Total Parathyroidectomy Without Autotransplantation for ESRD Patients With Secondary Hyperparathyroidism; an Effective Alternative.

BACKGROUND: The most common operations performed for secondary hyperparathyroidism include subtotal parathyroidectomy (STPX) and total parathyroidectomy with autotransplantation (TPX + AT). We present a series of ESRD patients treated with total parathyroidectomy without autotransplantation (TPX). METHODS: This is a retrospective cohort analysis of ESRD patients, age 18 years or older, with three or more glands resected on final pathology and follow-up parathyroid hormone levels obtained up to 1.5 years postoperatively. The primary endpoint was recurrence of hyperparathyroidism (defined as PTH > 500 pg/mL). RESULTS: The incidence of recurrent hyperparathyroidism at 1.5 years was 5.9% (2/34). The incidence of persistent hyperparathyroidism at 1.5 years was 11.8% (4/34). In this series, no patients were hospitalized for symptomatic hypocalcemia or experienced pathologic bone fractures. CONCLUSIONS: Recurrence rates are low with TPX. The most common cause of recurrent and persistent disease is resection of three rather than four glands. The known complications of TPX, pathologic fractures, and severe hypocalcemia, were not seen in this study.

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.

Design of a comparative outcome analysis of open, laparoscopic, or robotic-assisted incisional or inguinal hernia repair utilizing surgeon experience and a novel follow-up model.

BACKGROUND: In a recent publication, the International Guidelines for Groin Hernia Management by the European Hernia Society (EHS) recognized the need to individualize and tailor the surgical approach for hernia repair. There may be different opportunities for optimization of the surgical technique for surgeons performing open, laparoscopic, or robotic-assisted hernia repair. Robotic-assisted hernia repair is a relatively new minimally invasive surgical approach compared to laparoscopic and open repair. Currently, there is a lack of comparative prospective studies designed to evaluate long-term outcomes of patients undergoing robotic-assisted, laparoscopic, or open hernia repair. MATERIALS & METHODS: This manuscript presents an innovative study design with two study cohorts (incisional and inguinal hernia repair) that contain three arms (robotic-assisted, laparoscopic, and open). The trial objective is to collect short-term and long-term outcomes for patients undergoing robotic-assisted, laparoscopic, or open hernia repair. The present publication will discuss the trial design, methods used to ensure consistency in surgeon expertise, and provides strategies to obtain long-term (> 3 months) follow-up data for enrolled patients. RESULTS: One hundred subjects underwent incisional and one hundred underwent inguinal hernia repair at the time of this manuscript. Surgeon experience was analyzed across the three surgical techniques and follow-up compliance was assessed through 1 year. The follow-up completion rates for both study cohorts were >80% for all visits. CONCLUSIONS: The innovative trial design helped to improve the quality and quantity of long-term follow-up. More innovative options to improve patient retention may be tested in future trials of similar design.

Novel Technique for Full-Thickness Abdominal Wall Closure in Laparoscopic Ventral Hernia Repair.

Laparoscopic ventral hernia repair incorporating a prosthetic mesh underlay, first described in 1993, has demonstrated a lower long-term recurrence rate versus open non-mesh repair. However, over the past 25 years, the laparoscopic approach to ventral/incisional hernias is utilized in only approximately 30% of cases. One of the reasons that prevents it from being utilized more often is the inability to readily, reliably, and easily close the fascial defect. A novel technique has been developed for full-thickness abdominal wall closure in laparoscopic ventral hernioplasty, utilizing puncture sites to place multiple self-locking ligature straps. Introduction of the straps into the abdominal cavity in orthogonal orientation to the skin surface, followed by subcutaneous retrieval of the contralateral tip of the strap, achieves incorporation of full-thickness abdominal wall on either side of the defect. The self-locking property of each strap allows tension to be applied in sequential fashion. Incremental tension application facilitates re-apposition of the borders in large defects. The increased width of the strap compared with conventional suture serves to resolve the force exerted upon tissue during the acute phase of defect closure. The instrumentation was tested in six ventral hernias created in resected porcine belly walls. Subsequent tests were conducted in three swine with large congenital umbilical hernias. One of the test animals was re-examined laparoscopically 30 days post repair, with full healing and no recurrence exhibited upon re-examination. We anticipate that the simplicity and functionality of this technique will translate to clinical utility in the significant cohort of human ventral hernia patients.

Insufflation Effects on the Abdominal Wall Dimensions and Incisional-Ventral Hernia Orifice Size.

