Reducing the incidence of surgical site infection after ventral hernia repair: Outcomes from the RINSE randomized control trial.

BACKGROUND: The clinical and financial impact of surgical site infection after ventral hernia repair is significant. Here we investigate the impact of dual antibiotic irrigation on SSI after VHR. METHODS: This was a multicenter, prospective randomized control trial of open retromuscular VHR with mesh. Patients were randomized to gentamicin â€‹+ â€‹clindamycin (G â€‹+ â€‹C) (n â€‹= â€‹125) vs saline (n â€‹= â€‹125) irrigation at time of mesh placement. Primary outcome was 30-day SSI. RESULTS: No significant difference was seen in SSI between control and antibiotic irrigation (9.91 vs 9.09 â€‹%; p â€‹= â€‹0.836). No differences were seen in secondary outcomes: SSO (11.71 vs 13.64 â€‹%; p â€‹= â€‹0.667); 90-day SSO (11.1 vs 13.9 â€‹%; p â€‹= â€‹0.603); 90-day SSI (6.9 vs 3.8 â€‹%; p â€‹= â€‹0.389); SSIPI (7.21 vs 7.27 â€‹%, p â€‹= â€‹0.985); SSOPI (3.6 vs 3.64 â€‹%; p â€‹= â€‹0.990); 30-day readmission (9.91 vs 6.36 â€‹%; p â€‹= â€‹0.335); reoperation (5.41 vs 0.91 â€‹%; p â€‹= â€‹0.056). CONCLUSION: Dual antibiotic irrigation with G â€‹+ â€‹C did not reduce the risk of surgical site infection during open retromuscular ventral hernia repair.

Assessing Patient-Reported Experiences for In-Person and Telemedicine-Based Preoperative Evaluations.

Background: The COVID-19 pandemic has transformed health care delivery through the rise of telehealth solutions. Though telemedicine-based care has been identified as safe and feasible in postoperative care, data on initial surgical consultations in the preoperative setting are lacking. We sought to compare patient characteristics, anticipated downstream care utilization, and patient-reported experiences (PREs) for in-person versus telemedicine-based care conducted for initial consultation encounters at a hernia and abdominal wall center. Methods: Patients evaluated at an abdominal wall reconstruction center from August 2021 to August 2022 were prospectively surveyed. Patient characteristics, anticipated downstream care utilization, and PREs were compared. Results: Of the 176 respondents, 50.6% (n = 89) utilized telemedicine-based care and had similar demographic and disease characteristics to those receiving in-person care. Telemedicine-based care saved a median of 47 min [interquartile range 20-112.5 min] of round-trip travel time per patient, with 10.1% of encounters resulting in supplemental in-person evaluation. A large proportion of telemedicine-based and in-person encounters resulted in recommendations for operative intervention, 38.2% versus 55.2%, respectively. Indirect costs of care were significantly lower for patients utilizing telemedicine-based services. Patient satisfaction related to encounters was non-inferior to in-person care. Overall, the majority of patients responded that they preferred future care to be delivered via telemedicine-based services, if offered. Conclusions: Preoperative telemedicine-based care was associated with significant cost-savings over in-person care related with comparable patient satisfaction. Health systems should continue to dedicate resources to optimizing and expanding perioperative telemedicine capabilities.

Bedside vs webside: Assessing patient-reported experiences for in-person and telemedicine-based perioperative evaluations.

BACKGROUND: Though telemedicine has been identified as safe and feasible, data on patient reported experiences (PREs) are lacking. We sought to compare PREs between in-person and telemedicine-based perioperative care. METHODS: Patients evaluated from August-November 2021 were prospectively surveyed to assess experiences and satisfaction with care rendered during in-person and telemedicine-based encounters. Patient and hernia characteristics, encounter related plans, and PREs were compared between in-person and telemedicine-based care. RESULTS: Of 109 respondents (86% response rate), 55% (n = 60) utilized telemedicine-based perioperative care. Indirect costs were lower for patients using telemedicine-based services, including work absence (3% vs. 33%, P < 0.001), lost wages (0% vs. 14%, P = 0.003), and requirements for hotel accommodations (0% vs. 12%, P = 0.007). PREs related to telemedicine-based care were non-inferior to in-person care across all measured domains (P > 0.4). CONCLUSIONS: Telemedicine-based care yields significant cost-savings over in-person care with similar patient satisfaction. These findings suggest that systems should focus on optimization of perioperative telemedicine services.

