Robotic thoracoabdominal hernia repair: a novel approach.

PURPOSE: Thoracoabdominal hernias remain a rare and poorly understood entity. Data remain sparse as terminology varies in the literature and case reports demonstrate wide variability in technique. We present a novel approach for repair of thoracoabdominal hernias using the robotic platform. METHODS: Two patients underwent a robotic thoracoabdominal hernia repair in June 2022. They were followed for 1 year with CT scans every 6 months to exclude recurrence. Patient demographics and peri-operative details including defect size, closure technique, mesh size, length of stay, and complications were reported. RESULTS: Both patients successfully underwent a robotic repair of a thoracoabdominal hernia, addressing the intercostal hernia, diaphragmatic disruption, and flank hernia discretely during the operation. One patient had an uneventful recovery and discharged on post-operative day 3; the other developed a small bowel obstruction due to an early port site hernia which required surgical intervention. He eventually discharged on post-operative day 9. At one year, there is no clinical or radiographic evidence of recurrence for either patient. CONCLUSION: Robotic thoracoabdominal hernia repair is feasible and offers a minimally invasive repair option for these extremely complex hernias.

A prospective, multicenter trial of a long-term bioabsorbable mesh with Sepra technology in cohort of challenging laparoscopic ventral or incisional hernia repairs (ATLAS trial).

BACKGROUND: This prospective, multicenter, single-arm, open-label study evaluated P4HB-ST mesh in laparoscopic ventral or incisional hernia repair (LVIHR) in patients with Class I (clean) wounds at high risk for Surgical Site Occurrence (SSO). METHODS: Primary endpoint was SSO requiring intervention <45 days. Secondary endpoints included: surgical procedure time, length of stay, SSO >45 days, hernia recurrence, device-related adverse events, reoperation, and Quality of Life at 1, 3, 6, 12, 18, and 24-months. RESULTS: 120 patients (52.5% male), mean age of 55.0 ± 14.9 years, and BMI of 33.2 ± 4.5 kg/m2 received P4HB-ST mesh. Patient-reported comorbid conditions included: obesity (86.7%), active smoker (45.0%), COPD (5.0%), diabetes (16.7%), immunosuppression (2.5%), coronary artery disease (7.5%), chronic corticosteroid use (2.5%), hypoalbuminemia (0.8%), advanced age (10.0%), and renal insufficiency (0.8%). Hernia types were primary ventral (44.2%), primary incisional (37.5%), recurrent ventral (5.8%), and recurrent incisional (12.5%). Patients underwent LVIHR in laparoscopic (55.8%) or robotic-assisted cases (44.2%), mean defect size 15.7 ± 28.3 cm2, mean procedure time 85.9 ± 43.0 min, and mean length of stay 1.0 ± 1.4 days. There were no SSOs requiring intervention beyond 45 days, n = 38 (31.7%) recurrences, n = 22 (18.3%) reoperations, and n = 2 (1.7%) device-related adverse events (excluding recurrence). CONCLUSION: P4HB-ST mesh demonstrated low rates of SSO and device-related complications, with improved quality of life scores, and reoperation rate comparable to other published studies. Recurrence rate was higher than expected at 31.7%. However, when analyzed by hernia defect size, recurrence was disproportionately high in defects ≥7.1 cm2 (43.3%) compared to defects <7.1 cm2 (18.6%). Thus, in LVIHR, P4HB-ST may be better suited for small defects. Caution is warranted when utilizing P4HB-ST in laparoscopic IPOM repair of larger defects until additional studies can further investigate outcomes.

Effect of Helicobacter pylori Treatment on Unexplained Iron Deficiency Anemia.

