Laparoscopic Heller Myotomy With EGD and Balloon Dilation: A Durable Solution for Achalasia.

BACKGROUND: Laparoscopic Heller myotomy (LHM) and esophageal balloon dilation (BD) are the two mainstays of achalasia treatment-this study examines the outcomes when they are performed simultaneously without fundoplication. METHODS: All patients undergoing LHM&BD were reviewed for demographic and procedural data, and to see if additional procedures for achalasia had been performed. Patients were surveyed using the Eckardt score and the GERD quality-of-life score (GERD-HRQL) to assess the durability of repair. RESULTS: From 2013-2020, 66 patients underwent LHM&BD. There were no esophageal perforations and a median LOS of 1 day. Seven patients have required additional operations or procedures at median 4-years follow up. 31 patients (47%) responded to the survey. The average Eckardt score was 2.9 (goal<4) with mean GERD-HRQL of 14.4 (goal<25). CONCLUSIONS: LHM&BD allows for a safe, durable repair of achalasia. Reflux symptoms are manageable with PPI without fundoplication and the re-intervention rate similar to published values.

Contamination of hybrid hernia meshes compared to bioresorbable Phasix™ Mesh in a rabbit subcutaneous implant inoculation model.

BACKGROUND: Hybrid hernia meshes combine biological tissue-derived extracellular matrix with permanent or resorbable synthetic. The objective of this study was to evaluate hybrid meshes (Gore® Synecor, Zenapro™, Ovitex™ 1S Reinforced Bioscaffold Permanent, and Ovitex™ 1S Reinforced Bioscaffold Resorbable) compared to non-hybrid, bioresorbable synthetic mesh (Phasix™ Mesh) in a rabbit bacterial inoculation model. MATERIALS AND METHODS: Subcutaneous pockets were bilaterally created in male, New Zealand White rabbits (n = 25). Circular meshes (3.8 cm diameter) were implanted and inoculated with 1 × 106 colony forming units (CFU) of clinically-isolated methicillin-resistant Staphylococcus aureus (MRSA). A given animal received a single mesh type. Seven days post-inoculation, animals were euthanized and white material and microbial colonization were assessed by abscess scoring and CFU quantification, respectively. Non-parametric Kruskal-Wallis with Dunn's post-hoc tests compared results for different meshes. RESULTS: Phasix™ Mesh and Synecor exhibited significantly lower abscess scores than Zenapro™, Ovitex™ 1S Permanent, and Ovitex™ 1S Resorbable (p < 0.05). All pocket swabs for Zenapro™ and Ovitex™ meshes were positive for MRSA (100%), with 20% of Synecor and 0% Phasix™ Mesh. Microbial colonization was significantly lower for Phasix™ Mesh (0 CFU) relative to Zenapro™ (6.73 × 107 CFU (median)), Ovitex™ 1S Permanent (7.87 × 107 CFU) and Ovitex™ 1S Resorbable (1.45 × 108 CFU), and for Synecor (0 CFU) relative to both Ovitex™ meshes. Phasix™ Mesh was the only device with no detectable abscess or microbial colonization. CONCLUSION: Phasix™ Mesh demonstrated no detectable abscess or microbial colonization at 7-days post-implantation and inoculation, in contrast with four hybrid meshes, which all demonstrated colonization in a rabbit bacterial inoculation model.

Biomechanical Comparison of Fibrin Sealants for Mesh Fixation.

Adhesive use for fixation in hernia repair allows for complete and immediate mesh surface area adherence. Little is known about the fixation strengths of the products and application methods available. The purpose of this study was to compare the immediate and early strength of fixation of Tisseel™ and Evicel™ using hand and spray application techniques. Sixteen Mongrel swine underwent implantation of large-pore, mid-weight polypropylene mesh fixated with either Tisseel™ or Evicel™, applied by hand or with a spray apparatus. Time points studied were zero and four days. All samples underwent lap shear testing to quantify the strength of the mesh-tissue interface as an indicator of mesh fixation strength. Thirty Day 4 and 16 Day 0 samples were tested. Manually applied Tisseel™ mean fixation strength was 2.05 N/cm at Day 0 and 6.02 N/cm at Day 4. Sprayed Tisseel™ had mean fixation strength of 1.22 N/cm at Day 0 and 7.21 N/cm at Day 4. Manually applied Evicel™ showed mean fixation strength of 0.92 N/cm at Day 0 and 6.73 N/cm at Day 4. Mean fixation strength of sprayed Evicel™ was 0.72 N/cm at Day 0 and 6.70 N/cm at Day 4. Analysis of variance showed no difference between groups at Day 0 or Day 4. Immediate strength of mesh fixation could have significant implications for early recurrence and mesh contraction. This study demonstrates that no difference exists in immediate or early fixation strength between these two brands of sealants or their method of application.

