Long-term outcomes and quality of life assessment after posterior component separation with transversus abdominis muscle release (TAR).

BACKGROUND: Although transversus abdominis release (TAR) to treat large incisional hernias has shown favorable postoperative outcomes, devastating complications may occur when it is used in suboptimal conditions. We aimed to evaluate postoperative outcomes and long-term follow-up after TAR for large incisional hernias. METHODS: A consecutive series of patients undergoing TAR for complex incisional hernias between 2014 and 2019 with a minimum of 6 month follow-up was included. Demographics, operative and postoperative variables were analyzed. Postoperative imaging (CT-scan) was also evaluated to detect occult recurrences. The HerQLes survey for quality of life (QoL) assessment was performed preoperatively and 6 months after the surgery. RESULTS: A total of 50 TAR repairs were performed. Mean age was 65 (35-83) years, BMI was 28.5 ± 3.4 kg/m2, and 8 (16%) patients had diabetes. Mean Tanaka index was 14.2 ± 8.5. Mean defect area was 420 (100-720) cm2, average defect width was 19 ± 6.2 cm, and mesh area was 900 (500-1050) cm2; 78% were clean procedures, and in 60% a panniculectomy was associated. Operative time was 252 (162-438) minutes, and hospital stay was 4.5 (2-16) days. Thirty-day morbidity was 24% (12 patients), and 16% (8 patients) had surgical site infections. Overall recurrence rate was 4% (2 patients) after 28.2 ± 20.1 months of follow-up. QoL showed a significant improvement after surgery (p = 0.001). CONCLUSIONS: The TAR technique is an effective treatment modality for large incisional hernias, showing an acceptable postoperative morbidity, a significant improvement in QoL, and low recurrence rates at long-term follow-up.

Emergent laparoscopic sigmoid resection for perforated diverticulitis: can it be safely performed by residents?

AIM: Outcomes after resident involvement in emergent colectomies have rarely been studied. The aim of this study was to analyse the outcomes of laparoscopic sigmoidectomy for Hinchey III diverticulitis performed by residents. METHOD: This study was a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for diverticulitis. The sample was divided into two groups: patients operated on by a supervised resident (SR) or a senior surgeon (SS). Supervising surgeons and SSs could be general surgeons (GSs) or colorectal surgeons (CSs). A SR was considered the first surgeon if he/she completed at least three of five defined steps of the procedure. The primary end-points included length of hospital stay (LOS), morbidity and 30-day mortality. A sub-analysis of patients operated on by a SR assisted by either a CS or GS was performed. RESULTS: Supervised residents and SSs operated on 59 and 42 patients, respectively. The presence of a CS was more frequent in the SS group (SR 41% vs SS 81%, P < 0.001). LOS (SR 9.4 days vs SS 6.4 days, P = 0.04) was higher in the SR group. Overall morbidity (SR 39% vs SS 43%, P = 0.69) and 30-day mortality (SR 5% vs SS 5%, P = 0.94) were also comparable among the groups. Procedures performed by SRs and supervised by a CS were associated with lower morbidity (GS 48% vs CS 25%, P = 0.06) and mortality (GS 8% vs CS 0%, P = 0.26). CONCLUSION: Laparoscopic sigmoidectomy for Hinchey III diverticulitis has comparable outcomes when performed by a supervised SR or a SS. Procedures performed by residents assisted by a CS seem to have better outcomes than those assisted by a GS.

Does DeMeester score still define GERD?

Gastroesophageal reflux disease (GERD) clinical presentation may encompass a myriad of symptoms that may mimic other esophageal and extra-esophageal diseases. Thus, GERD diagnosis by symptoms only may be inaccurate. Upper digestive endoscopy and barium esophagram may also be misleading. pH monitoring must be added often for a definitive diagnosis. The DeMeester score (DMS) is a composite score of the acid exposure during a prolonged ambulatory pH monitoring that has been used since 1970s to categorize patients as GERD+ or GERD-. We showed in this review that DMS has some limitations and strengths. Although there is not a single instrument to precisely diagnose GERD in all of its variances, pH monitoring analyzed at the light of DMS is still a reliable method for scientific purposes as well as for clinical decision making. There are no data that show that acid exposure time is superior-or for that matter inferior-as compared to DMS.

The 2018 ISDE achalasia guidelines.

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

The role of Heller myotomy and POEM for nonachalasia motility disorders.

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders such as Diffuse Esophageal Spasm (DES), Nutcracker Esophagus (NE) and the Hypertensive Lower Esophageal Sphincter (HTN-LES). Most patients with DES and HTN-LES who complain of dysphagia improve after a myotomy. Patients with NE whose main complaint is chest pain, often do not have relief of the pain and can even develop dysphagia as a consequence of the myotomy. POEM is a relatively new procedure, and there are no studies with long-term follow-up and no prospective and randomized trials comparing it to surgical myotomy. Overall, the key to success is based on a complete evaluation and a careful patient selection. The best results, regardless of the technique, are in fact obtained in patients with outflow obstruction and impaired esophageal emptying, a picture similar to achalasia.