Perioperative Telemedicine Utilization Among Geriatric Patients Being Evaluated for Abdominal Wall Reconstruction and Hernia Repair.

Introduction: Perioperative telemedicine services have increasingly been utilized for ambulatory care, although concerns exist regarding the feasibility of virtual consultations for older patients. We sought to review telemedicine encounters for geriatric patients evaluated at a hernia repair and abdominal wall reconstruction center. Methods: A retrospective review of telemedicine encounters between May 2020 and May 2021 was performed. Patient characteristics and encounter-specific outcomes were compared among geriatric (older than65 years old) and nongeriatric patients. Clinical care plans for encounters were reviewed to determine potential downstream care utilization. Patient-derived benefits related to time saved in travel time was calculated using geo-mapping. Outcomes for postoperative encounters were assessed to determine if complication rates differed between geriatric and nongeriatric populations. Results: A total of 313 telemedicine encounters (geriatric: 41.9%) were conducted among 251 patients. Reviewing preoperative factors for hernia care, geriatric patients presented with higher rates of recurrent or incisional hernias (87.9% vs. 70.7%, p < 0.01). Potential travel time was longer for geriatric patients (104 min vs. 42 min, p = 0.03) in the preoperative setting. No differences in clinical care plans were found. Only 8.6% of preoperative encounters resulted in recommendations for supplemental in-person evaluation. Operative plans were coordinated for 42.5% of all preoperative telemedicine encounters. There was no difference in complication rate between geriatric and nongeriatric patients (p > 0.05) in the postoperative setting, with no complications directly attributable to telemedicine-based care. Conclusions: Telemedicine-based evaluations appear to function well among geriatric patients seeking hernia repair and abdominal wall reconstruction. Clinical care plans rendered following telemedicine-based encounters are appropriate with a low rate of supplemental in-person evaluations. Telemedicine use resulted in significantly more time saved in commuting to and from clinic for geriatric patients.

Patient-performed at-home surgical drain removal is safe and feasible following hernia repair and abdominal wall reconstruction.

BACKGROUND: Traditionally, surgical drains are considered a relative contraindication to telemedicine-based postoperative care. We sought to assess the safety, feasibility, and outcomes of an at-home patient-performed surgical drain removal pilot program. METHODS: A prospective cohort study among patients who were discharged with surgical drains was performed. Patients discharged with drains were given the option for in-clinic, provider-performed removal, or at-home, patient-performed drain removal. Patient demographics, health characteristics, perioperative metrics, and operative outcomes were compared and analyzed. RESULTS: A total of 68 encounters with drain removal were included (at-home: 28%, n = 19; in-clinic: 72%, n = 49), with both groups having similar demographics, except for age (median age of telemedicine-based at-home: 50 vs in-clinic: 62 years, p = 0.03). Patients who opted into at-home, patient-performed drain removal were more likely to have drain removal occur earlier (9 vs 13 days for in-clinic, p < 0.001). In-clinic removal resulted in increased encounters with surgical nursing staff and increased travel time, with no significant difference in complication burden. CONCLUSIONS: Patient-performed at-home drain removal is safe and allows for more timely drain removal.

Outcomes of Telemedicine-Based Consultation among Rural Patients Referred for Abdominal Wall Reconstruction and Hernia Repair.

BACKGROUND: Perioperative telemedicine use has increased as a result of the COVID-19 pandemic and may improve access to surgical care. However, studies assessing outcomes in populations at risk for digital-health disparities are lacking. We sought to characterize the pre- and postoperative outcomes for rural patient populations being assessed for hernia repair and abdominal wall reconstruction with telehealth. METHODS: Patients undergoing telehealth evaluation from March 2020 through May 2021 were identified. Rurality was identified by zip code of residence. Rural and urban patients were compared based on demographics, diagnosis, treatment plan, and visit characteristics and outcomes. Downstream care use related to supplementary in-person referral, and diagnostic testing was assessed. RESULTS: Three hundred-seventy-three (196 preoperative, 177 postoperative) telehealth encounters occurred during the study period (rural: 28% of all encounters). Rural patients were more likely to present with recurrent or incisional hernias (90.0 vs 72.7%, p = 0.02) and advanced comorbidities (American Society of Anesthesiologists status score > 2: 73.1 vs 52.1%, p = 0.009). Rural patients derived significant benefits related to time saved commuting, with median distances of 299 and 293 km for pre- and postoperative encounters, respectively. Downstream care use was 6.1% (N = 23) for additional in-person evaluations and 3.4% (N = 13) for further diagnostic testing, with no difference by rurality. CONCLUSIONS: Perioperative telehealth can safely be implemented for rural populations seeking hernia repair and may be an effective method for reducing disparities. Downstream care use related to additional in-person referral or diagnostic testing was minimally impacted in both the preoperative and postoperative settings. These findings suggest that rurality should not deter surgeons from providing telemedicine-based surgical consultation for hernia repair.