BACKGROUND: A large number of patients with iron deficiency anemia have no known cause of their anemia despite a full evaluation. Optimal management and follow-up for this issue is unclear. Results of previous studies have implicated Helicobacter pylori infection as a potential cause of iron deficiency anemia. OBJECTIVES: To investigate whether H pylori infection could be a cause of unexplained iron deficiency anemia. METHODS: All adult patients with both unexplained iron deficiency anemia and H pylori infection diagnosed between January 1, 2008 and April 30, 2015 were identified from Kaiser Permanente Northern California's electronic medical records database and were followed-up for up to 2 years. We employed bivariate statistics to analyze demographic and clinical characteristics between H pylori treatment groups (treated and untreated). Multivariable logistic regression was used to assess the odds of continued presence of anemia at follow-up. RESULTS: Of 508 subjects who fit our inclusion criteria, 408 subjects were treated for H pylori. The median initial level of hemoglobin was 10.5 g/dL and ferritin was 7.0 ng/mL. No difference existed in the continued presence of iron deficiency anemia at follow-up between those treated for H pylori and those not treated (24.3% vs 26.5%, p = 0.71). Both groups had improved levels of hemoglobin (25.4% mean increase in treated vs 27.5% mean increase in untreated) at follow-up. CONCLUSION: In contrast to the findings of previous studies, we found no evidence that H pylori is involved in causing iron deficiency anemia. Iron deficiency anemia resolved in most subjects regardless of H pylori treatment status.

Primary Peritonitis: An Index Case of Mycoplasma hominis Infection in a Healthy Female.

INTRODUCTION: Primary peritonitis in healthy immunocompetent individuals is rare. Several case reports of Streptococcus species causing peritonitis have been described. Here, we present the first case of Mycoplasma hominis as the cause of primary peritonitis in a healthy woman. CASE REPORT: A 42-year-old female with history of uterine fibroids was admitted with abdominal pain and intraperitoneal fluid of unknown etiology. She was initially managed nonoperatively and empirically treated with broad spectrum antibiotics. Blood and urine cultures were unrevealing. Increasing abdominal pain and peritoneal fluid prompted diagnostic laparoscopy which revealed a dense fibrinous exudate covering the entire peritoneal cavity. Peritoneal fluid and biopsies were sent for cytology and culture. The peritoneal fluid was eventually sent for 16 s ribosomal analysis, which discovered Mycoplasma hominis RNA. Her antibiotics were narrowed, and she eventually made a full recovery. DISCUSSION: M. hominis is a rare source of systemic infection but has been known to colonize the urogenital tract and cause localized infections. This is the first presentation of M. hominis causing primary peritonitis in a healthy immunocompetent female. Multidisciplinary management of these patients is critical to achieve a timely diagnosis. Surgical exploration is often unavoidable to rule out secondary peritonitis.

Healthcare Encounters for Pokémon Go: Risks and Benefits of Playing.

OBJECTIVE: Our aim was to quantify the health risks and benefits of Pokémon Go, an augmented reality game played on the mobile phone utilizing real-world locations. MATERIALS AND METHODS: Healthcare encounters containing references to Pokémon Go in Kaiser Permanente Northern California (KPNC) from July 5, 2016 to November 5, 2016 were reviewed. Subjects were classified according to the nature of the healthcare encounter subsequent to playing Pokémon Go: adverse event/injury, self-reported benefit, or incidental mention. Comparisons were made using the Wilcoxon-Mann-Whitney nonparametric test where variables were continuous and the chi-squared or Fisher's exact test where variables were binomial. RESULTS: Of 222 Pokémon Go players reporting an adverse event or benefit, 75 (33.8%) experienced adverse events and 147 (66.2%) reported benefits. Among our cohort, 114 subjects (54.0%) were obese, and 62 (27.9%) were diabetic or prediabetic. More subjects reporting benefits had an endocrine-related comorbidity than those reporting injuries (40.1% vs. 16.0%, P < 0.001). Median family income was higher in the benefit group than in the adverse event group ($83,846 vs. $70,378, P = 0.027). Of 75 subjects having adverse events, 8 (10.7%) had severe injuries, including fractures and head trauma, with 4 (5.3%) having inpatient stays. Most adverse events were musculoskeletal or skin injuries (n = 51, 68.0%). CONCLUSIONS: Injuries were similar to those seen with other light-to-moderate outdoor physical activities. Given KPNC's membership of 3.85 million, the number of severe injuries reported was low; this suggests that the game is safe to play. Pokémon Go may be reaching a population that requires increased physical activity.

