Feasibility and Efficacy of Magnetic Sphincter Augmentation for the Management of Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy for Obesity.

BACKGROUND: Patients with medically intractable GERD after laparoscopic sleeve gastrectomy (LSG) have limited surgical options. Fundoplication is difficult post-LSG. Roux-en-Y gastric bypass may be used as a conversion procedure but is more invasive with potential for serious complications. Magnetic sphincter augmentation (MSA) is a less invasive GERD treatment alternative. The objective of this study was to assess safety and efficacy outcomes of MSA after LSG. METHODS: The primary outcome of this observational, multicenter, single-arm prospective study was the rate of serious device and/or procedure-related adverse events (AEs). The efficacy of the LINX device was measured comparing baseline to 12-month post-implant reductions in distal acid exposure, GERD-HRQL score, and average daily PPI usage. RESULTS: Thirty subjects who underwent MSA implantation were followed 12 months post-implant. No unanticipated adverse device effects were observed. There were two adverse events deemed serious (dysphagia, pain, 6.7%) which resolved without sequelae. GERD-HRQL scores showed significant improvement (80.8%, P < 0.001), and reduction in daily PPI usage was seen (95.8%, P < 0.001). Forty-four percent of subjects demonstrated normalization or > = 50% reduction of total distal acid exposure time (baseline 16.2%, 12 months 11%; P = 0.038). CONCLUSIONS: Post-LSG, MSA showed an overall improvement of GERD symptoms, and reduction in PPI use with explants within anticipated range along with improvement in distal esophageal acid exposure time.

Evaluation of Electromagnetic Navigational Bronchoscopy Using Tomosynthesis-Assisted Visualization, Intraprocedural Positional Correction and Continuous Guidance for Evaluation of Peripheral Pulmonary Nodules.

BACKGROUND: Electromagnetic navigational bronchoscopy (ENB) has been shown to have variable diagnostic accuracy for the assessment of peripheral pulmonary nodules. This may be because of discrepancies between the preplanned computed tomography of chest target lesion location versus actual target location (computed tomography-to-body divergence), and the lack of a continuous navigational image. The ILLUMISITE (Medtronic, Minneapolis, MN) is a newly developed ENB platform that utilizes tomosynthesis, an imaging technology that can visualize the target location using fluoroscopy (F-ENB). This new system also allows for intraprocedural positional correction and continuous navigation guidance during sampling to overcome these limitations and improve diagnostic yield. We report our first experience in a single center, single proceduralist using this new technology. METHODS: We conducted a retrospective, single center, single operator study reviewing 72 consecutive patients (78 nodules) over a 3-month period. We investigated the overall diagnostic yield and diagnostic yield by nodule location, size, and sedation type using this new F-ENB system. RESULTS: The overall diagnostic yield was 87% and pnemothoraces occurred in 2/78 procedures. We did not find any statistically significant difference when comparing pulmonary nodule location, size or sedation method utilized ( P =0.231, 0.338, and 0.112, respectively). Sixty-nine percent of the pulmonary nodules biopsied were 2 to 3 cm in size. The average distance corrected after tomosynthesis visualization was 15.4 mm (0.4 to 29.8 mm). CONCLUSION: We report our initial experience with the ILLUMISITE system using fluoroscopic tomosynthesis-assisted visualization with continuous navigational guidance at our institution. This new technology allows the operator to correct for better target lesion alignment and real time positional correction and may improve diagnostic yields with minimal complications for evaluation of peripheral pulmonary nodules.

Laparoscopic peritoneopericardial herniorrhaphy in 2 dogs.

Two peritoneopericardial hernias (PPDH) repaired laparoscopically are reported. Both PPDHs were approached with the dog in dorsal recumbency. Herniated organs (gallbladder and 2 liver lobes in Case 1 and omental fat in Case 2) were dissected and reduced. Hernias were closed in a 2-layer horizontal mattress pattern using 2-0 polyester (Case 1), and in a single-layer simple continuous pattern using 0 barbed polyglyconate (Case 2). Reduction and herniorrhaphy were achieved without conversion. Moderate to severe systemic hypotension was observed in both dogs which responded rapidly to reducing abdominal insufflation. Ten- and 7-month follow-up confirmed good clinical outcome in both dogs.