Outcomes for audio-only and video-based preoperative encounters for abdominal wall reconstruction and hernia consultations.

BACKGROUND: Digital health is commonly utilized for surgical evaluation, however little is known regarding the relative effectiveness of audio-only and video-based encounters. METHODS: A retrospective analysis of all patients undergoing preoperative digital health encounters at a hernia center from March 2020-May 2021 was conducted. Visit types were dichotomized to audio-only and video-based encounters. Downstream care utilization and visit-specific outcomes were analyzed. RESULTS: 204 preoperative digital health encounters were conducted during the study period. Audio-only encounters were more commonly performed for patients classified as older and rural. Supplemental in-person examinations were required among 13.5% and 4.0% of new- and established-patient encounters, respectively, with no significant difference between audio-only and video-based assessments. Finalized operative plans were coordinated for 43.6% of patients, with no significant difference among groups. CONCLUSIONS: Patients being evaluated with audio-only encounters are more likely to be older and reside in rural settings, yet demonstrate no significant difference in downstream care utilization and clinic encounter outcomes relative to those being evaluated via video-based assessment. Enabling audio-only surgical consultations may minimize disparities in digital care.

A National Evaluation of Surgeon Experiences in Telemedicine for the Care of Hernia and Abdominal Core Health Patients.

BACKGROUND: Surgeons are increasingly utilizing telemedicine to provide perioperative services to patients. Safety, satisfaction, and feasibility of these programs in general populations have been established, but it is unclear how telemedicine can be integrated into subspecialty care. We report results of a national survey related to telehealth practices among members of the Abdominal Core Health Quality Collaborative (ACHQC). METHODS: Survey responses were analyzed to determine current strategies in telemedicine utilization. Surgeon preferences, perceptions of validity, and identified barriers to implementation of telemedicine were assessed. RESULTS: Forty surgeons within the ACHQC responded, with 90% of respondents reporting use of telemedicine to deliver perioperative care to patients with hernias and abdominal core health concerns. Surgeons appeared to be more comfortable managing preoperative patients with image-confirmed diagnoses of hernias. Surgeons were universally more comfortable delivering postoperative care via telemedicine. Connectivity, patient engagement, and reimbursement were identified as potential barriers to expansion of telemedicine. Seventy-eight percent of respondents reported that they would increase telemedicine utilization if current regulations were maintained in the future. CONCLUSIONS: This study found that hernia specialists are utilizing telemedicine at a higher rate than before the COVID-19 pandemic, with surgeons reporting interest in continued use of this modality beyond the pandemic. These findings suggest that future work in telemedicine optimization may improve the quality of care that can be delivered to patients with abdominal core health concerns.

Abdominal Wall Reconstruction Risk Stratification Tools: A Systematic Review of the Literature.

BACKGROUND: Ventral hernias are a common pathology encountered by surgeons. Multiple risk stratification tools have been developed in attempts to predict a patient's postoperative risk for complication. The aim of this systematic review was to identify published stratification tools, to assess their generalizability, and develop an ensemble risk score model. METHODS: A systematic review of the literature was performed using PubMed and following the PRISMA guidelines. Two independent reviewers identified articles describing hernia stratification tools or validating an established tool. Inclusion criteria included articles that studied ventral hernia risk score models developed through expert consensus or from data of at least 500 subjects, performed a multivariable analysis of at least 500 patients, or assessed a previously reported model. Studies were grouped by primary outcome, and the odds ratios for correlated variables were compiled. Outcomes described in 4 or more articles were then stacked to generate a cumulative risk score model for patients undergoing abdominal wall repair. RESULTS: A total of 20 articles were found to meet our inclusion criteria and used to develop our ensemble model. Surgical-site infection, surgical-site occurrence, and hernia recurrence were the 3 primary outcomes used to calculate our stacked cumulative risk stratification score. CONCLUSIONS: There are multiple risk score tools published; however, all have their strengths and limitations. For this reason, we created a composite score model with data from major articles to predict a patient's risk for postoperative complications. This model aims to ease the shared-decision making process for patients, surgeons, and institutions.

