Bilateral Lumbar Hernias Following Spine Surgery: A Case Report and Laparoscopic Transabdominal Repair.

Lumbar hernias are rare abdominal wall defects. Fewer than 400 cases have been reported in the literature and account for 2% of all abdominal wall hernias. Lumbar hernias are divided into Grynfelt-Lesshaft or Petit hernias. The former are hernia defects through the superior lumbar triangle, while the latter are defects of the inferior lumbar triangle. Primary lumbar hernias are further subdivided into congenital or acquired hernias and can further be classified as either primary or secondary. Secondary hernias occur after previous flank surgeries, iatrogenic muscular disruption, infection, or trauma. We review a rare presentation of metachronous symptomatic bilateral secondary acquired lumbar hernia following spine surgery. A successful laparoscopic transabdominal lumbar hernia repair with extraperitoneal mesh placement was performed, with resolution of the hernia symptoms. An extensive literature review regarding lumbar hernia and different types of repairs was performed.

Paraduodenal Pancreatitis: A Deceptive Abdominal Mass with Unique Histologic Findings.

Paraduodenal pancreatitis (PP) is an uncommon abdominal pathology characterized by scarring of the pancreaticoduodenal space. Diagnosis of this inflammatory process is challenging as its clinical presentation is similar to that of pancreatic cancer. Currently, no definitive radiologic or pathologic features have been established to permit diagnosis of PP without surgical resection. However, the presence of eosinophilic concretions has been reported with increasing frequency in the histologic evaluation of PP. To the best of our knowledge, these concretions are distinctive for PP and not reported in neoplasms commonly involving the pancreaticoduodenal space. Herein, we discuss the case of a 60-year-old man who was found to have PP after pancreaticoduodenectomy for a paraduodenal mass with an initially nondiagnostic biopsy. Retrospective review of the preoperative FNA samples revealed eosinophilic concretions like those found in the final surgical specimen. If the identification of eosinophilic concretions in a background of inflammatory changes was to be accepted as a diagnostic criterion for PP, patients such as ours could be spared the morbidity associated with surgical resection.

Anastomosis after Minimally Invasive Esophagectomy.

BACKGROUND: Esophagectomies are a notoriously difficult procedure that have undergone drastic changes over the last decade. In particular, the adoption of minimally invasive esophagectomies (MIEs) as the gold standard. METHODS: We examine the evolution of the MIE, the support for this method, and our preferred methods for the creation of anastomoses following the resection. RESULTS: The submission of techniques that, after many years of practice, have become our standard methods for anastomosing the Neo-esophagus to the remnant esophagus both at the neck, and within the thorax. CONCLUSION: No matter which MIE technique is chosen, these anastomotic methods are readily available. Each is provided with step-by-step instructions, performed with standard laparoscopic instruments, and in a safe and reproducible manner.

Collagenase Clostridium Histolyticum for Dupuytren's Contracture: Comparing Single and Concurrent Injections.

BACKGROUND: The U.S. Food and Drug Administration approved collagenase clostridium histolyticum for treatment of Dupuytren's contracture in 2010, and for the concurrent treatment of up to two cords in 2014. Although outcomes and adverse events have been well described for single injections, comparative data on concurrent injections are lacking. METHODS: The authors reviewed 121 concurrent collagenase clostridium histolyticum injections and compared these with 177 single injections over 8 years. All injections were performed by a single surgeon, our senior author (D.F.). A retrospective cohort model was used to compare clinical outcomes and adverse events (i.e., skin tears, spontaneous cord rupture, tendon rupture, lymphadenopathy, blood blisters, and ecchymosis) between groups. RESULTS: There were no statistical differences between groups in clinical success rate or change in contracture per joint. The rate of skin tears per joint in concurrent injections (22.3 percent) was not statistically different from that of single injections (18.6 percent; p = 0.46), and was consistent with previously reported rates. The rate of skin tears did not change significantly over time in either group. Concurrent injection did not influence the incidence of skin tears in a dose-dependent manner (relative risk, 1.20). Patients receiving concurrent injections experienced a higher rate of lymphadenopathy compared with those receiving single injections (p = 0.001). CONCLUSIONS: Concurrent collagenase clostridium histolyticum injections for Dupuytren's contracture have a similar safety profile and treatment efficacy when compared to single injections. The authors did not find a dose-dependent relationship between skin tears and collagenase clostridium histolyticum injected. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Preoperative Hypoglycemia and Hyperglycemia Are Related to Postoperative Infection Rates in Implant-Based Breast Reconstruction.

