Trends in outcomes of 862 giant hiatus hernia repairs over 30 years.

PURPOSE: Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years. METHODS: Retrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into "composite repair" (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991-2002; Group 2, 2003-2012; Group 3, 2012-2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis. RESULTS: 862 giant PEH repairs met selection criteria. There was an increasing proportion of "composite repair" after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study's end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien-Dindo grade ≥ III complications including two perioperative deaths (0.2%). CONCLUSION: Hernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of "composite repair", supporting the possible improvement in recurrence rates with this approach.

Targeting errors and reduced oculomotor range following ablations of the superior colliculus or pretectum/thalamus.

The physiology of the superior colliculus (SC) implicates it in the visual control of eye movements. In the primate, acute inactivation of the superior colliculus delays the onset of a visually guided saccade, slows its velocity, and shortens its amplitude. Previous research leaves uncertain whether other oculomotor disorders which sometimes follow ablation of this structure are due to tectal pathology, to neural damage surrounding the tectum, or to both causes. In this study, 7 cynomolgus monkeys received SC ablations. In 3 others, control lesions were placed in the pretectal/posterior thalamic region. Both procedures produced a qualitatively similar syndrome of 4 oculomotor changes. Reaction time to initiate saccades to visual targets was slowed. Secondly, the surgery constricted the normal ocular range. At the worst, movement was confined to a radius of 10-12 degrees of primary gaze. The monkeys displayed two kinds of inaccuracies when attempting to foveate stationary visual targets within their surviving ocular range. Saccadic amplitude was reduced, causing the monkeys' initial attempt to fall short of foveating the target. If the target remained lighted there then ensued a series of stepwise corrective saccades toward it. The corrective saccades ceased with the eyes still at a position short of the target. Eye position remained in error for the duration of the trial. The final position was independent of the target's retinal position or the vector of the motor command needed to acquire the target. Rather, the error was related to the angular position of the target about the head ( = desired eye position). The syndrome appeared qualitatively similar whether resulting from tectal or the more rostral pretectal/diencephalic ablation. When occurring along the horizontal axis, the deficits appeared to require damage to the superior colliculus, perhaps combined with pathology of some other structure. The same syndrome along the vertical axis was better correlated with pretectal/diencephalic pathology. Invasion of these areas together with invasion of the transthalamic axons from the frontal eye fields is interpreted as the critical pathology responsible for the syndrome. A similar oculomotor trajectory can be modelled by supposing a loss in the gain of the signal which conveys the target's retinal position, combined with one other fault in the circuit: either a loss in gain of the eye position signal, or the signal representing the target's position in craniocentric coordinates.

Saccadic disorders caused by cooling the superior colliculus or the frontal eye field, or from combined lesions of both structures.

We used reversible cold lesions to explore the oculomotor consequences of separate and combined dysfunction of the superior colliculus (SC) and the frontal eye field (FEF). Two monkeys were trained to fixate visual targets. In one we measured visually driven saccades while cooling the right SC, first alone, then in combination with bilateral FEF ablation. Two cryodes in the other subject permitted measurement of eye movements during cooling of either the right FEF or the right SC, or both structures together. Cooling FEF mainly caused a neglect. Raising the cryode temperature slightly alleviated the neglect and uncovered a subtle saccadic deficit. It consisted of a slight reduction in saccadic amplitude and increase in saccadic reaction time. Cooling the SC alone lengthened saccadic reaction time and reduced saccadic amplitude more dramatically, causing the monkeys' initial saccade to miss the target. Some correction occurred but a targeting error persisted to the end of the trial. Combined lesions of FEF and SC greatly increased reaction times, reduced saccadic amplitude, and caused large and persistent targeting errors. The changes in saccadic amplitude and the targeting errors were a function of the monkey's eye position. Combined lesions also truncated the ocular range of the monkeys.

Disconnection of parietal and occipital access to the saccadic oculomotor system.

The experiment explored the networks through which signals arising from visual areas of cortex control saccadic eye movements. Electrical stimulation of the inferior parietal and the occipital cortex (here termed the "posterior eye fields") normally evokes saccadic eye movements. We replicated previous reports that these evoked eye movements ceased after large tectal ablations. This initial finding suggested that the "posterior eye fields" depended on a single route of access to the saccade generator, one descending through the superior colliculus (SC). On closer examination, the critical lesion appeared to be one which removed the SC and cut efferents from the frontal eye field (FEF) coursing nearby. Subsequently we confirmed that eye movements evoked from the posterior eye fields ceased after cooling the SC, or cutting its efferents- but only when one of these procedures was combined with FEF ablation. Thus, visual signals from the occipital and inferior parietal cortex have more than one, but perhaps only two routes of access to the oculomotor system. One passes through the superior colliculus, the other through the frontal eye field. Ancillary experiments revealed that inferior parietal and FEF ablations, alone or combined, do not disrupt saccades evoked from the occipital lobe. Striate and prestriate areas can therefore use their own direct input to the SC or to the basal ganglia to drive saccadic eye movements.

Prediction of adherence and control in diabetes.

This study aims to predict adherence to diabetic treatment regimens and sustained diabetic control. During two clinic visits that were 2 months apart, 63 adult outpatients completed measures of diabetic history, current treatment, diabetic control, adherence, and self-efficacy about adherence to treatment. Results showed that self-efficacy was a significant predictor of later adherence to diabetes treatment even after past levels of adherence were taken into account. Posttest levels of adherence in turn were significantly associated with posttest %HbA1c after control for illness severity. A stepwise multiple regression to predict %HbA1c at post entered pretest measures of diabetic control, treatment type, and self-efficacy, which together predicted 50% of the variance. Results are related to self-efficacy theory and implications for practice are discussed.