Over-the-Scope-Clips Can Be Fired Safely Over a Guidewire: Proof of Concept in an Ex-Vivo Porcine Model.

Background and Objectives: To assist in achieving optimal position when deploying over-the-scope (OTS)-clips, the concept of cannulating the defect with a guidewire, backloading the endoscope onto the wire, and firing the OTS-clip over the wire with subsequent wire removal has been demonstrated. The safety of this technique has not been evaluated. Methods: An ex-vivo porcine foregut model was utilized. Biopsy punches were used to create 3-mm diameter full-thickness gastrointestinal tract defects through which a guidewire was threaded. An endoscope was backloaded over the wire and OTS-clips (OVESCO, Tuebingen, Germany) were fired over the mucosal defect and wire. The wire was removed through the endoscope and the removal difficulty was graded using a Likert scale. This process was repeated for each unique combination of nine OTS-clip types, two wire types, four wire angles, and three tissue types. Statistical analysis included t test and ANOVA. Results: Two hundred sixteen OTS-clip firings with wire removal attempts were performed with the following Likert score breakdown: 1 - No difficulty (80.6%), 2 - mild difficulty (16.2%), 3 - moderate difficulty (2.3%), 4 - extreme difficulty (0.9%), and 5 - unable to remove (0%). Statistically significant differences were noted in removal difficulty between OTS-clip sizes (p < 0.05). No differences were identified between clip teeth types, wire types, tissue types, and wire angles (p > 0.05). Conclusion: In this ex-vivo model, the guidewire was successfully removed through the endoscope in all cases. This technique can be employed to facilitate OTS-clip closure of gastrointestinal tract defects, but further study is indicated before wide clinical implementation.

Esophagogastric Junction Outflow Obstruction and Hiatal Hernia: Is Hernia Repair Alone Sufficient?

Introduction: Esophagogastric junction outflow obstruction (EGJOO) is attributed to primary/idiopathic causes or secondary/mechanical causes, including hiatal hernias (HH). While patients with HH and EGJOO (HH+EGJOO) may undergo HH repair without myotomy, it is unclear if an underlying motility disorder is missed by therapy which addresses only the secondary EGJOO cause. The goal of this study was to determine if HH repair alone is sufficient management for HH+EGJOO patients. Methods: A retrospective review of patients who underwent HH repair between January 1, 2016 and January 31, 2020 was performed. Patients who underwent high-resolution esophageal manometry(HREM) within one year before HH repair were included. Patients with and without EGJOO on pre-operative HREM were compared. Results: Sixty-three patients were identified. Pre-operative HREM findings included: 43 (68.3%) normal, 13 (20.6%) EGJOO, 4 (6.3%) minor disorder or peristalsis, 2 (3.2%) achalasia, and 1 (1.6%) major disorder of peristalsis. No differences between patients with EGJOO or normal findings on pre-operative manometry were found in pre-operative demographics/risk factors, pre-operative symptoms, and pre-operative HREM, except higher integrated relaxation pressure in EGJOO patients. No differences were noted in length of stay, 30-day complications, long-term persistent symptoms, or recurrence with mean follow-up of 26-months. Of the 3 (23.1%) EGJOO patients with persistent symptoms, 2 underwent HREM demonstrating persistent EGJOO and none required endoscopic/surgical myotomy. Conclusion: Most HH+EGJOO patients experienced symptom resolution following HH repair alone and none required additional intervention to address a missed primary motility disorder. Further study is required to determine optimal management of patients with persistent EGJOO following HH repair.

Paragastric Autonomic Neural Blockade to Prevent Early Visceral Pain and Associated Symptoms After Laparoscopic Sleeve Gastrectomy: a Randomized Clinical Trial.

BACKGROUND: Visceral pain (VP) following laparoscopic sleeve gastrectomy remains a substantial problem. VP is associated with autonomic symptoms, especially nausea and vomiting, and is unresponsive to traditional pain management algorithms aimed at alleviating somatic (incisional) pain. The present study was performed to evaluate the safety and effectiveness of laparoscopic paragastric autonomic neural blockade (PG-ANB) in managing the symptoms associated with VP following sleeve gastrectomy. STUDY DESIGN: This prospective, double-blinded, randomized clinical trial involved patients undergoing laparoscopic sleeve gastrectomy at two high-volume institutions. The patients were randomized to laparoscopic transversus abdominis plane block with or without PG-ANB. The primary outcome was patient-reported pain scores assessed at 1, 8, and 24 h postoperatively. The secondary outcome measures were analgesic requirements, nausea, vomiting, hiccups, and hemodynamic changes immediately after PG-ANB and postoperatively. RESULTS: In total, 145 patients (block group, n = 72; control group, n = 73) were included in the study. The heart rate and mean arterial pressure significantly decreased 10 min after PG-ANB. The visual analog scale score for pain was significantly lower in the PG-ANB than in the control group at 1 h postoperatively (p < 0.001) and 8 h postoperatively (p < 0.001). Vomiting, nausea, sialorrhea, and hiccups were significantly less prevalent in the PG-ANB group. Patients in the PG-ANB group received fewer cumulative doses of analgesics at 1 h postoperatively (p = 0.003) and 8 h postoperatively (p < 0.001). No differences between the groups were detected at 24 h (p = 0.298). No complications related to PG-ANB occurred. CONCLUSION: PG-ANB safely and effectively reduces early VP, associated autonomic symptoms, and analgesic requirements after laparoscopic sleeve gastrectomy.

