enabling closure of large defects.

ß-Nicotinamide adenine dinucleotide acts at prejunctional adenosine A1 receptors to suppress inhibitory musculomotor neurotransmission in guinea pig colon and human jejunum.

Intracellular microelectrodes were used to record neurogenic inhibitory junction potentials in the intestinal circular muscle coat. Electrical field stimulation was used to stimulate intramural neurons and evoke contraction of the smooth musculature. Exposure to ß-nicotinamide adenine dinucleotide (ß-NAD) did not alter smooth muscle membrane potential in guinea pig colon or human jejunum. ATP, ADP, ß-NAD, and adenosine, as well as the purinergic P2Y1 receptor antagonists MRS 2179 and MRS 2500 and the adenosine A1 receptor agonist 2-chloro-N6-cyclopentyladenosine, each suppressed inhibitory junction potentials in guinea pig and human preparations. ß-NAD suppressed contractile force of twitch-like contractions evoked by electrical field stimulation in guinea pig and human preparations. P2Y1 receptor antagonists did not reverse this action. Stimulation of adenosine A1 receptors with 2-chloro-N6-cyclopentyladenosine suppressed the force of twitch contractions evoked by electrical field stimulation in like manner to the action of ß-NAD. Blockade of adenosine A1 receptors with 8-cyclopentyl-1,3-dipropylxanthine suppressed the inhibitory action of ß-NAD on the force of electrically evoked contractions. The results do not support an inhibitory neurotransmitter role for ß-NAD at intestinal neuromuscular junctions. The data suggest that ß-NAD is a ligand for the adenosine A1 receptor subtype expressed by neurons in the enteric nervous system. The influence of ß-NAD on intestinal motility emerges from adenosine A1 receptor-mediated suppression of neurotransmitter release at inhibitory neuromuscular junctions.

Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy.

BACKGROUND: Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC. METHODS: Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot's triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected. RESULTS: Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m(2), respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min, p < 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C. CONCLUSIONS: NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.

Innervation of enteric mast cells by primary spinal afferents in guinea pig and human small intestine.

Mast cells express the substance P (SP) neurokinin 1 receptor and the calcitonin gene-related peptide (CGRP) receptor in guinea pig and human small intestine. Enzyme-linked immunoassay showed that activation of intramural afferents by antidromic electrical stimulation or by capsaicin released SP and CGRP from human and guinea pig intestinal segments. Electrical stimulation of the afferents evoked slow excitatory postsynaptic potentials (EPSPs) in the enteric nervous system. The slow EPSPs were mediated by tachykinin neurokinin 1 and CGRP receptors. Capsaicin evoked slow EPSP-like responses that were suppressed by antagonists for protease-activated receptor 2. Afferent stimulation evoked slow EPSP-like excitation that was suppressed by mast cell-stabilizing drugs. Histamine and mast cell protease II were released by 1) exposure to SP or CGRP, 2) capsaicin, 3) compound 48/80, 4) elevation of mast cell Ca²âº by ionophore A23187, and 5) antidromic electrical stimulation of afferents. The mast cell stabilizers cromolyn and doxantrazole suppressed release of protease II and histamine when evoked by SP, CGRP, capsaicin, A23187, electrical stimulation of afferents, or compound 48/80. Neural blockade by tetrodotoxin prevented mast cell protease II release in response to antidromic electrical stimulation of mesenteric afferents. The results support a hypothesis that afferent innervation of enteric mast cells releases histamine and mast cell protease II, both of which are known to act in a diffuse paracrine manner to influence the behavior of enteric nervous system neurons and to elevate the sensitivity of spinal afferent terminals.

Mast cell expression of the serotonin1A receptor in guinea pig and human intestine.