Laparoscopic and open distal pancreatic resection for benign pancreatic disease.

The aim of the study is to provide comparisons of the perioperative outcomes between open and laparoscopic distal pancreatic resection (DPR) for benign pancreatic disease. From 2002 and 2005, there were 28 patients (16 open, 12 laparoscopic) with a mean age of 52 who had presumptive diagnoses of benign pancreatic lesions. Pathology was neuroendocrine tumor (nine and five), mucinous cystic neoplasm (three and three), symptomatic pancreatic pseudocyst (two and two), and others (two and two). The mean operative time was 278 vs 212 min (p = 0.05), the estimated blood lost was 609 vs 193 ml (p = 0.01), and the success rate of preoperative intent for splenic preservation was 17 vs 62% (p = 0.08) in the open and laparoscopic groups, respectively. Two patients (16%) were converted to an open procedure. There was no perioperative mortality. The mean hospital stay and total perioperative morbidity were 10.6 vs 6.2 days (p = 0.001) and nine vs two events (p = 0.03) in the open and laparoscopic groups, respectively. Ten of 12 patients (83%) with laparoscopic DPR had adequate oral intake within 72 h post operatively in contrast to 2 of 16 (12.5%) patients in the open DPR group (p = 0.0001). Laparoscopic DPR is technically feasible, safe, and associated with less perioperative morbidity and a shorter hospital stay than open DPR. In centers with the appropriate expertise, laparoscopic DPR should be considered the procedure of choice for putative benign lesions of the pancreatic body and tail.

Forty-eight-hour pH monitoring increases sensitivity in detecting abnormal esophageal acid exposure.

Ambulatory 24-hour esophageal pH measurement is the standard for detecting abnormal esophageal acid exposure (AEAE), but it has a false negative rate of 15% to 30%. Wireless 48-hour pH monitoring (Bravo; Medtronic, Shoreview, MN) may allow more accurate detection of AEAE versus 24-hour pH monitoring. Forty-eight-hour wireless data were reviewed from 209 patients at three different tertiary care referral centers between 2003 and 2005. Manometric or endoscopic determination of the lower esophageal sphincter helped place the Bravo probe 5 to 6 cm above the lower esophageal sphincter. A total of 190 studies in 186 patients had sufficiently accurate data. There were 114 women and 72 men with an average age of 51 years. AEAE was defined by a Johnson-DeMeester score greater than 14.7 and was obtained in 115 of 190 studies (61%). Only 64 of 115 patients (56%) demonstrated AEAE for both days of the study, whereas 51 of 115 patients (44%) demonstrated AEAE in a single 24-hour period. There was no difference in the prevalence of AEAE on day 1 versus day 2 only (26% vs. 18%, P = .26). Compared with 24-hour alone data, 48-hour data showed 22% more patients with AEAE. Frequent day-to-day variability in patients with AEAE may be missed by a single 24-hour pH test. Forty-eight-hour pH testing may increase detection accuracy and sensitivity for AEAE by as much as 22%.

Cost-effectiveness of gastric bypass for severe obesity.