Onlay with Adhesive Use Compared with Sublay Mesh Placement in Ventral Hernia Repair: Was Chevrel Right? An Americas Hernia Society Quality Collaborative Analysis.

BACKGROUND: The use of mesh during ventral hernia repair (VHR) is a well-accepted concept. However, the ideal location of mesh placement remains strongly debated. Although VHR with onlay mesh placement has historically been associated with a high rate of wound events, this surgical approach is technically less challenging than VHR with sublay mesh placement. The purpose of this study was to compare 30-day wound events after onlay mesh placement with adhesive fixation vs those after sublay mesh placement using the Americas Hernia Society Quality Collaborative database. STUDY DESIGN: All patients undergoing elective, open VHR with synthetic mesh placement from January 2013 through January 2016 were identified within the Americas Hernia Society Quality Collaborative. Only patients with clean wounds were included. Patients were divided into 2 groups: onlay mesh placement with the use of adhesive and sublay mesh placement. The association of mesh location with 30-day wound events was investigated using a matched analysis. RESULTS: A total of 1,854 patients met inclusion criteria; 1,761 (95.0%) underwent sublay mesh placement and 93 (5.0%) underwent onlay mesh placement with the use of adhesive. A 2:1 sublay to onlay matched analysis was performed based on factors previously shown to influence wound events after VHR. After matching, both groups had a lower mean Ventral Hernia Working Group grade and fewer associated comorbidities. There was no statistically significant difference between the sublay and onlay groups with respect to 30-day surgical site infections (2.9% vs 5.5%; p = 0.30), surgical site occurrences (15.2% vs 7.7%; p = 0.08), or surgical site occurrences requiring procedural intervention (8.2% vs 5.5%; p = 0.42). CONCLUSIONS: Ventral hernia repair with onlay mesh placement is a safe alternative to VHR with sublay mesh placement in low-risk patients. Additional studies are needed to determine the long-term mesh outcomes and recurrence rates in both of these groups.

Resection and Abdominal Wall Reconstruction of a Desmoid Tumor with Endometrioma Features.

Desmoid tumors are rare, musculoaponeurotic mesenchymal origin tumors arising from the proliferation of well-differentiated fibroblasts. Desmoid tumors may arise from any location with the abdominal cavity, abdominal wall and extremity locations being most frequent. We present the case of a 35-year-old female with a history of endometriosis who presented palpable abdominal mass and cyclic abdominal pain. Resection was performed for a presumed desmoid soft tissue tumor. Final pathology demonstrated desmoid histology admixed with abdominal wall endometriosis (endometrioma). This unique pathologic finding has only been rarely reported and is discussed with a brief review of the literature.

Sutureless onlay hernia repair: a review of 97 patients.

BACKGROUND: Repair of large ventral/incisional (V/I) hernias is a common problem. Outside of recurrence, other factors such as wound complications and mesh infection can create significant morbidity. Chevrel described the premuscular repair and later modified it by using glue over the midline closure. We previously described our onlay technique using fibrin glue alone in a small case series. The aim of this study is to review the largest case series of sutureless onlay V/I hernia repair whereby mesh is fixated with fibrin glue alone for complex ventral hernias, and how the technique has evolved. METHODS: All patients who underwent onlay V/I hernia repair over a 3-year period were reviewed. Patient demographics, operative details, complications, and follow-up were reviewed. RESULTS: In total, 97 patients were included. 54.6 % were female, with a mean age of 57.3 years. Mean BMI was 32.2. 23(23.7 %) patients had diabetes. 90 (92.8 %) of the operations were for incisional hernias, 3 (3.1 %) primary ventral hernias, 2 (2.1 %) flank hernias, and 2 (2 %) complex abdominal wall reconstruction. 88 (90.7 %) of the cases were performed on an elective basis. 77 (77.3 %) cases were classified as clean, 21 (21.6 %) clean-contaminated, and 1 (1.0 %) contaminated. The mean defect size was 150 cm(2). Mean follow-up was 386 days, and maximum was 3.1 years. There were 21 (21.6 %) seromas, 4 (4.1 %) wound infections, 7 (7.4 %) had skin necrosis, and 9 (9.3 %) required re-operation due to a complication. At 3 years, there have been no recurrences or mesh explants. CONCLUSIONS: The sutureless onlay V/I hernia repair with fibrin glue fixation has proven to be durable with a comparable complication profile to other techniques. The most common sequela, seroma, is easily managed in the outpatient setting. This sutureless technique is an effective option for onlay hernia repair that may provide several advantages over traditional suture techniques.

