Effects of Spinal Deformities on Hiatal Hernia Occurrence and Recurrence.

BACKGROUND: Spinal deformities such as kyphosis, lordosis, and scoliosis have demonstrated a possible association between these deformities. Our hypothesis is that the presence of spinal deformities will increase the risk of hiatal hernia recurrence after repair. METHODS: The following data was retrospectively gleaned for patients undergoing hiatal hernia repair (1997-2022): age, sex, date of hiatal hernia repair, presence and type of spinal deformity, Cobb angle, type of hiatal hernia and size, type of hiatal hernia repair, recurrence and size, time to recurrence, reoperation, type of reoperation, and time to reoperation. RESULTS: Spinal deformities were present in 15.8% of 546 patients undergoing hiatal hernia repair, with a distribution of 21.8% kyphosis, 2.3% lordosis, 58.6% scoliosis, and 17.2% multiple. There was no difference in sex or age between groups. Spinal deformity patients were more likely to have types III and IV hiatal hernias (52.3% vs. 38.9%, p = 0.02) and larger hernias (median 5 [3-8] vs. 4 [2-6], p = 0.01). There was no difference in access, fundoplication use, or mesh use between groups. However, these patients had a higher recurrence rate (47.7% vs 30.0%, p = 0.001) and a shorter time to recurrence (months) (10.3 [5.6-25.1] vs 19.2 [9.8-51.0], p = 0.02). Cobb angle did not affect recurrence. CONCLUSIONS: Spinal deformity patients were more likely to have more complex and larger hiatal hernias. They were at higher risk of hiatal hernia recurrence after repair with shorter times to recurrence. This is a group that requires special attention with additional preoperative counseling and possibly use of surgical adjuncts in repair.

Severe Heat Stroke Resuscitation Using a Body Bag in a Community Emergency Department.

Heat stroke can lead to severe complications such as end-organ damage and death. The primary treatment modality for heat stroke is rapid cold-water immersion to lower the patient's body temperature. This typically requires a large bath to place the patient in, which may not be available in small or community emergency departments. Although rarely present in the literature, a body bag for cold-water immersion can be used if a bath is not available. Here, we present a case of a 63-year-old male who presented to the emergency department unresponsive with hyperthermia after a heat wave warning was issued. After a thorough workup and imaging, the patient was given IV saline and naloxone, which did not improve his condition. Therefore, the patient was placed in a body bag filled with cold water and ice until his body temperature reduced to 100°F, after which he was removed and closely monitored. The patient was safely discharged and only required repeat lab work three days after discharge. This case highlights a unique technique that emergency physicians can utilize in scenarios where a typical cold-water immersion setup and execution are not possible.

Novel Per-Oral Cricopharyngotomy for Cricopharyngeal Bar: Feasibility Study With Emphasis on Technical Limitations.

Per-oral endoscopic cricopharyngotomy (c-POEM) is a treatment for cricopharyngeal dysfunction, specifically cricopharyngeal bars (CPB). C-POEM differs from other endoscopic surgical procedures, such as per-oral endoscopic myotomy (POEM), gastric per-oral endoscopic myotomy (g-POEM), and Zenker per-oral endoscopic myotomy (z-POEM). We report three patients who underwent c-POEM for CPB, their clinical course, and outcomes. We underwent a single institution retrospective chart review of three patients who underwent c-POEM and their immediate postoperative course. These three patients represent all patients who underwent c-POEM. The operating surgeons were experienced endoscopists who regularly performed endoscopic myotomy. The three patients were female, over 50 years old, and presented with dysphagia secondary to the CPB. All three patients had perioperative complications consistent with esophageal leaks requiring prolonged hospital courses and recovery. All three patients had improved but persistent dysphagia up to nine months following the procedure. The results of this small case series exemplify the high rate of complications, specifically postoperative esophageal leak, when performing c-POEM for CPB. Thus, we stress caution and recommend against performing c-POEM for CPB.

Abdominal Wall Reconstruction After Extirpation of a 140-Pound Primary Ovarian Mucinous Adenocarcinoma.

