Management of the Crura During Laparoscopic Sleeve Gastrectomy.

METHODS: This is a retrospective cohort study that evaluated patients undergoing LSG performed by a single surgeon in a 7-year period. Data were collected via chart review. The primary endpoint was hiatal hernia presence at 5 years post-operatively. Secondary endpoints included post-procedural complications (nausea, vomiting, dysphagia, or reflux) at 30 days post-operatively. RESULTS: A total of 361 patients were included in the analysis: 154 without crural closure, 164 primary crural closure, and 43 primary crural closure with mesh reinforcement. Rates of hiatal hernia occurrence at 5 years were 9.7% (no closure), 14.0% (primary closure), and 16.3% (closure with mesh reinforcement), respectively, and did not differ significantly among the 3 cohorts (P = .37). Overall rates of 30-day complications were 11.5%, 21.5%, and 28.6%, respectively (P = .015). CONCLUSION: Rates of hiatal hernia after sleeve gastrectomy do not differ, regardless of management of the crura. In addition, and perhaps more significantly, avoidance of crural closure was associated with fewer 30-day complications. In fact, the highest rate of 30-day complications was seen in the group that received closure with mesh reinforcement. These data suggest that crural closure during LSG should be avoided. Further prospective study of these findings is warranted.

Predicting Successful Laparoendoscopic Transhiatal Esophagectomy (THE) by Mediastinal Height Measurement.

BACKGROUND: Laparoendoscopic transhiatal esophagectomy (THE) provides advantages over traditional THE by not only avoiding laparotomy but by also allowing more precise esophageal mobilization. Occasionally, the length of the gastric conduit is insufficient to allow delivery into the neck after laparoscopic mobilization and requires laparotomy to complete the procedure. We hypothesize that the need for laparotomy will correlate with the measurement of mediastinal height (distance from thoracic vertebrae T1-T12) on chest CT. METHODS: Medical records of all patients who underwent attempted laparoendoscopic-assisted THE at a tertiary referral center between March 1, 2003 and January 31, 2019 were reviewed. Patients' mediastinal height was measured using computed tomography (CT) imaging of the chest by investigators and analyzed for correlation between mediastinal height and successful completion of a totally laparoendoscopic procedure. RESULTS: A total of 21 cases met inclusion criteria: 9 successful laparoendoscopic THE procedures and 12 failed laparoendoscopic THE procedures (those requiring addition of a mini-laparotomy or thoracotomy). The mean mediastinal length for successful laparoendoscopic surgery was 23.5 cm, whereas the mean mediastinal length for failed laparoscopic surgeries was 24.8 cm (P = .03). Patient's overall height was not found to correlate with the need for conversion. CONCLUSIONS: Shorter mediastinal length is associated with successful laparoendoscopic or laparoscopic THE. This information is readily available to clinicians from routine preoperative staging studies (chest CT) and may be used to potentially predict the success rate of a totally laparoendoscopic approach and aid in patient selection. Further prospective evaluation of these findings is warranted.

Substance Abuse-Related Soft Tissue Infections: A Uniquely Complicated Subset of a Common Problem.

We hypothesize that soft tissue infections (SSIs) related to intravenous drug usage (IVDU) are associated with a more complicated and costly course than those not associated with IVDU. For the period 2005-2018, ICD 9/ICD 10 billing codes were used to identify patients admitted with SSIs and their causes/complications and associated costs. IVDU-related infections were then compared with non-IVDU-related infections. t test was used to compare treatment costs and length of stay. Logistic regression analysis was used to assess the likelihood/risk of specific events in the IVDU versus non-IVDU populations. Of 47,281 patients admitted with SSIs, 1323 were associated with IVDU. IVDU-related patients tended to be younger (36.2 vs 49.3 years, P = 0.001). Both cost and length of stay were significantly greater in the IVDU group ($30,471 vs $16,020, P = 0.001; 5.7days vs 3.7days, P = 0.001). In addition, IVDU admissions were more likely to be associated with chronic blood-borne infections (hepatitis B/C, HIV, P = 0.001) and a significantly greater incidence of secondary infectious complications, including endocarditis (P = 0.001), bacteremia (P = 0.001), and osteomyelitis (P = 0.003). SSI admissions related to IVDU are a unique subgroup of patients. These patients not only have longer and more costly lengths of stay but are also at higher risk for secondary complications such as chronic blood-borne viral illness and secondary bacterial infectious complications, such as bacteremia, endocarditis, and osteomyelitis. Further prospective study of these findings is warranted as we continue to battle the growing problem of IVDU in the United States.