Enhanced Recovery Pathway for Complex Abdominal Wall Reconstruction.

Ventral hernia repair with abdominal wall reconstruction can be a challenging endeavor, as patients commonly present not only with complex and recurrent hernias but also often with comorbidities that increase the risk of postoperative complications including wound morbidity and hernia recurrence, among other risks. By optimizing patient comorbidities in the preoperative setting and managing postoperative care in a regimented fashion, enhanced recovery after surgery pathways allow for a systematic approach to reduce complications and speed up recovery following ventral hernia repair.

Stapled Transabdominal Ostomy Reinforcement with retromuscular mesh (STORRM): Technical details and early outcomes of a novel approach for retromuscular repair of parastomal hernias.

BACKGROUND: Parastomal hernia repair (PHR) remains a challenge with no optimal repair technique. During retromuscular hernia repair, traversing the stomal conduit through the abdominal wall can result in angulation and compression. Widening of traditional cruciate incisions in mesh and/or fascia likely contributes to recurrences. To address these pitfalls, the Stapled Transabdominal Ostomy Reinforcement with Retromuscular Mesh (STORRM) technique utilizing a circular stapler was developed. METHODS: A prospective registry of consecutive patients undergoing STORRM was analyzed. We characterized demographics, hernia characteristics, and perioperative results. Primary outcomes were complications, surgical site events (SSEs) and hernia recurrence. RESULTS: 12 patients underwent PHR with STORRM; mean age 64 and BMI 36 kg/m2. Synthetic mesh was used in 92% of patients. We observed two (17%) SSEs, one case of cellulitis and one organ space infection. With mean 12.8-month follow-up, we documented two recurrences. CONCLUSIONS: STORRM represents a safe method to repair parastomal hernias. The unified aperture with stapled reinforcement results in reproducible repairs, minimizing intestinal angulation associated with traditional stoma passage. Early outcomes evidenced minimal complications and favorable recurrence rate.

Outcomes of Posterior Component Separation With Transversus Abdominis Muscle Release and Synthetic Mesh Sublay Reinforcement.

OBJECTIVE: To evaluate the safety and efficacy of transversus abdominis muscle release (TAR) with retrorectus synthetic mesh reinforcement in a large series of complex hernia patients. BACKGROUND: Posterior component separation via TAR during abdominal wall reconstruction (AWR) continues to gain popularity. Although our early experience with TAR has been promising, long-term outcomes have not been reported. METHODS: From December 2006 to December 2014, consecutive patients undergoing open AWR utilizing TAR were identified in our prospectively maintained database and reviewed retrospectively. Main outcome measures included demographics, perioperative details, wound complications, and recurrences. RESULTS: During the study period, 428 consecutive TAR procedures were analyzed. Mean age was 58, with mean body mass index 34.4 kg/m (range 20-65). Major comorbidities included diabetes (21%), chronic obstructive pulmonary disease (12%), and immunosuppression (3%). Mean hernia defect area was 606 cm (range 180-1280) and average mesh size was 1220 cm (range 600-4500). The majority of cases (66%) were clean, 26% were clean-contaminated, and 8% were contaminated. Eighty (18.7%) surgical-site events occurred, of which 39 (9.1%) were surgical-site infections. Three patients required mesh debridement; however, no instances of mesh explantation occurred. Of the 347 (81%) patients with at least 1-year follow-up (mean 31.5 mo), there were 13 (3.7%) recurrences. CONCLUSIONS: Complex AWR represents a formidable surgical challenge. In this large series, we demonstrated that posterior component separation via TAR with wide synthetic mesh sublay provides a very durable repair with low morbidity, even in comorbid patients with large defects. We strongly advocate TAR as a robust addition to the armamentarium of reconstructive surgeons.

Risk factors for wound morbidity after open retromuscular (sublay) hernia repair.