Herniorraphie péritonéo-péricardique laparoscopique chez deux chiens. Deux hernies péritonéopéricardiques (PPDH) réparées par laparoscopie sont rapportées. Les deux PPDHs ont été réalisées avec le chien en décubitus dorsal. Les organes herniés (vésicule biliaire et deux lobes hépatiques dans le cas 1 et graisse épiploïque dans le cas 2) ont été disséqués et réduits. Les hernies ont été fermées avec un patron de suture matelas horizontal à deux couches en utilisant du polyester 2-0 (cas 1) et avec un modèle de suture continu simple à une seule couche en utilisant du polyglyconate barbelé 0 (cas 2). La réduction et l'herniorraphie ont été réalisées sans conversion. Une hypotension systémique modérée à sévère a été observée chez les deux chiens qui ont répondu rapidement à la réduction de l'insufflation abdominale. Un suivi de dix et sept mois a confirmé de bons résultats cliniques chez les deux chiens.(Traduit par Dr Serge Messier).

Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic Surgery.

BACKGROUND: Opioid addiction continues to be a devastating problem in our communities, and up to 40% of patients begin their addiction with legally prescribed opioids after injury or surgical procedure. An opioid-free multimodal pain regimen was developed with the goal of decreasing opioid exposure while maintaining adequate pain control. METHODS: A retrospective single-institution study was conducted of 313 consecutive patients undergoing minimally invasive lobectomy before (n = 211) and after (n = 102) implementation of an opioid-free protocol from 2016 to 2020. Data analysis was conducted on preoperative characteristics, postoperative opioid use at set time points (postoperative day 0, postoperative days 1 to 7, and total stay), pain scores, discharge with opioid prescription, and postoperative outcomes. RESULTS: Patients on the opioid-free protocol had significantly lower average total morphine milligram equivalents at all time points. In addition, 56% of patients in the opioid-free group received no oral opioids at all, and 91% did not receive a patient-controlled analgesia pump. Average pain scores were significantly lower in the opioid-free protocol patients along with percentage of time spent with pain scores <3 and <6. With implementation of the protocol, 62% of patients are discharged without an opioid prescription compared with only 7% previously. CONCLUSIONS: Implementation of an opioid-free protocol led to a significant decrease in the use of postoperative opioids at all time points while improving overall management of pain. In addition, most patients are discharged with no home opioid prescription, decreasing a potential source of community opioid spread.

Tracheal Transection From Gunshot Wound to the Neck.

A male patient presented with a gunshot wound superior to his left scapula and difficulty breathing. En route to the emergency department, he rapidly became unresponsive, culminating in a cricothyroidotomy by paramedics. Oxygen saturation was 70% on arrival, and a tracheobronchial injury was suspected. In the operating room, a complete transection of the mid trachea was found and repaired. Postoperatively, the patient had acute respiratory distress syndrome. He was placed on extracorporeal membrane oxygenation and was eventually decannulated on postoperative day 12. The need for immediate identification of airway inadequacy, despite appropriate interventions, is underscored by this case report.

Establishment of a per oral endoscopic myotomy program at a rural tertiary care center.

BACKGROUND: This study's purpose is to determine the application and effectiveness of a POEM program in the rural healthcare setting. Achalasia has a substantial impact on the lives of afflicted patients. Traditionally, a Heller myotomy with fundoplication has been the standard of care for treatment. In 2008, the first per oral endoscopic myotomy (POEM) was performed in Japan. Since 2017, our rural healthcare institution has performed approximately 60 POEMs. METHODS: An IRB approved, single-institution retrospective review of patient outcomes after POEM was performed along with prospective analysis of post-operative surveys. An institutional cost analysis was also performed. Demographic and qualitative variables were measured and included PPI use, a Likert scale of 0-5 for progressively worsening symptoms of heartburn, dysphagia, and regurgitation. In addition, we included a Dysphagia Outcome and Severity Scale. RESULTS: The number of myotomy operations increased from 4.5 per year to 28.8 per year after initiation of the POEM program. Mean Likert scale scores were 0.91, 0.73, and 1 for heartburn, dysphagia, and regurgitation, respectively. 72.5% percent of patients were satisfied with their present condition. 87.5% of patients reported minimal or no dysphagia on the Dysphagia Severity Scale. Intraoperative costs were $2477 for laparoscopic myotomy and $1650 for POEM. The capital expense of the equipment required to perform POEM was $110,232. Average contribution margin per case was $6024. The procedure pays off capital outlay upon completion of the 19th case. CONCLUSIONS: This study shows that patients have excellent symptom control after POEM. When compared to the institution's laparoscopic myotomy volume, POEM far surpasses in terms of operative volume and monetary benefit. Examination of these data shows that a rural hospital can successfully employ a state-of-the-art intervention when there is a population in need and an infrastructure in place.