Serotonin [5-hydroxytryptamine (5-HT)] is released from enterochromaffin cells in the mucosa of the small intestine. We tested a hypothesis that elevation of 5-HT in the environment of enteric mast cells might degranulate the mast cells and release mediators that become paracrine signals to the enteric nervous system, spinal afferents, and secretory glands. Western blotting, immunofluorescence, ELISA, and pharmacological analysis were used to study expression of 5-HT receptors by mast cells in the small intestine and action of 5-HT to degranulate the mast cells and release histamine in guinea pig small intestine and segments of human jejunum discarded during Roux-en-Y gastric bypass surgeries. Mast cells in human and guinea pig preparations expressed the 5-HT1A receptor. ELISA detected spontaneous release of histamine in guinea pig and human preparations. The selective 5-HT1A receptor agonist 8-hydroxy-PIPAT evoked release of histamine. A selective 5-HT1A receptor antagonist, WAY-100135, suppressed stimulation of histamine release by 5-HT or 8-hydroxy-PIPAT. Mast cell-stabilizing drugs, doxantrazole and cromolyn sodium, suppressed the release of histamine evoked by 5-HT or 8-hydroxy-PIPAT in guinea pig and human preparations. Our results support the hypothesis that serotonergic degranulation of enteric mast cells and release of preformed mediators, including histamine, are mediated by the 5-HT1A serotonergic receptor. Association of 5-HT with the pathophysiology of functional gastrointestinal disorders (e.g., irritable bowel syndrome) underlies a question of whether selective 5-HT1A receptor antagonists might have therapeutic application in disorders of this nature.

The role of dumping syndrome in weight loss after gastric bypass surgery.

BACKGROUND: Roux-en-Y gastric bypass is the most commonly performed operation for the treatment of morbid obesity in the US. Dumping syndrome is an expected and desired part of the behavior modification caused by gastric bypass surgery; it can deter patients from consuming energy-dense food. In this study we assessed the role dumping has in weight loss and its relationship with the patient's eating behavior. METHODS: Fifty patients who underwent gastric bypass between January 2008 and June 2008 were enrolled. Two questionnaires, the dumping syndrome questionnaire and the Three-Factor Eating Questionnaire (TFEQ), were used to record the patients' responses. The diagnosis of dumping syndrome was based on the Sigstad scoring system, where a score of 7 and above was considered positive. TFEQ evaluated the patients' eating behavior under three scales: cognitive restraint, uncontrolled eating, and emotional eating. The results were analyzed with descriptive and parametric statistics where applicable. RESULTS: The prevalence of dumping syndrome was 42 %, with 66.7 % of the subjects being women. The nondumpers were observed to have a greater mean decrease in body mass index than the dumpers at 1 and 2 years (18.5 and 17.8 vs. 14.4 and 13.7 respectively). There was no definite relationship between the presence of dumping syndrome and the eating behavior of the patient. However, the cognitive restraint scores, greater than 80 %, were associated with an average decrease in BMI of 19 and 20.8 at 1 and 2 years compared with 14.6 and 12.4 in those with scores less than 80 % (p = 0.01 and p = 0.03, respectively). CONCLUSION: The presence of dumping syndrome after gastric bypass does not influence weight loss, though eating behaviors may directly influence it.

Current national practice patterns for inpatient management of ventral abdominal wall hernia in the United States.

BACKGROUND: The health-care burden related to ventral hernia management is substantial, with more than 3 billion dollars in expenditures annually in the US. Previous studies have suggested that the utilization of laparoscopic repair remains relatively low although national volume estimates have not been reported. We sought to estimate the inpatient national volume of elective ventral hernia surgery and characterize the proportion of laparoscopic versus open operations. METHODS: We analyzed data from the Nationwide Inpatient Sample to identify adults with a diagnosis of an umbilical, incisional, or ventral hernia who underwent an elective inpatient repair between 2009 and 2010. Cases that involved other major abdominal or pelvic operations were excluded. Covariates included patient demographics, surgical approach, and use of mesh. National surgical volume estimates were generated and length of stay and total hospital charges were compared for laparoscopic versus open repairs. RESULTS: A total of 112,070 ventral hernia repairs were included in the analysis: 72.1 % (n = 80,793) were incisional hernia repairs, while umbilical hernia repairs comprised only 6.9 % (n = 7,788). Laparoscopy was utilized in 26.6 % (n = 29,870) of cases. Mesh was placed in 85.8 % (n = 96,265) of cases, including 49.3 % (n = 3,841) of umbilical hernia repairs and 90.1 % (n = 72,973) of incisional hernia repairs. Length of stay and total hospital charges were significantly lower for laparoscopic umbilical, incisional, and "other" ventral hernia repairs (p values all <0.001). Total hospital charges during this 2-year period approached 4 billion dollars ($746 million for laparoscopic repair; $3 billion for open repair). CONCLUSIONS: Utilization of laparoscopy for elective abdominal wall hernia repair remains relatively low in the US despite its excellent outcomes. Given the substantial financial burden associated with these hernias, future research focused on preventing the development and optimizing the surgical treatment of ventral abdominal wall hernias is warranted.

Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass.