The possibility that ventral hernia orifice size may increase with insufflation at the time of laparoscopic ventral hernia repair has a number of consequences, including mesh size used and trocar placement. We measured ventral hernia orifice defects intraoperatively at 8 mm Hg and 15 mm Hg for comparison. We also took measurements of the external abdominal wall at various points to determine the relationship between insufflation and the abdominal wall externally. Of 39 patients measured, we found a mean increase of 3.7 mm in the hernia defect transversely and 2.9 mm vertically. The external measurements showed correlation with insufflation pressure, as expected. The transverse measurements across the mid-abdomen showed a mean increase of 5 mm from 0 to 8 mm Hg insufflation and a full additional centimeter when insufflation was increased from 8 to 15 mm Hg. We were able to detect and quantify an increase in hernia defect size with insufflation, but the increase is so small it is unlikely to be clinically significant in the management of surgical patients.

Initial Experience with Robotic Hernia Repairs: A Review of 150 Cases.

BACKGROUND: Robotic-assisted surgery has proved to be a valuable modality in specialties such as urology and gynecology and has gained wide acceptance in those fields. Its value in general surgery, however, has had a slower acceptance rate among surgeons. This study reviews my first 150 cases using the robot for one of the most common general surgery operations-the repair of hernias. MATERIALS AND METHODS: All robotic hernia cases performed by a single surgeon were documented in an Excel? (Microsoft Corporation, Redmond, Washington) spreadsheet beginning in April, 2014. Data recorded included patient diagnosis, hernia defect size, mesh type and size, console time and total operative time, as well as first assistant (fellow, resident, or none). The postoperative course was carefully reviewed through the electronic medical record to identify complications and readmissions. RESULTS: The average total case time was 138 minutes, while the average console time was 100 minutes. Incisional hernias made up 50.4% of the procedures, inguinal hernias-17.2%, ventral/umbilical-9.8%, parastomal-9.2%, lumbar-5.5%, hiatal-4.9%, and spigelian-2.5%. The average defect size was 48.47cm2. Complication rates were low at 5.3%, most of which were minor. There were no mortalities. There has been one known hernia recurrence. CONCLUSIONS: This review shows that the use of the robot has proven to be safe and effective, and it has many benefits in hernia repair. One of those benefits is the ability to close the fascial defect with a running suture, thus avoiding the postoperative pain associated with transfascial sutures. The ability to intracorporeally fix a large piece of mesh to the abdominal wall that adequately and evenly covers the defect is another benefit. The high-quality three-dimensional view and the ability to articulate the instruments are well-established benefits of the robot as well. Robotic assistance also allows us to perform a minimally invasive hernia repair on large complex defects that would have otherwise been performed via an open approach.

A multicenter prospective study of patients undergoing open ventral hernia repair with intraperitoneal positioning using the monofilament polyester composite ventral patch: interim results of the PANACEA study.

PURPOSE: This study assessed the recurrence rate and other safety and efficacy parameters following ventral hernia repair with a polyester composite prosthesis (Parietex™ Composite Ventral Patch [PCO-VP]). PATIENTS AND METHODS: A single-arm, multicenter prospective study of 126 patients undergoing open ventral hernia repair with the PCO-VP was performed. Patient outcomes were assessed at discharge and at 10 days, 1, 6, 12, and 24 months postoperative. RESULTS: All patients had hernioplasty for umbilical (n = 110, 87.3%) or epigastric hernia (n = 16, 12.7%). Mean hernia diameter was 1.8 ± 0.8 cm. Mean operative time was 36.2 ±15.6 minutes, with a mean mesh positioning time of 8.1 ± 3.4 minutes. Surgeons reported satisfaction with mesh ease of use in 95% of surgeries. The cumulative hernia recurrence rate at 1 year was 2.8% (3/106). Numeric Rating Scale (NRS) pain scores showed improvement from 2.1 ± 2.0 at preoperative baseline to 0.5 ± 0.7 at 1 month postoperative (P < 0.001), and this low pain level was maintained at 12 months postsurgery (P < 0.001). The mean global Carolina's Comfort Scale® (CCS) score improved postoperatively from 3.8 ± 6.2 at 1 month to 1.6 ± 3.5 at 6 months (P < 0.001). One patient was unsatisfied with the procedure. CONCLUSION: This 1-year interim analysis using PCO-VP for primary umbilical and epigastric defects shows promising results in terms of mesh ease of use, postoperative pain, and patient satisfaction. Recurrence rate is low, but, as laparoscopic evaluation shows a need for patch repositioning in some cases, an accurate surgical technique remains of utmost importance.

Energy Metabolic Adaptation and Cardiometabolic Improvements One Year After Gastric Bypass, Sleeve Gastrectomy, and Gastric Band.