Fundic gastropexy for high risk of recurrence laparoscopic hiatal hernia repair and esophageal sphincter augmentation (LINX) improves outcomes without altering perioperative course.

BACKGROUND: The aim of this study is to show that the addition of a fundic gastropexy to a laparoscopic hiatal hernia repair (HHR) and magnetic sphincter augmentation (MSA) with LINX (Johnson and Johnson, New Brunswick, NJ) in patients with high risk for hiatal hernia recurrence improves outcomes without altering perioperative course. METHODS: An IRB approved, single institution retrospective review of patient outcomes after hiatal hernia repair with magnetic sphincter augmentation was performed. Data were obtained from the electronic health record and stored in a REDCap database. Using statistical software, the patient data were analyzed and stratified to assess the specific variables of the perioperative and postoperative course focusing on the high risk of hiatal hernia recurrence group (HRHR) and low risk hiatal hernia of recurrence group (LRHR). The HRHR group received a gastropexy and were defined using the following variables: comorbid state increasing abdominal pressure, gastric herniation > 30%, maximum transverse crural diameter > 4 cm, age 70 years or older, previous hiatal or abdominal wall hernia repair, BMI > 34, heavy weight bearing job/hobby, and/or emergent repair. RESULTS: Hiatal hernia repair with magnetic sphincter augmentation was performed on 137 patients. The HRHR group (N = 86) and the LRHR group (N = 51) were compared and there was a difference observed with acute hernia recurrence, dysphagia (p value = 0.008), and number of post-op EGDs (p value = 0.005) in favor of the HRHR group. Other postoperative variables observed (i.e., length of stay and PPI use) showed no significant difference between the two groups. CONCLUSIONS: Fundic gastropexy for individuals who are considered high risk for recurrence does not appear to alter the perioperative course in our sample of patients. The HRHR group has the same length of stay experience and improved postoperative outcomes with reference to postoperative EGD, dysphagia and a decreasing trend in hiatal hernia recurrence.

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy.

INTRODUCTION: Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection. OBJECTIVE: To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study. METHODS: NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort. RESULTS: The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10 mm (range 4-22) and 83.3% were <20 mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0 mm from the pleura. The median ENB-specific procedure time was 11.5 minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24). CONCLUSION: In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.

Fiducial marker placement with electromagnetic navigation bronchoscopy: a subgroup analysis of the prospective, multicenter NAVIGATE study.

BACKGROUND: Fiducial markers (FMs) help direct stereotactic body radiation therapy (SBRT) and localization for surgical resection in lung cancer management. We report the safety, accuracy, and practice patterns of FM placement utilizing electromagnetic navigation bronchoscopy (ENB). METHODS: NAVIGATE is a global, prospective, multicenter, observational cohort study of ENB using the superDimension™ navigation system. This prospectively collected subgroup analysis presents the patient demographics, procedural characteristics, and 1-month outcomes in patients undergoing ENB-guided FM placement. Follow up through 24 months is ongoing. RESULTS: Two-hundred fifty-eight patients from 21 centers in the United States were included. General anesthesia was used in 68.2%. Lesion location was confirmed by radial endobronchial ultrasound in 34.5% of procedures. The median ENB procedure time was 31.0 min. Concurrent lung lesion biopsy was conducted in 82.6% (213/258) of patients. A mean of 2.2 ± 1.7 FMs (median 1.0 FMs) were placed per patient and 99.2% were accurately positioned based on subjective operator assessment. Follow-up imaging showed that 94.1% (239/254) of markers remained in place. The procedure-related pneumothorax rate was 5.4% (14/258) overall and 3.1% (8/258) grade ⩾ 2 based on the Common Terminology Criteria for Adverse Events scale. The procedure-related grade ⩾ 4 respiratory failure rate was 1.6% (4/258). There were no bronchopulmonary hemorrhages. CONCLUSION: ENB is an accurate and versatile tool to place FMs for SBRT and localization for surgical resection with low complication rates. The ability to perform a biopsy safely in the same procedure can also increase efficiency. The impact of practice pattern variations on therapeutic effectiveness requires further study. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02410837.

Robotic-Assisted Thoracoscopic Repair of Right-Sided Bochdalek Hernia in Adults: A Two-Case Series.