Influence of direct or indirect contact for the cytotoxicity and blood compatibility of spider silk.

Spider silk became one of the most-researched biomaterials in the last years due to its unique mechanical strength and most favourable chemical composition for tissue engineering purposes. However, standardized analysis of cytocompatibility is missing. Therefore, the aim of this study was to investigate hemolysis, cytotoxicity of native spider silk as well as influences on the cell culture medium. Changes of cell culture medium composition, osmolarity as well as glucose and lactate content were determined via ELISA measurement. Possible hemolysis and cytotoxicity in vitro of spider silk were performed via measurement of hemoglobin release of human red blood cells or relative metabolic activity of L929 fibroblasts, respectively, according to international standard procedures. In ELISA measurement, no significant changes in medium composition could be found in this study. Spider silk was not hemolytic in direct and indirect testing. However, a borderline cytotoxicity according to definitions was found in indirect cytotoxicity testing. Nevertheless, in direct cytotoxicity testing, relative metabolic activity measurement revealed that spider silk is not cytotoxic under these conditions. This is the first study to conduct standardized tests regarding cytotoxicity and hemolysis of native spider silk, which might be considered inert in cell culture. As neither hemolysis nor cytotoxicity was found in direct contact in standardized procedures, safety in biomedical applications may be assumed. The indirect cytotoxicity seems to play a minor role in vivo. However, a borderline toxicity was revealed, suggesting potential leachables not yet identified. Displays one of the weaving frames used in this study after seeding with the single drop technique described herein.

Algorithm for early discharge after total thyroidectomy using PTH to predict hypocalcemia: prospective study.

PURPOSE: Hypocalcemia is the most common complication after total thyroidectomy. The aim of this study was to determine whether postoperative parathyroid hormone (PTH) levels predict hypocalcemia in order to design an algorithm for early discharge. METHODS: We present a prospective study including patients who underwent total thyroidectomy. Hypocalcemia was defined as serum ionized calcium < 1.09 mmol/L or clinical evidence of hypocalcemia. PTH measurement was performed preoperatively and at 1, 3, and 6 h postoperatively. The percent decline of preoperative values was calculated for each time point. RESULTS: One hundred and six patients were included. Thirty-six (33.9%) patients presented hypocalcemia. A 50% decline in PTH levels at 3 h postoperatively showed the highest sensitivity and specificity to predict hypocalcemia (91 and 73%, respectively). No patients with a decrease <35% developed hypocalcemia (100% sensitivity), and all patients with a decrease >80% had hypocalcemia (100% specificity). CONCLUSIONS: PTH determination at 3 h postoperatively is a reliable predictor of hypocalcemia. According to the proposed algorithm, patients with less than 80% drop in PTH levels can be safely discharged the day of the surgery.

Losartan modifies mesh integration after abdominal wall repair: an experimental study.

PURPOSE: Angiotensin II (AT II) receptor blockers have previously shown to reduce inflammatory response in many settings. We aimed to assess the effects of ATII receptor blocker (Losartan) on mesh integration after abdominal wall repair in a rat model. METHODS: A total of 16 Wistar-Kyoto (WKY) and 16 previously hypertensive (SHRSP) rats were isolated. An acute ventral hernia followed by a bridged repair with heavyweight polypropylene mesh was performed. Subjects received either normal saline (WKY-C n = 8 and SHRPS-C n = 8) or 40 mg/kg losartan (WKY-L n = 8) and SHRPS-L n = 8) in the postoperative period. Blood pressure was recorded preoperatively and weekly after surgery. Necropsy with en-bloc resection of the abdominal wall was performed at postoperative day 30. Macroscopic and microscopic evaluations of the specimens were conducted. H&E and Masson's trichrome were used for histologic evaluation. RESULTS: Both groups receiving Losartan showed a significant reduction of blood pressure after surgery (WKY-L: 130/85 vs 116/81 mmHg, SHRPS-L: 176/137 vs 122/101 mmHg, p < 0.01). A significant reduction in mesh incorporation and adherence scores were also observed on macroscopic analysis in Losartan groups (p < 0.01 and p = 0.02, respectively). Microscopically, higher immature fibroplasia was observed after Losartan, with a significant reduction in scar plate formation and inflammatory response on the prosthetic surface (p = 0.04 and p = 0.02, respectively). CONCLUSION: Losartan modifies the interaction between the host tissue and the prosthesis. An impairment in mesh integration and immature fibroplasia in both normotensive and hypertensive rats detected in our model warrants further research.

Disparities in Emergent Colectomy for Colorectal Cancer Contribute to Inequalities in Postoperative Morbidity and Mortality in The US Health Care System.