CONTEXT: It is not known whether the magnitude of metabolic adaptation, a greater than expected drop in energy expenditure, depends on the type of bariatric surgery and is associated with cardiometabolic improvements. OBJECTIVE: To compare changes in energy expenditure (metabolic chamber) and circulating cardiometabolic markers 8 weeks and 1 year after Roux-en-y bypass (RYGB), sleeve gastrectomy (SG), laparoscopic adjustable gastric band (LAGB), or a low-calorie diet (LCD). Design, Setting, Participants, and Intervention: This was a parallel-arm, prospective observational study of 30 individuals (27 females; mean age, 46 ± 2 years; body mass index, 47.2 ± 1.5 kg/m2) either self-selecting bariatric surgery (five RYGB, nine SG, seven LAGB) or on a LCD (n = 9) intervention (800 kcal/d for 8 weeks, followed by weight maintenance). RESULTS: After 1 year, the RYGB and SG groups had similar degrees of body weight loss (33-36%), whereas the LAGB and LCD groups had 16 and 4% weight loss, respectively. After adjusting for changes in body composition, 24-hour energy expenditure was significantly decreased in all treatment groups at 8 weeks (-254 to -82 kcal/d), a drop that only persisted in RYGB (-124 ± 42 kcal/d; P = .002) and SG (-155 ± 118 kcal/d; P = .02) groups at 1 year. The degree of metabolic adaptation (24-hour and sleeping energy expenditure) was not significantly different between the treatment groups at either time-point. Plasma high-density lipoprotein and total and high molecular weight adiponectin were increased, and triglycerides and high-sensitivity C-reactive protein levels were reduced 1 year after RYGB or SG. CONCLUSIONS: Metabolic adaptation of approximately 150 kcal/d occurs after RYGB and SG surgery. Future studies are required to examine whether these effects remain beyond 1 year.

Next Generation Mesh Fixation Technology for Hernia Repair.

Laparoscopic ventral hernia repair (LVHR) remains a safe, reproducible, and popular method employed by surgeons to repair abdominal wall hernias. Patient selection, operative technique, instrumentation, and implant choice all remain surgeon dependent. Inherent in the technique is the option of using mesh. The decision of where to place the mesh and how to optimally fixate the mesh in the onlay, sublay, or intraabdominal positions also remain surgeon dependent and has been the subject of ongoing debates for the past two decades. In an ongoing effort to develop new methods for securing mesh to minimize pain without increased recurrence rates, novel mesh fasteners and mesh textiles have been developed. With increasing surgeon responsibility to improve value, surgeons should concentrate more on choosing the novel options that not only improve outcomes, but also reduce overall costs. This chapter reviews some of the emerging markets for these technologies.

The effects of transoral incisionless fundoplication on chronic GERD patients: 12-month prospective multicenter experience.

PURPOSE: This study aimed to assess the impact of transoral incisionless fundoplication (TIF) on patients with chronic gastroesophageal reflux disease (GERD) at 12-month follow-up. METHODS: Clinical outcomes of 100 consecutive patients with chronic GERD who underwent TIF between January 2010 and February 2011 were analyzed. RESULTS: There were no major complications reported. Esophageal acid exposure was normalized in 14/27 (52%) of patients who underwent 12-month pH testing. Seventy-four percent of all patients were off proton pump inhibitors versus 92% on daily proton pump inhibitors before TIF, P<0.001. Daily bothersome heartburn and regurgitation symptoms were eliminated in 66/85 (78%) and 48/58 (83%) of patients. Median reflux symptom index score was reduced from 20 (0 to 41) to 5 (0 to 44), P<0.001. Two patients reported de novo dysphagia and 1 patient reported bloating (scores 0 to 3). Six patients underwent revision; 5 laparoscopic Nissen fundoplication and 1 TIF. CONCLUSIONS: TIF provided a safe and effective therapeutic option for carefully selected patients with chronic GERD.

Comparison of Stromal/Stem Cells Isolated from Human Omental and Subcutaneous Adipose Depots: Differentiation and Immunophenotypic Characterization.