BACKGROUND: Marginal ulcer formation remains a significant complication of Roux-en-Y gastric bypass (RYGB). Up to 1 % of all RYGB patients will develop free perforation of a marginal ulcer. Classically, this complication has required anastomotic revision; however, this approach is associated with significant morbidity. Several small series have suggested that omental patch repair may be effective. The aim of this study was to examine the management of perforated marginal ulcers following RYGB. METHODS: All patients who underwent operative intervention for perforated ulcers between 2003 and 2011 were reviewed. Those with a history of RYGB with perforation of a marginal ulcer were included in the analysis. Data collected included operative approach, operative time, blood loss, length of hospital stay, complications, smoking history, and steroid or NSAID use. RESULTS: From January 2003 to December 2011, a total of 1,760 patients underwent RYGB at our institution. Eighteen (0.85 %) developed perforation of a marginal ulcer. Three patients' original procedure was performed at another institution. Eight patients (44 %) had at least one risk factor for ulcer formation. Treatment included omental patch repair (laparoscopic, n = 7; open, n = 9) or anastomotic revision (n = 2). Compared to anastomotic revision, omental patch repair had shorter OR time (101 ± 57 vs. 138 ± 2 min), decreased estimated blood loss (70 ± 72 vs. 250 ± 71 mL), and shorter total length of stay (5.6 ± 1.4 vs. 11.0 ± 5.7 days). CONCLUSIONS: Perforated marginal ulcer represents a significant complication of RYGB. Patients should be educated to reduce risk factors for perforation, as prolonged proton pump inhibitor therapy may not prevent this complication in a patient with even just one risk factor. In our sample population we found laparoscopic or open omental patch repair to be a safe and effective treatment for this condition and it was associated with decreased operative time, blood loss, and length of stay.

Laparoscopic ventral hernia repair: does primary repair in addition to placement of mesh decrease recurrence?

BACKGROUND: The advent of laparoscopic ventral hernia repair (LVHR) not only reduced the morbidity associated with open repair but also led to a decrease in the hernia recurrence rate. However, the rate continues to remain significant. METHODS: A retrospective observational study was conducted on 193 patients who were treated with LVHR by two minimally invasive surgeons in a 24-month period. The patient population was broadly divided into two groups based on the laparoscopic repair of the fascial defect with mesh underlay, or with primary suture repair and mesh underlay (PSR + MU). Patient demographics, rates of hernia recurrence, and other associated complications were compared between the two groups. Patient variables and the clinical outcomes were analyzed with descriptive statistics and chi-square test. RESULTS: One hundred ninety-three consecutive patients underwent LVHR for incisional (n = 136), umbilical (n = 44), epigastric (n = 9), and parastomal (n = 4) hernia. Hernia recurrence was documented in eight patients (4.1%). The mean follow-up period was 10.5 months (range 1-36 months). Incisional hernias accounted for all eight recurrences. The rate of recurrence in those treated with PSR + MU was 3% (two of 67 cases) in comparison with 4.8% (six of 126 patients) associated with mesh alone. The rate of recurrence in the recurrent hernia group, treated with mesh only, was 10.5% (four of 38 patients) compared with 4.8% (one of 21 patients) in the PSR + MU group. CONCLUSIONS: Primary laparoscopic repair along with mesh placement for the management of ventral hernia was found to be effective in selected cases as evidenced by the low rate of recurrence when compared with conventional laparoscopic repair with mesh alone. Further retrospective and prospective studies, with larger patient enrollment, are warranted to confirm the benefit of this technique over traditional repair.

Epiregulin as an Alternative Ligand for Leptin Receptor Alleviates Glucose Intolerance without Change in Obesity.

The leptin receptor (LepR) acts as a signaling nexus for the regulation of glucose uptake and obesity, among other metabolic responses. The functional role of LepR under leptin-deficient conditions remains unclear. This study reports that epiregulin (EREG) governed glucose uptake in vitro and in vivo in Lepob mice by activating LepR under leptin-deficient conditions. Single and long-term treatment with EREG effectively rescued glucose intolerance in comparative insulin and EREG tolerance tests in Lepob mice. The immunoprecipitation study revealed binding between EREG and LepR in adipose tissue of Lepob mice. EREG/LepR regulated glucose uptake without changes in obesity in Lepob mice via mechanisms, including ERK activation and translocation of GLUT4 to the cell surface. EREG-dependent glucose uptake was abolished in Leprdb mice which supports a key role of LepR in this process. In contrast, inhibition of the canonical epidermal growth factor receptor (EGFR) pathway implicated in other EREG responses, increased glucose uptake. Our data provide a basis for understanding glycemic responses of EREG that are dependent on LepR unlike functions mediated by EGFR, including leptin secretion, thermogenesis, pain, growth, and other responses. The computational analysis identified a conserved amino acid sequence, supporting an evolutionary role of EREG as an alternative LepR ligand.

