Augmentation of the Esophageal Sphincter Using LINX.

Gastroesophageal reflux disease (GERD) is the retrograde flow of gastric contents into the distal esophagus and may be treated medically or surgically. Magnetic sphincter augmentation surgery using LINX has recently demonstrated comparable results to Nissen fundoplication. We aimed to evaluate preoperative patient risk factors that were associated with LINX removal rates or postoperative EGD with dilation rates (POEGDD). This is a single institution retrospective review of patients undergoing LINX between 2015 and 2021. One hundred and twelve patients were reviewed, 106 included within the study; those excluded had prior foregut surgery or device fracture. Variables including age, sex, BMI, size of device, DeMeester score, manometry, GERD Health-Related Quality of Life (GERD HRQL) questionnaires, POEGDD, and removal rates were recorded. Comparing removal and dilation status, the chi-square or Fisher's exact test and the Mann-Whitney U test were used to analyze categorical and continuous variables, respectively. A P < .05 was considered to be statistically significant. Eleven LINX devices were removed (10%); of these, 9 (81%) underwent POEGDD (P = .0023). There was no difference in DeMeester scores, size of device, or BMI in patients requiring LINX removal compared to those not removed or POEGDD rates. Patients who required LINX removal had higher GERD HRQL scores both preoperatively (median 34 vs 28) and postoperatively at all visits compared to those patients who did not undergo removal (P = .032). Manometry and DeMeester scores were not associated with LINX removal suggesting a less invasive GERD HRQL questionnaire may be a better predictor of patients who will succeed with LINX surgery.

Strategies for General Surgery Training Programs During the COVID-19 Pandemic.

The COVID-19 pandemic presented a unique challenge for Medical systems worldwide. Initial response to the crisis situation for the pandemic closely mirrored plans for a mass casualty event. By leveraging resources including human and physical, and by dividing our surgeon workforce into micro teams we were able to create a flexible and responsive infrastructure to address the crisis as it unfolded. By adoption of virtual platforms and equal division of labor, surgical resident education was continued. Specific adjustments to the schedule and curriculum for medical students allowed them to continue their studies safely and on schedule. Our model serves as an example by which hospital systems of similar size may utilize principles of mass casualty preparedness to craft their own plan for a future contagion response strategy.

Wittmann Patch : Superior Closure for the Open Abdomen.

INTRODUCTION: Damage control laparotomy (DCL) is a life-saving surgical technique, but the resultant open abdomen (OA) carries serious morbidity/mortality. Many methods are utilized to manage OAs, but discrepancy exists in distinguishing closure from coverage techniques. We observed a difference in our DCL patient outcomes managed with the Wittmann Patch (WP) closure device versus the more popular ABThera (AB) coverage device. We hypothesized that the WP contributed to an improved fascial closure rate of the OAs after DCL. METHODS: A retrospective review of OAs managed with the AB or WP at our Level 1 trauma center was performed using billing codes to capture DCL patients from 2011 to 2019. Patients were divided into AB alone or WP groups. Major endpoints included primary fascial closure (PFC) and delayed fascial closure (DFC, fascial closure after greater than 7 days). RESULTS: 189 patients were identified as AB and 38 as WP. Rates of death before closure, age, gender, and Injury Severity Score were similar in both groups. PFC = 81%-90% for AB versus WP, respectively. Excluding patients with preexisting hernias PFC = 87%-100% for AB versus WP (P < .05) and DFC = 44%-100% for AB versus WP (P ≤ 0.001). WP had a statistically higher rate of PFC and DFC. There was a decreased incidence of complications in the WP versus AB group. CONCLUSIONS: While not well reported in the peer-reviewed literature, the application of the WP for management of the OA is an active form of pursuing PFC when compared with the AB, a coverage device. Our interinstitutional results have demonstrated superior PFC and DFC rates and fewer complications, in patients managed with the WP compared with the AB.

Interleukin-lß induces migration of rat arterial smooth muscle cells through a mechanism involving increased matrix metalloproteinase-2 activity.

BACKGROUND: Interleukin-lß (IL-lß) is associated with vascular smooth muscle cell (VSMC) migration during neointimal formation following arterial injury, of which matrix metalloproteinase-2 (MMP-2) may have an important role. We investigated whether IL-lß stimulated migration and MMP-2 production in VSMC, and, if so, whether migration correlated with MMP-2 activity. MATERIALS AND METHODS: Modified Boyden chamber assay quantified cultured rat aorta VSMC migration. Methyl-thiazolyl-tetrazolium assay assessed cell growth. Gelatin zymography and Western blotting determined MMP-2 activity and protein levels, respectively. RESULTS: IL-lß (0.1 - 10 ng/mL) induced migration of VSMC in a concentration-dependent manner without cell proliferation. VSMC released increasing levels of active MMP-2 in a dose-response fashion at IL-1ß 1-10 ng/mL (P < 0.05) while significantly increased levels of latent MMP-2 (pro-MMP-2) were attained more gradually (10 ng/mL, P < 0.05). There was a dose-dependent increase in the ratio of active MMP-2 to pro-MMP-2 in response to IL-1ß (1-10 ng/mL, P < 0.05), suggesting extracellular activation of pro-MMP-2. Protein levels on Western blot paralleled enzyme activity, with the synthesis of more active MMP-2 than pro-MMP-2 in response to IL-1ß. IL-lß-stimulated VSMC migration was significantly attenuated by both the pan-selective MMP inhibitor GM6001 and cis-9-octadecenoyl-N-hydroxylamide, a MMP-2-selective inhibitor. CONCLUSIONS: IL-lß increases MMP-2 activity in VSMC through increased protein synthesis and activation of pro-MMP-2. VSMC migration induced by IL-lß requires active MMP-2. IL-lß may play a role in arterial remodeling following injury.

Three-year results of mandated work hour restrictions: attending and resident perspectives and effects in a community hospital.

In response to the Accreditation Council of Graduate Medical Education mandated resident work hour restrictions, our residency program used a night float system in 2003. We undertook a survey of attending staff and residents to assess its effects on patient care and resident education. An anonymous survey was administered to attending staff and residents 1 year and 3 years after work hour restrictions took effect. The areas of disagreement include: beneficial effect on education (residents vs faculty: in 2004, 87% vs 22%, respectively, P = 0.02; in 2006, 71% vs 22%, P = 0.03); beneficial effect on patient care (in 2004, 53% vs 10%, P = 0.03); and compromised continuity of care (in 2004, 27% vs 70%, P = 0.04; in 2006, 7% vs 89%, P = 0.0002). One area of agreement was that residents' quality of life had improved. Both disagreed that more errors were being made and that work hour restrictions should be mandated on practicing surgeons. Attending staff and residents have deeply held opinions regarding the effects of work hour restrictions. This reflects a continuing dissatisfaction with providing patient care and educating residents under a set of requirements that solely addresses resident sleepiness and fatigue.