PURPOSE: To estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity. SUBJECTS AND METHODS: We performed a cost-effectiveness analysis of gastric bypass versus no treatment from the payer perspective. We discounted quality-adjusted life-years (QALYs), life-years, and cost during the patient's lifetime. Our target group comprised women and men aged 35 to 55 years with a body mass index between 40 and 50 kg/m(2), and who did not have cardiovascular disease and in whom conservative bariatric therapies had been unsuccessful. RESULTS: The base case cost-effectiveness ratios ranged from 5000 dollars to 16,100 dollars per QALY for women and from 10,000 dollars to 35,600 dollars per QALY for men, depending on age and initial body mass index. In a few subgroups of older, less obese men, variation in parameters such as loss of excess weight, obesity-related quality of life, complication rates, and perioperative mortality affected the cost-effectiveness ratios. Parameter variation did not result in meaningful changes in the remaining patients. CONCLUSION: Gastric bypass is a cost-effective alternative to no treatment, providing substantial lifetime benefits in patients who are severely obese.

Angiotensin-converting enzyme-related cough among Chinese-Americans.

BACKGROUND: Few studies have examined the relationship between ethnicity and tolerance of hypertension medications. We investigated the perception that Chinese-Americans may have a higher incidence of chronic cough from angiotensin-converting enzyme inhibitors. METHODS: We searched electronic databases to identify patients who had received a new lisinopril prescription. This cohort was separated into 295 patients of Chinese descent and 4263 patients in the general population group with an instrument that used surnames to identify Chinese ethnicity. For those who discontinued lisinopril within 1 year, we reviewed medical records to determine reasons for discontinuation. We compared rates of discontinuation overall and due to cough by ethnic group (Chinese vs general population). RESULTS: The Chinese population was more likely to discontinue their medication (47%) than the general population (31%). When the cause for discontinuation was examined, cough was significantly higher among Chinese, with a relative risk of 2.53; 95% confidence interval (CI), 2.11-3.03. The risk for angioedema was <1%, and no difference in the risk of angioedema was found between the 2 groups. When controlled for age, sex, and smoking, the risk of cough among Chinese-Americans remained significant (relative risk 2.63; 95% CI, 2.20-3.15). CONCLUSIONS: We observed that our Chinese group was more than twice as likely as the general population to discontinue lisinopril due to cough, controlling for the influence of sex, age, and smoking.

New approaches to the minimally invasive treatment of pancreatic cancer.

Advances in minimally invasive surgery have revolutionized the field of surgery. Despite the great strides in equipment and experience, operative conduct remains confined by the limits of exposure. Retroperitoneal fat can be abundant and can contribute greatly to difficulty in exposure. Visceral organs ventral to the retroperitoneum preclude direct access and require optimal patient positioning to operate. Additionally, the major vascular pedicles all originate in the retroperitoneum off of the abdominal aorta or enter the inferior vena cava. The pancreas, in particular, is surrounded by the portal vein, celiac axis, superior mesenteric vein and artery, and splenic vein and artery. If injured during surgery, these vessels can present a life-threatening emergency. The issues related to the vasculature, coupled with the difficulty in resecting portions of the pancreas and the relative paucity of pancreatic procedures, have greatly concentrated these cases at tertiary care centers staffed by experienced laparoscopists. However, as surgical technology improves and fellowships train more surgeons with advanced laparoscopic skills, minimally invasive pancreatic surgery may diffuse with more community-based health care networks.

Minimally invasive management of the prenatally torsed ovarian cyst.

BACKGROUND: Fetal and neonatal ovarian cysts are detected frequently by ultrasonography. The presence of these lesions can result in adnexal torsion in utero with autoamputation. Historically, these have been removed at laparotomy. METHODS: Retrospective chart review was performed at a single children's hospital from October 1996 to September 2001. RESULTS: Six cases of torsion of ovarian cysts were removed laparoscopically. Five of the 6 patients had prenatal ultrasound diagnosis. The sixth had the cyst detected incidentally by magnetic resonance imaging (MRI) at 3 months of age. All cysts were complex by ultrasound criteria. All 6 procedures were performed via a 2-port laparoscopic approach. The average age at surgery was 3.7 months (range, 9 days to 7.5 months). There were no postoperative complications. Five patients were discharged on the day of surgery. CONCLUSION: Laparoscopy offers a safe, effective, and cosmetic means of managing perinatal torsion of ovarian cysts.