Outcomes of laparoscopic modified Cellan-Jones repair versus open repair for perforated peptic ulcer at a community hospital.

INTRODUCTION: Minimally invasive or open Graham Patch repair remains the gold standard approach for management of perforated peptic ulcers (PPU). Herein, we report outcomes of laparoscopic technique and compare it with open approach at a community hospital. METHODS: Retrospective observational study conducted comparing laparoscopic modified Cellan-Jones repair (mCJR) versus the standard open repair of PPU. Patients aged 18-90 years during 2016-2021 were offered either a minimally invasive or open approach depending on surgeon laparoscopic capability, and were compared in terms of demographics, co-morbidities, intra-operative details, and short-term outcomes. RESULTS: A total of 49 patients were included (46.9% males, mean age 52.9 years, mean BMI 25.0, ASA ≥ III 75.5%, 75.5% smokers, 26.5% current NSAIDs use, and 71.4% alcohol drinkers). Duodenum was the most common perforation site (57.1%), and majority of ulcers were 1-2 cm (72.9%). Laparoscopic approach was performed in 16 consecutive patients (32.7%) by a single surgeon, with no conversions. Preoperative characteristics were similar for both groups. Compared to open approach, laparoscopic group were taken to operation immediately (< 4 h) (87.5% vs. 15.2%, p < 0.001), had lower estimated blood loss (11.8 ml vs. 73.8 ml, p = 0.063), and longer operative time (117.1 min vs. 85.6 min, p = 0.010). Postoperatively, nasogastric tube was removed earlier in laparoscopic group (POD1-2, 87.5% vs. 24.2%, p = 0.001), with earlier resumption of diet (POD1-2, 62.6% vs. 9.1%, p = 0.002), less narcotic usage (< 3 days, 58.3% vs. 6.1%, p < 0.001), earlier return of bowel function (POD1-2, 43.8% vs. 9.1%, p = 0.003) and shorter length of stay (LOS) (3.7 days vs. 16.1 days, p < 0.001). Both in-house mortality and morbidity rates were lower in the laparoscopic group, but not statistically significant [(0% vs. 6.1%, p = 0.347) and (12.5% vs. 39.4%, p = 0.500), respectively]. CONCLUSION: Laparoscopic mCJR is a feasible method for repair of PPU, and it is associated with shorter LOS, and less narcotics usage in comparison to the open repair approach.

Near infrared perfusion assessment of gastric conduit during minimally invasive Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic leak and conduit necrosis are devastating complications following Ivor Lewis esophagectomy. Near infrared imaging (NIR) using IndoCyanine Green allows for real time tissue perfusion assessment which may reduce anastomotic leak during minimally invasive Ivor Lewis esophagectomy (MIE). METHODS: Forty consecutive MIE were performed by a single surgeon at a tertiary referral center. The first 20 were assessed for gastric conduit perfusion by clinical criteria (Group 1). The second 20 were also assessed using NIR laparoscopic system (Group 2). RESULTS: Comparing Group 1 to Group 2, no significant differences were found in overall complication rate, readmission or reoperation rate. NIR resulted in resection of the non perfused proximal portion of the conduit in 30% (6/20). Two patients in group 2 group developed anastomotic leak (2/20) compared to 0 in Group 1 (p = 0.49). Graft necrosis led to one mortality in Group 1, while there were 0 mortalities in Group 2. (p = 1.0). CONCLUSION: Although NIR plays a role in assessment of tissue perfusion, in our study its use did not result in reduction of anastomotic leak rate.

Salutary effect of calcium channel blockade following hypoxic and septic insult.

BACKGROUND: Intestinal ischemia and reperfusion is a major problem associated with a high morbidity and mortality following trauma and hemorrhagic shock. Apoptosis is the major mode of cell death following reperfusion. The cytoskeleton damage precedes the apoptotic final microscopic features. Calcium plays a central role in apoptosis. Therefore, we studied whether verapamil could preserve the function of the cytoskeleton in an in vitro intestinal model following hypoxia-reoxygenation (H/R). Our goal was to assess mainly the cytoskeleton functions, which includes IgA transport and the cell monolayer barrier integrity. METHODS: Confluent HT29 intestinal monolayers grown in a two-chamber cell culture system were held under hypoxic (5% CO2) conditions for 90 minutes followed by normoxia (21% O2) (H/R). Cell subsets were exposed to lipopolysaccharide (10 µg/mL) before H/R. Verapamil (8 µM) was added to HT29 cell subsets after H/R treatment. Dimeric IgA was added to the basal compartment, and apical media were sampled at intervals to quantitate IgA transcytosis using enzyme-linked immunosorbent assay. HT29 cells held under normoxic conditions served as controls. HT29 permeability to FD4 was assessed at the end of each experiment. In a separate experiment, HT29 cells were stained for F actin using rhodamine-labeled phalloidin. RESULTS: Intestinal monolayer permeability was increased following treatment with H/R and/or lipopolysaccharide. Verapamil treatment prevented increased permeability in HT29 cells and led to an increase in IgA transport. Disruption of actin microfilaments was demonstrated following H/R insult but was abrogated by the addition of verapamil following H/R insult. CONCLUSION: Reperfusion can lead to both physical and immune derangement of epithelial cell barrier function. Verapamil may be important in preserving gut barrier function. Additional studies including in vivo confirmation in animal shock models are needed to validate these findings.

Estrogen modulation of pneumonia? An immunoglobulin A effect.

BACKGROUND: Laboratory and clinical studies demonstrated a salutary effect of estradiol (E2) on pneumonia and other infectious complications after trauma, while dihydrotestosterone (DHT) failed to show a similar effect. Secretory immunoglobulin A is the principle antibody in the respiratory and other mucosal secretions. Immunoglobulin A (IgA) production and transport into the mucosal secretion is regulated by Toll-like receptor 4 (TLR-4). In addition, E2 may influence immune regulatory cells via TLR-4. We hypothesized that the protective effect of E2 on the development of pneumonia may be related to modulation of IgA transport into respiratory secretions. METHODS: Calu-3 respiratory epithelial cell monolayers were established in a two-chamber cell culture system. Calu-3 cells were then treated with either E2 or DHT for 3 days for maximal cell stimulation. Dimeric IgA was added to the basal chamber of Calu-3 cells, and IgA transcellular transport was indexed by recovery of secretory immunoglobulin A in the apical chamber media. In separate experiments, Klebsiella pneumonia (10(5) CFU/mL) was added to the apical chamber of treated Calu-3 cell monolayers, and bacterial passage across Calu-3 cells was determined by bacterial recovery from the basal chamber. Calu-3 cells not treated with E2 or DHT served as control. RESULTS: Calu-3 cells pretreated with E2 significantly increased IgA transport, and this effect was augmented in a dose-dependent fashion. Only cells pretreated with E2 significantly decreased bacterial passage, and this effect was exhibited in a dose- and time-dependent fashion. E2 led to a significant increase in TLR-4 expression. CONCLUSION: The protective effect of E2 against pneumonia may be related to augmented transport of IgA into the respiratory mucosal secretions.