Ovarian cancer is a feared diagnosis for women and clinicians alike. Ovarian mucinous adenocarcinoma is a unique subset of ovarian cancer. As a primary tumor, massive ovarian masses, and more specifically mucinous adenocarcinomas, have been infrequently reported in the medical literature. Team approaches to massive tumor extirpations are essential, as patients often require the expertise of various subspecialists including, but not limited to, gynecologic-oncologists, general surgeons, and plastic and reconstructive surgeons. Here we present a case of a 71-year-old woman with a massive, incapacitating pelvic mass, later found to be a primary ovarian mucinous adenocarcinoma. Once medically optimized, a multi-service team approach was utilized for tumor extirpation and abdominal wall reconstruction. Involved surgical services included Gynecologic-Oncology, General Surgery, and Plastic and Reconstructive Surgery. Exploratory laparotomy for tumor extirpation, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal stripping, bilateral inguinal lymphadenectomy, and appendectomy was performed. Extensively thin, devascularized, and attenuated abdominal wall fascia that was adherent to the tumor was removed. The abdominal wall defect was reconstructed and reinforced with inlay and overlays of biologic monofilament mesh. Inverted-T of the vertical and horizontal skin components was performed in a tailor-tacking fashion, assuring the maintenance and protection of the abdominal skin flap vascularity through utilizing the Huger Zones of perfusion. Pathology revealed a stage IA grade 2 mucinous adenocarcinoma of the ovary without evidence of metastasis. No adjuvant therapies were required. The tumor's weight was 140 pounds, and its dimensions were 63 x 41 x 40 cm. It is our hope that presenting this experience will raise awareness of this spectrum of diseases and allow for earlier diagnoses and treatments, as well as exemplify the virtues of a team-based approach in the successful extirpation and subsequent reconstruction of the abdominal wall and skin.

Primary Cutaneous Secretory Carcinoma: A Case Report and Literature Review.

Cutaneous secretory carcinomas (CSCs) are primary neoplasms of the skin that have been just recently described in the literature through case reports and series. In this case, a cutaneous lesion was found on the left temporal region of an 83-year-old male. He was referred to plastic surgery for complete excision, with negative margins confirmed by pathology. Histology, immunostaining, and genetic testing showed characteristics confirming the diagnosis of CSC and were supported by the information present in the current literature. Our patient showed no evidence of nodal disease or recurrence during regular follow-ups. Given the rarity of CSCs, we aim to present our experience regarding the diagnosis, pathological analysis, and management of our patient as well as summarize the present literature to further open avenues of research.

Prediction models in hernia repair: a systematic review.

BACKGROUND: Hernias can present with unique challenges when it comes to management and repair. Prediction models can be a useful tool for clinicians to better anticipate and understand the severity of a hernia, the type of surgical technique, or presurgical planning that may be required to treat the patient, and the risk of complications. Our goal is to evaluate and consolidate prediction models in hernia repair present in the literature for which physicians can reference to best improve patient outcomes and postoperative management. METHODS: We performed a literature search in PubMed using keywords, "rectus width to defect width ratio," "predicting myofascial release," "computed tomography hernia repair prediction," "component separation radiology prediction hernia," "fat volume and hernia repair," "body morphometrics and Query hernia repair," "body morphometrics and reherniation," "computed tomography findings and risk of emergency hernia repair," "loss of domain and hernia radiology," and "volumetry and hernia repair." We searched for publications that used radiographic parameters to predict hernia severity, interventions, and outcomes. RESULTS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found twenty-three studies related to prediction models in hernia repair published between 2000 and 2021. We summarized studies pertaining to predicting acute care, predicting operative planning with loss of domain and component separation, predicting complications, paraesophageal hernia predictions, and predicting postoperative respiratory complications. CONCLUSION: Radiographic prediction models can be an objective and efficient way for surgeons to analyze hernias and better understand a patient's situation so that they can inform patients about the best treatment options and the risk of complications.

Current State of Pleural-Directed Adjuncts Against Malignant Pleural Mesothelioma.