A comparison of outcomes between open and laparoscopic surgical repair of recurrent inguinal hernias.

BACKGROUND: Inguinal hernia recurrence after surgical repair is a major concern. The authors report their experience with open and laparoscopic repair of recurrent inguinal hernias. METHODS: After institutional review board approval, a retrospective review was performed with the charts of 197 patients who had undergone surgical repair of recurrent inguinal hernias from January 2000 through August 2009, and the data for 172 patients who met the inclusion criteria were analyzed. Surgical variables and clinical outcomes were compared using Student's t test, the Mann-Whitney U test, chi-square, and Fisher's exact test as appropriate. RESULTS: The review showed that 172 patients had undergone either open mesh repair (n=61) or laparoscopic mesh repair (n=111) for recurrent inguinal hernias. Postoperative complications were experienced by 8 patients in the open group and 17 patients in laparoscopic group (p=0.70). Five patients (8.2%) in the open group and four patients (3.6%) in the laparoscopic group had re-recurrent inguinal hernias (p=0.28). Four patients in the open group (9.5%) and no patients in the laparoscopic group had recurrence during long-term follow-up evaluation (p=0.046). In the laparoscopic group, 76 patients (68.5%) underwent total extraperitoneal (TEP) repair, and 35 patients (31.5%) had transabdominal preperitoneal (TAPP) repair. Postoperative complications were experienced by 13 patients in the TEP group and 4 patients in the TAPP group (p=0.44). Two patients (2.6%) in the TEP group and two patients (5.7%) in the TAPP group had re-recurrent inguinal hernias (p=0.59). CONCLUSIONS: This retrospective review showed no statistical difference in the re-recurrence rate between the two techniques during short-term follow-up evaluation. However, the laparoscopic technique had a significantly lower re-recurrence rate than the open technique during long-term follow-up evaluation. Both procedures were comparable in terms of intra- and postoperative complications. Among laparoscopic techniques, TEP and TAPP repair are acceptable methods for the repair of recurrent inguinal hernia. A multicenter prospective randomized control trial is needed to confirm the findings of this study.

Transgastric endoscopic peritoneoscopy does not lead to increased risk of infectious complications.

BACKGROUND: It remains important to determine the risk of bacterial contamination and infectious complications of the peritoneal cavity as it pertains to transgastric natural orifice translumenal endoscopic surgery (NOTES) procedures. The infectious implications of such procedures have been quantified in animal models. This report discusses the infectious risks of transgastric endoscopic peritoneoscopy (TEP) in a human clinical trial. METHODS: Under institutional review board approval, 40 patients scheduled for laparoscopic Roux-en-Y gastric bypass (LRYGB) participated in this study. The TEP procedure was performed without preoperative gastric decontamination and without laparoscopic guidance. Preoperative intravenous antibiotics were given. Saline aspirates were taken from the gastric lumen before endoscopic gastrotomy creation and from the peritoneal cavity after transgastric access. Samples were sent for culture, identification, and bacterial counts. Subgroup analysis was performed on patients taking proton pump inhibitors (PPIs). These data were compared with data for "sterile" peritoneal aspirates from a historical cohort of 50 patients undergoing LRYGB. RESULTS: The median number of bacteria isolated from the gastric aspirates was 980 colony-forming units (CFU)/ml (n=40). The median number of bacteria isolated from the peritoneal aspirates was 323 CFU/ml. Cross-contamination from the stomach to the peritoneal cavity was documented in eight cases. No abscesses or anastomotic leaks were recorded. One port-site infection occurred. Subgroup analysis of 15 patients receiving PPIs showed elevated bacterial counts in gastric aspirates and the post-TEP peritoneal samples compared with patients not receiving PPIs (n=25). This subgroup on PPI's did not have an increase in infectious complications. CONCLUSIONS: Contamination of the peritoneal cavity does occur with TEP, but this does not lead to an increased risk of infectious complications. Similarly, patients receiving PPIs have an increased gastric bacterial load and increased contamination after TEP but not an increased risk of infectious complications.

