Long-term outcomes of PGA-TMC absorbable synthetic scaffold in both clean and contaminated ventral hernia repairs.

BACKGROUND: Biosynthetic meshes afford the cost advantages of being made from fully synthetic material, but are also biodegradable, making them a versatile option that can be used in both clean and contaminated cases. The aim of this study is to evaluate the safety profile and long-term outcomes of using GORE BIO-A (BIO-A) as an adjunct to abdominal wall reconstruction in all wound classes. METHODS: A retrospective review identified patients undergoing abdominal hernia repair using BIO-A from October 2008 to June 2018. The primary outcome was hernia recurrence rate. Only patients with at least 6-month follow-up were included when looking at recurrence rates. Secondary outcomes included 30-day morbidity categorized according to CDC Surgical Site Infection Criteria, return to operating/procedure room (RTOR), 30-day readmission, length of stay (LOS), and mortality. RESULTS: A total of 207 patients were identified, CDC Wound Classification breakdown was 127 (61.4%), 41 (19.8%), 14 (6.8%), and 25 (12.1%) for wound classes I, II, III, and IV, respectively. Median follow-up was 55.4 months (range 0.2-162.4). Overall recurrence rate was 17.4%. Contaminated cases experienced higher recurrence rates (28.8% versus 10.4%, p = 0.002) at a mean follow up of 46.9 and 60.8 months for contaminated and clean patients, respectively. Recurrent patients had higher BMI (32.4 versus 28.4 kg/m2, p = 0.0011), larger hernias (162.2 versus 106.7 cm2, p = 0.10), higher LOS (11.1 versus 5.6 days, p = 0.0051), and higher RTOR rates (16.7% versus 5.6%, p = 0.053). 51 (24.5%) patients experienced some morbidity, including 19 (9.2%) surgical site occurences, 7 (3.4%) superficial surgical site infections, 16 (7.7%) deep surgical site infections, and 1 (0.5%) organ space infection. CONCLUSION: This study affirms the use of biosynthetic mesh as a cost-effective alternative in all wound classifications, yielding good outcomes, limited long-term complications, and low recurrence. rates.

Despite regression of healthy lifestyle habits, weight loss after bariatric surgery is not affected during the COVID-19 pandemic.

BACKGROUND: The coronavirus pandemic has caused a worldwide health crisis. Bariatric patients require extensive pre- and post-operative follow-up, which may be less feasible during public health social distancing mandates. We assessed the impact of the pandemic on the behaviors and weight loss outcomes of our pre- and post-operative bariatric patients. METHODS: A retrospective review of a prospectively maintained database identified patients who underwent either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at a single institution between March 2018 and May 2020. A cohort undergoing surgery within 12 months before the pandemic as well as a cohort undergoing a medically supervised diet prior to surgery was surveyed regarding pre- and post-COVID-19 lifestyle habits. Excess weight loss (EWL) outcomes from a group of pre-COVID surgical patients were compared to that of a group of post-COVID surgical patients. Primary outcome was whether the lockdown changed 1-year weight loss outcomes. Secondary outcome was whether patient lifestyle behaviors were changed during the pandemic. RESULTS: There was no difference in 1-year EWL between pre- and post-COVID SG patients (51.7% versus 55.9%, p = 0.35), or between pre- and post-COVID RYGB patients (88.9% versus 80.4%, p = 0.42). Pre-stay-at-home order, 91.8% endorsed physical activity compared to 80.3% post-stay-at-home order (p = 0.0025). Mean physical activity decreased from 4.2 h/week to 2.7 h/week after the stay-at-home order (p < 0.0001). Additionally, 41.3% reported worsened dietary habits post-stay-at-home order. CONCLUSION: The COVID-19 pandemic has greatly impacted the behaviors of bariatric surgery patients. Despite deterioration of lifestyle habits, 1-year weight loss outcomes after bariatric surgery remained the same before and after the instatement of social distancing measures. In the short term, the biological effect of metabolic procedures may mask the effects of suboptimal diet and physical activity, but more studies are necessary to better assess the impact of COVID-19 on outcomes after bariatric surgery.

A steady stream of knowledge: decreased urinary retention after implementation of ERAS protocols in ambulatory minimally invasive inguinal hernia repair.

BACKGROUND: Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair. METHODS: A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention. RESULTS: Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective. CONCLUSION: Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

It's not always too late: a case for minimally invasive salvage esophagectomy.