Bochdalek hernia is a congenital diaphragmatic hernia that presents rarely in adulthood. Because of the paucity of cases, no standard repair technique has been identified. Here we present two cases of robotic, thoracoscopic repair of this rare hernia defect. Two separate adult patients with right-sided abdominal pain presented to the emergency department for evaluation. Both patients were diagnosed with right-sided Bochdalek hernia and repair was undertaken with a robotic, transthoracic approach. Repair technique is described in detail, including port placement, dissection technique, and repair strategy. Advantages of the robotic, transthoracic approach are discussed in detail. A transthoracic minimally invasive approach using a robotic platform is noted to be both feasible and practical in the treatment of adult Bochdalek hernia.

Esophageal perforation secondary to malignant gastric outlet obstruction: a case report.

BACKGROUND: Esophageal perforation is a rare presenting sign of gastric cancer. To date, only nine case reports of this phenomenon have been previously published. CASE PRESENTATION: Esophageal perforation was diagnosed radiographically during workup for acute chest pain in a 67-year-old man. Emergent endoscopy confirmed esophageal perforation and biopsied a pre-pyloric mass confirmed to be adenocarcinoma. The perforation was managed with endoscopically placed transluminal pleural and mediastinal drains and esophageal stenting. The gastric outlet obstruction was temporized with a transpyloric stent. After the patient recovered from sepsis, distal gastrectomy was performed and he made a full recovery. CONCLUSIONS: Rarely, pre-pyloric gastric cancer can present with Boerhaave syndrome, spontaneous esophageal perforation associated with forceful vomiting. We present the tenth report in the literature of this phenomenon and the first to be initially treated with endoscopic stenting and transluminal thoracoscopic drainage. When endoscopic management is used to treat patients with Boerhaave syndrome, it may be beneficial to examine the entire stomach to evaluate for malignant etiology.

Thoracic Surgery Considerations in the Mentally Ill or Handicapped Patient.

Increasing prevalence of mentally ill and handicapped populations requiring surgical thoracic interventions has brought to light their worse associated morbidity and mortality. Baseline functional status, caretaker environment, and mental limitations in day to day life have an impact in the short and long term from these interventions. Aggressive perioperative care, multispecialty approach, technical aspects, palliative procedures, and ethical considerations all play a part in improving outcomes. In this article real cases are presented illustrating points of care and situations for discussion.

Feasibility and Safety of the Transbronchial Access Tool for Peripheral Pulmonary Nodule and Mass.

BACKGROUND: Navigational bronchoscopy and other imaging modalities have improved the ability to evaluate pulmonary nodules/mass. Many of these lesions are located outside the bronchial airway and are difficult to access even with these devices. The Transbronchial Access Tool (Medtronic, Minneapolis, MN) allows the bronchoscopist to create a pathway from the bronchial airway, across the lung parenchyma, and into the target lesion. We are reporting the feasibility and safety of this new device. METHODS: Patients with peripheral pulmonary nodules/mass with an absence of an air bronchogram on thoracic imaging underwent a navigational bronchoscopy in a hybrid operating room under general anesthesia. A navigational system located predetermined areas in the bronchial tree to deploy the Transbronchial Access Tool, and cone beam computed tomography confirmed that the target lesion was accessed. A standard protocol was developed and followed in the last 7 patients directing cone beam computed tomography use. The ability to enter the target lesion, diagnostic yield, radiation exposure, and procedural complications were recorded. RESULTS: The Transbronchial Access Tool was used in 14 patients who underwent an electromagnetic navigational bronchoscopy-guided biopsy from September 2015 to January 2016. The overall diagnostic yield was 71% (10 of 14) and 100% (7 of 7) when the standard protocol was instituted. Access was achieved in 75% (9 of 12) of the targeted lesions, with a diagnostic yield of 66% (8 of 12). One complication, a pneumothorax, occurred. The average radiation exposure during the procedure was 4.3 mSv (range, 3 to 5 mSv), and fluoroscopic time was 17 minutes (range, 2 to 44 minutes). CONCLUSIONS: The Transbronchial Access Tool is safe and permits access to pulmonary nodules/masses with navigational bronchoscopy.

Going Off Road: The First Case Reports of the Use of the Transbronchial Access Tool With Electromagnetic Navigational Bronchoscopy.

The ability to reach the peripheral pulmonary nodule/mass with bronchoscopy has improved greatly over the past several years with the use of Electromagnetic navigational bronchoscopy; however, many of these lesions are unable to be adequately sampled due to their location outside the bronchial airways. We report the first use of the transbronchial access tool that creates a pathway from the bronchial airway through the lung parenchyma into the targeted lung abnormality.