Lubiprostone reverses the inhibitory action of morphine on mucosal secretion in human small intestine.

BACKGROUND AND AIMS: Treatments with morphine or opioid agonists cause constipation. Lubiprostone is approved for treatment of adult idiopathic constipation and constipation-predominant IBS in adult women. We tested whether lubiprostone can reverse morphine-suppression of mucosal secretion in human intestine and explored the mechanism of action. METHODS: Fresh segments of jejunum discarded during Roux-En-Y gastric bypass surgeries were used. Changes in short-circuit current (ΔIsc) were recorded in Ussing flux chambers as a marker for electrogenic chloride secretion during pharmacological interactions between morphine, prostaglandin receptor antagonists, chloride channel blockers and lubiprostone. RESULTS: Morphine suppressed basal Isc. Lubiprostone reversed morphine suppression of basal Isc. Lubiprostone, applied to the mucosa in concentrations ranging from 3 nM to 30 µM, evoked increases in Isc in concentration-dependent manner when applied to the mucosal side of muscle-stripped preparations. Blockade of enteric nerves did not change stimulation of Isc by lubiprostone. Removal of chloride or application of bumetanide or NPPB suppressed or abolished responses to lubiprostone. Antagonists acting at CFTR channels and prostaglandin EP(4) receptors, but not at E(1), EP(1-3) receptors, partially suppressed stimulation of Isc by lubiprostone. CONCLUSIONS: Antisecretory action of morphine results from suppression of excitability of secretomotor neurons in the enteric nervous system. Lubiprostone, which does not affect enteric neurons directly, bypasses the action of morphine by directly opening mucosal chloride channels.

Transoral incisionless fundoplication for gastroesophageal reflux disease in an unselected patient population.

BACKGROUND: EsophyX is an endolumenal approach to the treatment of gastroesophageal reflux disease (GERD). This report describes one of the earliest and largest North American experiences with this device. METHODS: Prospective data were gathered on consecutive patients undergoing EsophyX fundoplication for a 1-year period between September 2007 and March 2009. During this time, the procedure evolved to the current technique. A P value less than 0.05 was considered significant. RESULTS: The study enrolled 26 patients with a mean age of 45 years. The patients included 16 women (62%) with a mean body mass index (BMI) of 28 and an American Society Anesthesiology (ASA) classification of 2. These patients included 11 with associated small hiatal hernias, 3 with Barrett's esophagus, and 5 with esophageal dysmotility. The procedure time was 65 min (range, 29-137 min), and the length of hospital stay was 1 day (range, 0-6 days). The postoperative valve circumference was 217 degrees, and the valve length was 2.7 cm. Two complications of postoperative bleed occurred, requiring transfusion. The mean follow-up period was 10 months. Comparison of pre- and postoperative Anvari scores (34-17; P = 0.002) and Velanovich scores (22-10; P = 0.0007) showed significant decreases. Although 68% of the patients were still taking antireflux medications, 21% had reduced their dose by half. Three patients had persistent symptoms requiring Nissen fundoplication, and there was one late death unrelated to the procedure. CONCLUSION: This study represents an initial single-institution experience with EsophyX. According to the findings, 53% of the patients had either discontinued their antireflux medication (32%) or had decreased their dose by half (21%). Both symptoms and health-related quality-of-life (HRQL) scores significantly improved after treatment. Further follow-up evaluation and objective testing are required.

Parastomal hernia repair.

Parastomal hernias remain a daunting challenge to general and colorectal surgeons. Their unique anatomy and alteration of abdominal wall mechanics contribute to a significant recurrence rate and associated morbidity in repair. Recent advances in synthetic and biologic meshes, as well as refinement of laparoscopic surgical techniques, may offer potential improvements in outcome for these patients. We conducted a review of the literature for parastomal hernia repair, including manuscripts specifically addressing the use of synthetic and biologic prostheses. We then chose selected references from these studies to include in this review. Results are summarized to reflect current evidence for use of prostheses and other techniques in the repair of parastomal hernias. Repair of parastomal hernias remains plagued by significant recurrence rates. Recurrence may be higher when other abdominal wall hernias are addressed simultaneously. Synthetic mesh repair appears to reduce recurrence compared with primary suture repair. The use of biologic prostheses may reduce recurrence rate and eliminate the potential for mesh infection. The laparoscopic approach should be individualized to both patient and surgeon factors.

Endoscopic treatments for GERD.

Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.