OBJECTIVES: Diabetic patients undergoing surgery are known to have a higher risk for infection. However, current literature does not adequately investigate the effects of preoperative hypoglycemia or hyperglycemia on postoperative infection risk. METHODS: A retrospective review of a national private payer database within the PearlDiver Supercomputer application (Warsaw, IN) for patients undergoing breast reconstruction with implant/expander (BR) was conducted. These patients were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9) ninth revision codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes ranging from 25 to 219 mg/dL, in 15 mg/mL increments. Patients with preexisting diabetes diagnoses were excluded. These patients were longitudinally tracked for infection at the 90 d and 1-y postoperative period using ICD-9 codes. RESULTS: The search query yielded 13,237 BR procedures with preoperative glycemic levels ranging from 25 to 219 mg/mL. Most procedures (34.6%) were performed on patients with preoperative glycemic levels ranging from 70 to 99 mg/dL. Of the total procedures performed (n = 13,237), 19.4% (n = 2564) resulted in infections documented at the 90-d interval, and 24.8% (n = 3285) resulted in infections documented at the 1-y interval. BR patients within the 40-54 mg/dL range had the highest rate of infection (90 d: 30.1%; 1 y: 53.4%). There was a statistically higher incidence of infection among patients with preoperative hypoglycemia (<70 mg/dL). CONCLUSIONS: The incidence of infection remains high in preoperatively hyperglycemic patients undergoing breast reconstruction procedures. However, our results show that preoperatively hypoglycemic patients also have an increased incidence of infection.

Spotlight on the Linx™ Reflux Management System for the treatment of gastroesophageal reflux disease: evidence and research.

BACKGROUND: The initial approach to gastroesophageal reflux disease (GERD) management typically involves lifestyle modification and medical therapy utilizing acid reducing agents such as histamine blockers and proton pump inhibitors. In severe cases refractory to such treatments, surgical therapy may be indicated. The gold standard for surgical treatment of GERD is the laparoscopic Nissen fundoplication. In recent years, a new technique known as magnetic sphincter augmentation (MSA) has been developed using the Linx™ Reflux Management System. This is an implantable ring of magnetic beads that is placed around the esophagus at the gastroesophageal junction to restore lower esophageal integrity. The aim of this review is to discuss the current literature regarding indications, surgical technique, efficacy, and complications of MSA using the Linx device. METHODS: A standardized literature search was performed yielding 367 abstracts. After elimination due to duplicates between databases and irrelevance, 96 articles remained. The information found to be significant and non-redundant was included in this review. CONCLUSION: After several years of clinical application, the Linx device has been shown to not only be effective for the management of GERD but also be as effective as fundoplication. With respect to safety, the most common complication of MSA is dysphagia. This often resolved without intervention, but esophageal dilation or device explanation are occasionally necessary. Not fully appreciated in earlier reviews, erosion of the device into the esophagus appears to be the most significant complication of the device after extended follow-up. While very rare, the potentially severe consequences of this phenomenon suggest that the device should be used with some restraint and that patients should be made aware of this potential morbidity. Fortunately, in the few cases of device erosion described in the literature reviewed, the Linx device was easily and safely removed.

An Extradigital Glomus Tumor of the Median Antebrachial Vein.

Glomus tumors are benign vascular neoplasms that arise from specialized dermal arteriovenous anastomoses called glomus bodies. These tumors are most often found in the digital pulp and subungual region of the fingertips; however, a review of the literature suggests that extradigital glomus tumors may occur more often than is generally recognized. Although most extradigital glomus tumors arise within subcutaneous tissues, glomus tumors have occasionally been found within bones, nerves, and blood vessels. An intravascular glomus tumor of the forearm is a very rare occurrence and only a few cases have been reported in the literature. Here we describe a 55-year-old right-handed man with a 10-year history of exquisite tenderness and dysesthesia of his right proximal forearm. Surgical exploration revealed the presence of a mass arising from the median antebrachial vein, which was confirmed histologically to be a glomus tumor.