The emerging field of regenerative medicine has identified adipose tissue as an abundant source of stromal/stem cells for tissue engineering applications. Therefore, we have compared the differentiation and immunophenotypic features of adipose-derived stromal/stem cells (ASC) isolated from either omental or subcutaneous adipose depots. Human tissue samples were obtained from bariatric and plastic surgical practices at a university-affiliated teaching hospital and a private practice, respectively, with informed patient consent. Primary cultures of human ASC were isolated from adipose specimens within 24 h of surgery and culture expanded in vitro. The passaged ASC were induced to undergo adipogenic or osteogenic differentiation as assessed by histochemical methods or evaluated for surface antigen expression profiles by flow cytometry. ASC yields per unit weight of tissue were comparable between omental and subcutaneous depots. At passage 0, the immunophenotype of omental and subcutaneous ASC were not significantly different with the exception of CD105 and endoglin, a component of the transforming growth factor ß receptor. The adipogenic differentiation of omental ASC was less robust than that of subcutaneous ASC based on in vitro histochemical and PCR assays. Although the yield and immunophenotype of ASC from omental adipose depots resembled that of subcutaneous ASC, omental ASC displayed significantly reduced adipogenic differentiation capacity following chemical induction. Further studies are necessary to evaluate and optimize the differentiation function of omental ASC in vitro and in vivo. Pending such analyses, omental ASC should not be used interchangeably with subcutaneous ASC for regenerative medical applications.

The radiologic appearance of prosthetic materials used in hernia repair and a recommended classification.

OBJECTIVE: This article analyzes radiopaque properties of meshes currently used in hernia surgery. A search was conducted using PubMed and a combination of the terms "hernia repair," "mesh," "laparoscopy," "CT," "MRI," "radiopaque," and "high-resolution techniques." CONCLUSION: The visibility of meshes varies from not visible at all (e.g., Ultrapro), to hardly discernible (Prolene), to readily seen (Composix), and finally to the always visible (Dualmesh). Radiopaque properties of meshes have been insufficiently recognized by both the manufacturers and clinicians.

Inguinal hernias: diagnosis and management.

Inguinal hernias are one of the most common reasons a primary care patient may need referral for surgical intervention. The history and physical examination are usually sufficient to make the diagnosis. Symptomatic patients often have groin pain, which can sometimes be severe. Inguinal hernias may cause a burning, gurgling, or aching sensation in the groin, and a heavy or dragging sensation may worsen toward the end of the day and after prolonged activity. An abdominal bulge may disappear when the patient is in the prone position. Examination involves feeling for a bulge or impulse while the patient coughs or strains. Although imaging is rarely warranted, ultrasonography or magnetic resonance imaging can help diagnose a hernia in an athlete without a palpable impulse or bulge on physical examination. Ultrasonography may also be indicated with a recurrent hernia or suspected hydrocele, when the diagnosis is uncertain, or if there are surgical complications. Although most hernias are repaired, surgical intervention is not always necessary, such as with a small, minimally symptomatic hernia. If repair is necessary, the patient should be counseled about whether an open or laparoscopic technique is best. Surgical complications and hernia recurrences are uncommon. However, a patient with a recurrent hernia should be referred to the original surgeon, if possible.

Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common co-morbidity identified in obese patients. It is well established that patients with GERD and morbid obesity experience a marked improvement in their GERD symptoms after Roux-en-Y gastric bypass. Conflicting data exist for adjustable laparoscopic gastric banding and GERD. Laparoscopic sleeve gastrectomy (LSG) has become a popular adjunct to bariatric surgery in recent years. However, very little data exist concerning LSG and its effect on GERD. METHODS: A retrospective chart review was performed of 176 LSG patients from January 2006 to August of 2009. The preoperative and postoperative GERD symptoms were evaluated using follow-up surveys and chart review. RESULTS: Of the 176 patients, 85.7% of patients were women, with an average age of 45 years (range 22-65). The average preoperative body mass index was 46.6 kg/m(2) (range 33.2-79.6). The average excess body weight lost at approximately 6, 12, 24 months was calculated as 54.2%, 60.7%, and 60.3%, respectively. Of the LSG patients, 34.6% had preoperative GERD complaints. Postoperatively, 49% complained of immediate (within 30 d) GERD symptoms, 47.2% had persistent GERD symptoms that lasted >1 month after LSG, and 33.8% of patients were taking medication specifically for GERD after LSG. The most common symptoms were heartburn (46%), followed by heartburn associated with regurgitation (29.2%). CONCLUSION: In the present study, LSG correlated with the persistence of GERD symptoms in patients with GERD preoperatively. Also, patients who did not have GERD preoperatively had an increased risk of postoperative GERD symptoms.

Complex hernia repair using component separation technique paired with intraperitoneal acellular porcine dermis and synthetic mesh overlay.