Concomitant Anterior and Posterior Component Separations: Absolutely Contraindicated?

Many experts in abdominal wall reconstruction believe that the combination of simultaneous ipsilateral anterior component separation (ACS) and posterior component separation (PCS) is contraindicated. We performed ipsilateral endoscopic ACS and either endoscopic or open PCS-transversus abdominis release (TAR) in 5 fresh cadaver models. The full length of the semilunar line and the lateral abdominal wall remained well reinforced by 2 complete layers, comprising the internal oblique (IO) and TA muscles and their investing fasciae. Myofascial releases occurred 4 cm (median) apart. Additionally, we reviewed computed tomography images at 1 month and 1 year after PCS-TAR in 17 patients (30 PCS-TARs). Lateral displacement of the TA relative to the rectus abdominis (RA) was significant only at the superior mesenteric artery level, where it was <1 cm (median). Muscle mass changed minimally over time. Several studies showed that abdominal wall reconstruction after PCS-TAR results in compensatory muscular hypertrophy of the RA, external oblique (EO), and IO muscles and provides better quality of life and improved core physiology. These changes did not occur when the midline was not restored. Theoretically, endoscopic ACS-EO may be added to PCS-TAR to avoid partially bridged mesh repair in patients in whom complete midline restoration is impossible via PCS-TAR alone. Nevertheless, we advise most surgeons to perform a small-bridged repair instead of risking increased morbidity by attempting a highly complicated procedure.

Nonalcoholic Fatty Liver Disease as a High-Value Predictor of Postoperative Hyperglycemia and Its Associated Complications in Major Abdominal Surgery.

BACKGROUND: For patients undergoing major abdominal operations, acute postoperative hyperglycemia (POHG) is associated with suboptimal outcomes and higher costs of care. This study was performed to determine whether CT-derived indices of nonalcoholic fatty liver disease (hepatic steatosis) or visceral adiposity may serve as predictors of POHG and its consequences in such patients. STUDY DESIGN: We reviewed records and preoperative abdominal CT images of 129 patients undergoing complex open ventral hernia repair (cVHR) from 2012 to 2016, with 90-day follow-up. Univariate and multivariate regressions were performed to estimate associations between CT-detected steatosis or visceral adiposity with POHG (serum glucose > 140 mg/dL within 48 hours), surgical site occurrence (SSO), and subsequent interventions (SSO-I). RESULTS: Type-2 diabetes (T2D) was present in 23% and POHG in 52%; SSO events occurred in 28% and SSO-I in 21%. Highest-effect associations with POHG were observed for T2D (odds ratio [OR] 21.54; 95% CI 4.85, 95.58), hepatic steatosis (OR 2.20, 95% CI 1.07, 4.52), and waist circumference-to-height ratio (WCHR > 0.65; OR 2.37, 95% CI 1.16, 4.83). After multivariate analysis, the effects of T2D (OR 16.73; CI 5.42, 73.87; p < 0.0001) and steatosis (OR 2.55; CI 1.17, 5.69; p = 0.02) remained independently associated with POHG. Independent associations with SSO were observed for steatosis (OR 3.31; CI 1.41, 8.06; p = 0.007), POHG (OR 2.85; CI 1.17, 7.38; p = 0.024), and WCHR (OR 2.68; CI 1.11, 6.85; p = 0.03). CONCLUSIONS: Image-based indices of chronic metabolic disturbance in the liver and adipose tissues may offer novel opportunities for identifying patients at risk for POHG and those who would benefit from preoperative metabolic optimization.

Transversus Abdominis Release for Abdominal Wall Reconstruction: Early Experience with a Novel Technique.

BACKGROUND: Ventral hernias are common sequelae of abdominal surgery. Recently, transversus abdominis release has emerged as a viable option for large or recurrent ventral hernias. Our objective was to determine the outcomes of posterior component separation via transversus abdominis release for the treatment of abdominal wall hernias in the first series of patients at one institution. METHODS: We performed a retrospective review of a prospectively maintained database of open ventral hernia repair patients to identify patients who underwent posterior component separation via transversus abdominis release at one institution from 2012 to 2015. Patients who were at least 1 year out from surgery were included. Patient demographic characteristics, operative details, perioperative and postoperative complications, and recurrences were analyzed. Postoperative imaging was reviewed for evidence of morbidity or recurrence. RESULTS: Thirty-seven patients met inclusion criteria; 23 (62.2%) of these patients were female, with a mean age of 57.5 ± 11 years and median BMI of 32.1 kg/m(2) (range 23.6 to 44.0 kg/m(2)). All patients underwent repair with mesh (81.1% polypropylene, 5.4% porcine dermal matrix, and 13.5% biologic/permanent synthetic hybrid). Median defect size was 392 cm(2) (range 250 to 2,700 cm(2)) and median mesh area was 930 cm(2) (range 600 to 3,600 cm(2)). Approximately 24% (9 of 37) of patients experienced a postoperative complication; ileus was the most common (4 patients). Surgical site events requiring intervention (ie drainage and antibiotics) developed in 2 patients. Median follow-up period was 21 months (range 12 to 42 months), during which one recurrence was identified (2.7%). CONCLUSIONS: Posterior component separation via transversus abdominis release is a safe and effective method of ventral herniorrhaphy with favorable rates of wound morbidity and recurrence.