Multimodality therapy including surgical resection is the current paradigm in treating malignant pleural mesothelioma (MPM), a thoracic surface cancer without cure. The main limitation of all surgical approaches is the lack of long-term durability because macroscopic complete resection (R1 resection) commonly predisposes to locoregional relapse. Over the years, there have been many studies that describe various intrapleural strategies that aim to extend the effect of surgical resection. The majority of these approaches are intraoperative adjuvants. Broadly, there are three therapeutic classes that employ diverse agents. The most common, widely used group of adjuvants are comprised of direct therapeutics such as intracavitary chemotherapy (± hyperthermia). By comparison, the least commonly employed intrathoracic adjuvant is the class comprised of drug-device combinations like photodynamic therapy (PDT). But the most rapidly evolving (new) class with much potential for improved efficacy are therapeutics delivered by specialized drug vehicles such as a fibrin gel containing cisplatin. This review provides an updated perspective on pleural-directed adjuncts in the management of MPM as well as highlighting the most promising near-term technology breakthroughs.

Promising therapeutic potential of tumor suppressor microRNAs for malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is an aggressive and recalcitrant surface neoplasm that defies current multimodality treatments. MicroRNAs (miRNAs) are small noncoding RNAs that epigenetically regulate multiple gene networks and cellular processes. In cancer, miRNA dysregulation is associated with tumorigenesis, with tumor suppressor miRNAs underexpressed or lost, while oncogenic miRNAs are overexpressed. Consequently, miRNAs have emerged as potential therapeutic candidates. Because loss of tumor suppressors predominates the pathophysiology of MPM, re-expressing tumor suppressor miRNAs could be an effective therapeutic strategy. This review highlights the most promising MPM-specific tumor suppressor miRNAs that could be developed into novel therapeutics, the supporting data, and what is known about their molecular mechanism(s).

Characterization of Outcomes by Surgical Management of Lung Neuroendocrine Tumors Associated With Cushing Syndrome.

Importance: Ectopic adrenocorticotropic hormone secretion from lung tumors causing Cushing syndrome are associated with high rates of morbidity. Optimal management remains obscure because knowledge is based on rare reports with few patients. Objective: To characterize the outcomes of lung neuroendocrine tumors associated with Cushing syndrome. Design, Setting, and Participants: An observational case series review from 1982 to 2020 was conducted in a single institution referral center. Kaplan-Meier analysis estimated disease-free survival (DFS). Participants underwent curative-intent surgery for a lung neuroendocrine tumor causing Cushing syndrome. Exposures: Lobectomy or pneumonectomy vs sublobar resection. Main Outcomes and Measures: Disease-free survival, disease persistence/recurrence. Results: Of the 68 patients, the median age was 41 years (range, 17-80 years), 42.6% (29 of 68) were male, 81.8% (54 of 66) were White, with a mean follow-up after surgery was 16 months (range, 0.1-341 months). Lobectomy was the most common procedure (48 of 68 [70.6%]), followed by wedge resection (16 of 68 [23.5%]) and segmentectomy (3 of 68 [4.4%]). Video-assisted thoracoscopic surgery was performed in 19 of 68 (27.9%) of patients. Surgical morbidity was 19.1% (13 of 68), and perioperative mortality was 1.5% (1 of 68). Lymph node positivity was 37% (22 of 59) when evaluable. The overall incidence of persistence/recurrence was 16.2% (11 of 68) with a median time to recurrence of 55 months (range, 18-152 months). The median DFS was reached in 12.7 years (0.1-334 months). There were no statistical differences in DFS based on tumor size, stage (8th edition TNM), whether full systematic lymphadenectomy was performed or not, nodal status, or surgical approach. Conclusions and Relevance: In this case series study, neuroendocrine pulmonary tumors associated with Cushing syndrome had increased nodal metastasis, higher recurrence, and lower DFS than quiescent bronchopulmonary carcinoid tumors, but many patients experienced favorable outcomes. This observation is underscored by the discordance of TNM-stage classifications vs prognosis. Observing no difference in surgical techniques, the implication may be that a lung-sparing approach could suffice. These results may reflect the intrinsic importance of the hormone physiology instead of the carcinoid biologic factors.