BACKGROUND AND AIMS: Colorectal cancer is the third most common cancer among both men and women in the United States. We aimed to determine racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer in the US Health Care system. MATERIAL AND METHODS: We performed a retrospective analysis of the National Inpatient Sample including adult patients (⩾18 years) diagnosed with colorectal cancer, and who underwent colorectal resection while admitted between 2008 and 2015. Multivariable logistic and linear regression were used to assess the association between emergent admissions, compared to elective admissions, and postoperative outcomes. RESULTS: A total of 141,641 hospitalizations were included: 93,775 (66%) were elective admissions and 47,866 (34%) were emergent admissions. Black patients were more likely to undergo emergent colectomy, compared to white patients (42% vs 32%, p < 0.0001). Medicaid and Medicare patients were also more likely to have an emergent colectomy, compared to private insurance (47% and 36% vs 25%, respectively, p < 0.0001), as were patients with low household income, compared to highest (38% vs 31%, p < 0.0001). Emergent procedures were less likely to be laparoscopic (19% vs 38%, p < 0.0001). Patients undergoing emergent colectomy were significantly more likely to have postoperative venous thromboembolism, wound complications, infection, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality. CONCLUSION: There are significant racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer. Efforts to reduce this disparity in colorectal cancer surgery patients should be prioritized to improve outcomes.

Could long-term follow-up modify the outcomes after laparoscopic TAPP? A 5-year retrospective cohort study.

PURPOSE: Laparoscopic inguinal hernia repair (LIHR) has demonstrated multiple benefits. However, long-term results regarding recurrence and quality of life (QoL) are still on debate. We aimed to analyze postoperative outcomes with long-term follow-up after LIHR. METHODS: A consecutive series from December 2012 to May 2017 of laparoscopic TAPP was included. A minimum of 6 months of follow-up was required for inclusion. The sample was divided into two groups, G1: patients with recurrence and G2: patients without recurrence. Patient's characteristics, operative variables and postoperative outcomes were analyzed. A QoL survey (Eura-HS QoL) was performed in the pre- and postoperative period. RESULTS: A total of 717 laparoscopic TAPP were performed in 443 patients. On univariate analysis, smoking, previous recurrence, mesh size smaller than 12 × 15 cm and surgical teams with less than 30 cases/year showed an increased recurrence rate (p < 0.05). But only smoking and less experienced teams were statistically significant on multivariate analysis (p < 0.01). After a 2-year follow-up, recurrence rate was 1.5%, while it increased to 2.6% (n = 19) at 5-year follow-up. Sixty percent of patients answered QoL survey. Average preoperative scores of pain, activities restriction and aesthetic dissatisfaction improved significantly after 6 months of follow-up in patients without recurrence. CONCLUSIONS: After LIHR, quality of life shows a significant improvement in all parameters. Extending follow-up beyond 2 years after laparoscopic TAPP allows a more accurate assessment of recurrence rate. Smoking and inexperienced teams were significant risk factors for its development.

Duodenal cytochrome b (Cybrd1) ferric reductase functional studies in cells.

Dietary non-heme ferric iron is reduced by the ferric reductase enzyme, duodenal cytochrome b (Dcytb), before absorption by the divalent metal transporter 1 (DMT1). A single nucleotide polymorphism (SNP rs10455 mutant) that is located in the last exon of the Dcytb gene was reported in C282Y haemochromatosis HFE subjects. The present work therefore investigated the phenotype of this mutant Dcytb in Chinese hamster ovary (CHO) cells. These cultured cells were transfected with either wild type (WT) or the SNP vector plasmids of Dcytb. Ferric reductase assays were performed in Dcytb transgenic CHO cells using the ferrozine spectrophometric assay protocol. The Dcytb SNP rs10455 showed a gain-of-function capability since ferric reductase activity increased significantly (p < 0.01) in the transgenic cells. Varying ferric reductase activity was found when CHO cells were pretreated with modulators of Dcytb protein expression. Although ferric reductase in endogenous CHO cells increased with deferoxamine or CoCl2, iron loading with ferric ammonium citrate (FAC) had the opposite effect. Taken together, the study reveals a gain-of-function phenotype for Dcytb rs10455 mutation that could be a putative modifier of colorectal cancer risk, with attendant variability in penetrance among human HFE C282Y homozygotes.

Small Bowel Obstruction Secondary to Interstitial Hernia: Laparoscopic Approach.

Interstitial hernias are a rare entity. Most of them are detected incidentally on imaging studies. We present a case of abdominal bowel obstruction secondary to interstitial hernia on the fifth postoperative day of an open incisional hernia repair. Laparoscopy confirmed the diagnosis and led to an accurate treatment avoiding a new laparotomy. In this case, prompt surgical decision based on clinical and CT scan findings allowed a mini-invasive approach with satisfactory outcome.

The 2018 ISDE achalasia guidelines

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.