INTRODUCTION: Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4-8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed > 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or > 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE). MATERIALS AND METHODS: Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival. RESULTS: 97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36-85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy < 90 days after CRT (n = 62) to > 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04). CONCLUSION: Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients.

Fluorescent cholangiography significantly improves patient outcomes for laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the "critical view of safety" with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes. METHODS: A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion. RESULTS: A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15-94), average BMI 29.4 kg/m2 (13.3-55.6). 989 patients (71.2%) underwent LC without fluorescence and 400 (28.8%) underwent FC with ICG. 30-day mortality detected 2 cases in the non-ICG group and zero with ICG. ICG reduced operative time by 26.47 min per case (p < 0.0001). For patients with BMI ≥ 30 kg/m2, operative duration for ICG vs non-ICG groups was 75.57 vs 104.9 min respectively (p < 0.0001). ICG required conversion to open at a rate of 1.5%, while non-ICG converted at a rate of 8.5% (p < 0.0001). Conversion rate remained significant with multivariable analysis (OR 0.212, p = 0.001). A total of 19 cases were aborted (1.35%), 8 in the ICG group (1.96%) and 11 in the non-ICG group (1.10%), these cases were not included in LC totals. Average LOS was 0.69 vs 1.54 days in the ICG compared to non-ICG LCs (p < 0.0001), respectively. Injuries were more common in the non-ICG group, with 9 patients sustaining Strasberg class A injuries in the non-ICG group and 2 in the ICG group. 1 CBDI occurred in the non-ICG group. There was no significant difference in 30-day complication rates between groups. CONCLUSION: ICG cholangiography is a non-invasive adjunct to laparoscopic cholecystectomy, leading to improved patient outcomes with respect to operative times, decreased conversion to open procedures, and shorter length of hospitalization. Fluorescence cholangiography improves visualization of biliary anatomy, thereby decreasing rate of CBDI, Strasberg A injuries, and mortality. These findings support ICG as standard of care during laparoscopic cholecystectomy.

More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation.

INTRODUCTION: Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients. RESULTS: Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m2. 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was significantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12-14 beads) versus a larger MSA implant (15-17 beads) had a significantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026). CONCLUSION: Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement.

The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy.

BACKGROUND: Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease. METHODS: A Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n = 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year. RESULTS: The model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year. CONCLUSION: The current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.

Lighting the Way with Fluorescent Cholangiography in Laparoscopic Cholecystectomy: Reviewing 7 Years of Experience.

BACKGROUND: Laparoscopic cholecystectomy with fluorescent cholangiography using indocyanine green dye (FC) identifies extrahepatic biliary structures, potentially augmenting the critical view of safety. We aim to describe trends for the largest single-center cohort of patients undergoing FC in laparoscopic cholecystectomy. STUDY DESIGN: A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy with FC at a single academic institution. Patient factors included age, sex, BMI, and American Society of Anesthesiologists score. Outcomes included operative time, conversion to open procedure, biliary injury, length of stay, and complications. RESULTS: A total of 828 patients underwent FC. Of these, 74.3% were female, the mean age was 50.4 years, and the average BMI 28.8 kg/m 2 . Mean operating room time was 68.6 minutes. There were no mortalities or common bile duct injuries. Morbidities included 4 bile leaks and 1 retained stone. Six patients required conversion to an open approach. Operative time, length of stay, and open conversion significantly decreased after a standard indocyanine green protocol (p < 0.05). Compared with white light, FC demonstrated lower operative times (99 vs 68 minutes), length of stay (1.4 vs 0.4 days), open conversions (8% vs 0.7%), emergency department visits (13% vs 8%) and drain placements (12% vs 3%) (all p < 0.05). Patients with BMI greater than 30 saw elevated operative times and length of stay. CONCLUSIONS: In conclusion, this paper demonstrates improved operative outcomes with the use of FC through the consistent ability to delineate biliary anatomy, even in the setting of complex anatomy. No common bile duct injuries have occurred in our 7-year experience with FC. We recommend FC as the standard of care when performing laparoscopic cholecystectomies.

Venous Thromboembolism and Pulmonary Embolism: Strategies for Prevention and Management.

Perioperative venous thromboembolism (VTE) is a common complication within the surgical patient population. Perioperative mechanical and chemoprophylaxis have been shown to reduce the incidence of both deep venous thrombosis and pulmonary embolism. Prophylactic regimen must be tailored to the patient's individual risk factors as well as the nature of the procedure. In the event of VTE, treatment most commonly includes long-term anticoagulation, whereas more severe cases may require lytic or mechanical interventions.