BACKGROUND: Retrorectus repairs (RR) of abdominal wall hernias are growing in popularity, yet wound morbidity and predictors in this context have been characterized poorly. Models aimed at predicting wound morbidity typically do not control for technique and/or location of mesh. Our aim was to describe wound morbidity and risk factors specifically in the context of RR hernia repair. Our hypothesis was that the incidence of wound morbidity with mesh sublay would be less than predicted by a model that does not control for mesh position. METHODS: Consecutive RR hernia repairs with at least a 90-day follow-up were identified in our prospective database and analyzed. The primary outcome measures were the incidence of surgical-site occurrence (SSO) and surgical-site infection (SSI) via modern, standardized definitions. For predictors of SSO, statistical analysis was performed with univariate analysis, χ(2), and logistic regression as well as multivariate regression. RESULTS: A total of 306 patients met the inclusion criteria. Eighty-four SSOs identified in 72 (23.5%) patients included 48 (15.7%) SSIs, 14 (4.6%) instances of wound cellulitis, 12 (3.9%) skin dehiscences, 6 (2.0%) seromas, and 4 (1.3%) hematomas but no instances of mesh excision or fistula formation. Treatment entailed antibiotics alone in 30 patients, 14 bedside drainage procedures, 9 radiographically assisted drainage procedures, and 10 returns to the operating room for debridement. After multivariate analysis, diabetes (OR 2.41), hernia width >20 cm (OR 2.49), and use of biologic mesh (OR 2.93) were statistically associated with the development of a SSO (P < .05). Notably, the mere presence of contamination was not independently associated with wound morbidity (OR 1.83, P = .11). SSO and SSI rates anticipated by a recent risk prediction model were 50-80% and 17-83%, respectively, compared with our actual rates of 20-46% and 7-32%. CONCLUSION: Based on a large cohort of patients, we identified factors contributing to SSOs specifically for RR hernia repairs. Paradoxically, biologic mesh was an independent predictor of wound morbidity. The development of clinically important mesh complications and rates of wound morbidity less than anticipated by recent predictive models suggest that the retromuscular (sublay) mesh position may be more advantageous.

Transversus abdominis muscle release for repair of complex incisional hernias in kidney transplant recipients.

BACKGROUND: Incisional hernias in kidney transplant recipients (KTRs) can be complex because of adjacent bony structures, proximity of the allograft/transplant ureter, and context of immunosuppression. We hypothesized that our novel posterior component separation with transversus abdominis muscle release (TAR) and retromuscular mesh reinforcement offers a safe and durable repair. METHODS: KTRs with incisional hernias repaired using the aforementioned technique were identified within our prospective database (2007 to 2013) and analyzed. RESULTS: Eleven patients were identified (median age 49 years, body mass index 32). The median hernia size was 30 cm(2) (range 88 to 1,040 cm(2)) and 8 of the 11 patients were recurrent. Intraoperative morbidity consisted of one transplant ureter injury repaired primarily over a stent. Postoperative morbidity consisted of 2 superficial surgical site infections that resolved and 1 readmission for a blood transfusion. There were no instances of mesh infection, explantation, graft loss, or graft dysfunction. With a median follow-up of 12 months (range 3 to 69), 1 (9%) lateral recurrence has been documented. CONCLUSIONS: For complex incisional hernias in KTRs, TAR is associated with low perioperative morbidity and durable repair.

Real-time cadaveric laparoscopy and laparoscopic video demonstrations in gross anatomy: an observation of impact on learning and career choice.

Medical curricula are continually evolving and increasing clinical relevance. Gross anatomy educators have tested innovations to improve the clinical potency of anatomic dissection and found that clinical correlations are an effective method to accomplish this goal. Recently, surgical educators defined a role for laparoscopy in teaching anatomy. We aimed to expand this role by using surgical educators to create clinical correlates between gross anatomy and clinical surgery. We held supplements to traditional anatomy open dissection for medical students, including viewing prerecorded operative footage and live laparoscopic dissection performed on cadavers. The main outcome measures were assessed through pre- and postsession surveys. Greater than 75 per cent of students found the demonstrations highly valuable, and students perceived a significant increase in their understanding of abdominopelvic anatomy (P < 0.01). Additionally, 62 per cent of students with previous interest in surgery and 10 per cent of students without previous interest in surgery reported increased interest in pursuing surgical careers. Our demonstrations advance the use of minimally invasive surgical technology to teach gross anatomy. Live laparoscopic demonstrations augment traditional anatomic instruction by reinforcing the clinical relevance of abdominopelvic anatomy. Additionally, laparoscopic demonstrations generate interest in surgery that would otherwise be absent in the preclinical years.

Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy.