Fibrin Sealant: A Review of the History, Biomechanics, and Current Applications for Prosthetic Fixation in Hernia Repair.

The role of surgical adhesives in hernia repair has continued to evolve. The purpose of this chapter is to review the role of fibrin sealant and its application in general surgery for mesh fixation, specifically the history, biomechanics, and clinical utilization. The utilization of fibrin sealant for repair of groin hernias, both open and laparoscopic, ventral hernias, and hiatal hernias will be discussed.

Impact of intracranial pressure monitor prophylaxis on central nervous system infections and bacterial multi-drug resistance.

BACKGROUND: Routine intracranial pressure monitor (ICP) prophylaxis is not practiced at our institution. Nevertheless, some patients receive de facto prophylaxis as a result of the use of antibiotics for injuries such as open or facial fractures. We tested the hypothesis that prophylactic antibiotics do not reduce the incidence of central nervous system (CNS) infections but instead are associated with the acquisition of multi-drug resistant (MDR) bacterial infections. METHODS: Patients admitted to the trauma intensive care unit (TICU) from January, 2001 through December, 2004 with blunt, non-operative traumatic brain injury who were managed solely with an ICP monitor were identified from our trauma registry and divided into two groups: (1) Those receiving no antibiotics prior to or during ICP monitoring (NONE; n = 71); and (2) those already receiving antibiotics at the time of ICP monitor insertion (PRO; n = 84). Groups were stratified on the basis of age, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) Score, base excess (BE), ICP days, transfusions in 24 h, ICU days, ventilator days, head Abbreviated Injury Score (AIS), and chest AIS. The study groups did not differ with respect to age, ISS, GCS, BE, ICP days, 24-h transfusions, ICU days, ventilator days, head AIS, or length of stay. In all, 183 patients were identified, of whom 28 died within seven days and were excluded from the analysis. All patients were followed until discharge for both CNS infections and subsequent infectious complications. RESULTS: Only two patients, both in the PRO group, developed CNS infection. Both infectious complications (0.7 vs 1.4 per patient; p < 0.05) and infections secondary to MDR pathogens (0.03 vs. 0.33 per patient; p < 0.01) were significantly more common in the PRO group. Twenty-nine percent of the ventilator-associated pneumonias and 33% of the blood stream infections in the PRO group were MDR, whereas only two blood stream infections in the NONE group (4% of the total infections) were MDR. CONCLUSIONS: The routine use of prophylactic antibiotics for ICP monitor insertion is not warranted. This practice does not reduce the CNS infection rate and is associated with more MDR pathogens in any subsequent infectious complications.

The effect of endoscopic sinus surgery on symptoms of eustachian tube dysfunction.

BACKGROUND: The symptom of eustachian tube dysfunction has been categorized as a "minor" symptom in chronic rhinosinusitis. The aim of this pilot study was to determine the frequency of otologic symptoms in patients with confirmed rhinosinusitis and the likelihood of its resolution in those patients undergoing endoscopic sinus surgery (ESS). METHODS: Questionnaires were obtained from 168 patients who had undergone prior ESS over a 5-year period. Patients were asked to evaluate if they suffered from several different potential symptoms of eustachian tube dysfunction before ESS and whether that symptom changed postoperatively. RESULTS: Using the binomial test, 95% confidence intervals were determined for the following otologic symptoms of tubal dysfunction: "earfullness and congestion," "ear cracking and popping," "dizziness," and "ear pain. "ESS was found to have a significant treatment effect for the indicated otologic symptoms of tubal dysfunction. CONCLUSION: Tubal dysfunction, as manifested by otologic symptoms, is common in patients with chronic rhinosinusitis undergoing ESS. The classification of this as a "minor" symptom of rhinosinusitis needs to be reevaluated. These symptoms improve or resolve in the majority of patients undergoing ESS.