Repairing complicated, recurrent ventral hernias poses many challenges and frustrations for both the patient and the surgeon. Patients with histories of multiple abdominal procedures, infection, and previous hernia repair are at higher risk for recurrence. They must be dealt with through a more sophisticated approach than the patient presenting with an initial hernia or even a simple recurrence. We describe our experience with 18 patients using component separation technique paired with acellular porcine dermis. We specifically focus on the use of intraperitoneal biologic mesh paired with a synthetic overlay. There were no hernia recurrences during the follow-up period: average 14 months (range, 4-24 months, 100% follow-up). Complications included seromas, wound breakdown, and infection; several of these requiring reoperation. The successful management of complicated hernias has been revolutionized by new synthetic and bioprosthetic meshes. However, these products, when used alone in complex hernia patients carry a higher recurrence rate. We have found that these meshes, used in conjunction with component separation technique, have had no recurrence to date, but are prone to complications.

Spigelian hernia as a cause of small bowel obstruction.

Spigelian hernia is a rare abdominal wall defect usually appearing between the abdominal muscle lateral to the rectus abdominis and through a debilitated spigelian aponeurosis. Spigelian hernias account for 0.12% to 2.4% of all abdominal wall hernias with a 17-24% risk of strangulation. We report the case of a 77-year-old male that presented with small bowel obstruction with incarcerated spigelian hernia which was successfully treated with a Ventralex hernia patch (Bard Access Systems, Inc., Murray Hill, NJ). A small open incision over the incarcerated hernia was a safe and effective method of repairing an incarcerated spigelian hernia in an urgent fashion.

Laparoscopic sleeve gastrectomy: our first 100 patients.

BACKGROUND: Laparoscopic sleeve gastrectomy is becoming a popular procedure for the morbidly obese patient. Its utilization as a standalone procedure has good results with weight loss in short- and midterm reports. The aim of this study was to assess our technique and whether it warranted any modifications in the early postoperative period. METHODS: Our first 100 consecutive patients undergoing laparoscopic sleeve gastrectomy were retrospectively reviewed. Data analysis was conducted at 3 and 6 months to assess the percentage of excess body weight loss and comorbidity status change. RESULTS: The percentage of excess body weight loss at the 3- and 6-month marks was 34.2% and 49.1%, respectively. Comorbidities were also improved at the 3- and 6-month marks. Hypertension resolved in 38%, hyperlipidemia resolved in 19%, and diabetes in 46%. Complication rate during the first 6 months was 10%. Major complications included 2 patients with postoperative bleeding, 2 patients with acute renal failure from dehydration, and 1 postoperative bleeding patient who developed a gastric fistula. No surgical reintervention was required for any complication. CONCLUSION: Our technique is a safe method that is easily reproducible and does not require any modification. Laparoscopic sleeve gastrectomy is an excellent surgical option with a low complication rate.

Enterotomy and mortality rates of laparoscopic incisional and ventral hernia repair: a review of the literature.

Laparoscopic incisional and ventral hernia (LVIH) repair is becoming more popular throughout the world. Although individual series have presented their own information, few data have been collected to identify the risk of the most serious complication, enterotomy. A literature review has identified this to occur in 1.78% of patients who undergo this procedure. Large bowel injury represents only 8.3% of these injuries. Eighty-two percent of the time, these injuries will be recognized and repaired. In the majority of published series in which this occurred, the hernia repair was completed with a laparoscopically placed prosthesis, as only 43% were converted to the open procedure. Complications related to this approach are infrequent. The mortality rate of this operation was noted to be 0.05%. However, if an enterotomy occurred, it increased to 2.8%. A recognized enterotomy was associated with a mortality rate of 1.7%, but an unrecognized enterotomy had a rate of 7.7%. Careful technique and close inspection of the intestine at the completion of the adhesiolysis and the herniorrhaphy is recommended. If the hernia repair proceeds as planned following repair of enterotomy, continuation of antibiotics and the placement of an antimicrobial impregnated prosthesis are recommended. More study is necessary before firm recommendations can be made, as the majority of these events are most likely unreported. Safety concerns may require postponement of the hernia repair if an enterotomy occurs.

Incisional hernia repair: laparoscopic techniques.

Repair of incisional hernias using the laparoscopic technique has continued to evolve since its inception in 1991. An analysis of the current literature has revealed that hernias as large as 1600 cm2 have been successfully repaired with this method. The average size appears to be about 105 cm2. Several choices of a biomaterial are available today, differing in the type of synthetic product or products that are used to manufacture them. Others incorporate an absorbable component. The goal of all of them is to prevent adhesion formation. The fixation devices that can be used are also varied. The results of laparoscopic incisional hernia repair are described. The conversion rate of these procedures is an impressive 2.4% with an enterotomy rate of 1.8%. These results affirm the low risk of this operation. The recurrence rate of 4.2% confirms the permanence of the repair. This procedure may become the standard of care in the near future.