INTRODUCTION: Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients who have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients who have undergone POEM and compare outcomes between patients who have or have not received previous treatment for achalasia. METHODS AND PROCEDURES: We evaluated our prospectively collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and postoperative GERD-Health-Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring. RESULTS: Forty patients received a POEM procedure between 2011 and 2013. Of these, 40% (n = 16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 min for patients with prior procedures (Prior Tx) and 118 min for patients without any prior procedure (No Tx) (p = 0.07). Intraoperative complication rates for the Prior Tx group were 12.5 versus 16.7% for the No Tx group. Mean follow-up was 10 months. Both groups independently demonstrated clinical improvement in both the GERD-HRQL and SF-12 scores following POEM. There were no statistical differences between the two groups for GERD-HRQL reflux and dysphagia subset scores, or SF-12 mental component summary. CONCLUSION: We found favorable outcomes following POEM in patients who have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no significant differences between these two groups with regards to operative times, GERD-HRQL scores, and mental component SF-12 scores. One complication requiring intervention occurred in a patient that had received multiple prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.

Retrograde myotomy: a variation in per oral endoscopic myotomy (POEM) technique.

BACKGROUND: Per oral endoscopic myotomy (POEM) has evolved as a novel therapeutic option for the treatment of esophageal motility disorders such as achalasia. The originally described dissection technique involves cutting the inner circular esophageal muscle fibers in an antegrade fashion. We have modified this technique by commencing the muscular division at the most distal aspect of the submucosal tunnel and continuing the dissection in a retrograde fashion. We present our initial series of patients performed using this modified technique. METHODS: We retrospectively reviewed our prospectively collected database. Peri- and postoperative data were collected and analyzed. POEM procedures were performed in a near-identical manner as previously published. RESULTS: Retrograde myotomy was performed on five patients with a diagnosis of achalasia. Four had a history of prior treatment including balloon dilation, with one of these having a prior surgical myotomy. Retrograde POEM procedures were performed with trace blood loss and without any complications. Mean operative time was 85 min. All patients had normal esophagram studies, and diets were advanced as per protocol. CONCLUSION: POEM was developed as a minimally invasive method for the treatment of achalasia. Our retrograde dissection modification allows the most critical portion of the case, namely division of the lower esophageal and upper gastric circular muscle fibers, to be performed earlier in the case. This ensures adequate dissection of the primary site of esophageal dysfunction should problems arise during the procedure. The modification is straightforward, without the need for additional training or equipment, and appears to provide a more rapid myotomy with less charring in this small cohort of patients.

Technical aspects of bile duct evaluation and exploration.

Choledocholithiasis is a common manifestation of biliary disease. Intraoperative cholangiography can be performed in several ways. Common bile duct exploration can be safely performed but necessitates an advanced level of surgical experience to limit complications and improve success. An algorithm based on available resources and the physician skill set is vital for safe and effective management of choledocholithiasis. Endoscopic retrograde cholangiopancreatography requires the availability of an advanced endoscopist as well as significant equipment and resources. Current training of young surgeons is limited for open biliary procedures and common bile duct explorations. Educational guidelines are necessary to reduce this educational gap.

Laparoscopic placement of adjustable gastric band in patients with autoimmune disease or chronic steroid use.

BACKGROUND: Past medical or family history of autoimmune diseases and patient chronic steroid use are label contraindications for laparoscopic placement of adjustable gastric band (LAGB). We reviewed our experience with placement of LAGB in patients with autoimmune disease or chronic steroid use. METHODS: This was a retrospective review of our prospective bariatric database. All patients who underwent LAGB and had a diagnosis of autoimmune disease or chronic steroid use with at least 1-year follow-up data were included in the study. Data on demographics, weight loss, and complications were collected. RESULTS: Sixteen patients with autoimmune diseases or chronic steroid use underwent LAGB. Diseases included were lupus (n = 6), sarcoidosis (n = 4), renal transplant (n = 2), rheumatoid arthritis (n = 1), ulcerative colitis (n = 1), Grave's disease (n = 1), and celiac disease (n = 1). No patients developed infectious complications. One patient required port replacement due to malfunction, and one patient underwent a conversion to gastric bypass due to failure of weight loss. The average preoperative body mass index was 46.8 kg/m(2) with an average weight of 292.0 lbs. Average excess weight loss was 39.8 % (range, 7.4 to 95.5 %) at a median follow-up of 54 months. CONCLUSIONS: Our review indicates that LAGB in patients with autoimmune diseases or chronic steroid use is safe, with no infectious complications and only one explant. Some of these autoimmune conditions may improve following significant weight loss, but larger studies are required to further substantiate these findings.