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.

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.

Migrated embolization coil causes intestinal obstruction.

Visceral artery pseudoaneurysm is a rare, potentially fatal entity, but proper identification and management with coil embolization can lead to good outcomes. Embolization coils can migrate to various destinations, causing delayed complications in several case reports. A case of small bowel obstruction due to migrated embolization coils from a gastroduodenal pseudoaneurysm 6 years after initial treatment is presented.

Biomechanical and Histologic Evaluation of LifeMesh™: A Novel Self-Fixating Mesh Adhesive.

Mesh fixation with the use of adhesives results in an immediate and total surface area adhesion of the mesh, removing the need for penetrating fixation points. The purpose of this study was to evaluate LifeMesh™, a prototype mesh adhesive technology which coats polypropylene mesh. The strength of the interface between mesh and tissue, inflammatory responses, and histology were measured at varying time points in a swine model, and these results were compared with sutures. Twenty Mongrel swine underwent implantation of LifeMesh™ and one piece of bare polypropylene mesh secured with suture (control). One additional piece of either LifeMesh™ or control was used for histopathologic evaluation. The implants were retrieved at 3, 7, and 14 days. Only 3- and 7-day specimens underwent lap shear testing. On Day 3, LifeMesh™ samples showed considerably less contraction than sutured samples. The interfacial strength of Day 3 LifeMesh™ samples was similar to that of sutured samples. At seven days, LifeMesh™ samples continued to show significantly less contraction than sutured samples. The strength of fixation at seven days was greater in the control samples. The histologic findings were similar in LifeMesh™ and control samples. LifeMesh™ showed significantly less contraction than sutured samples at all measured time points. Although fixation strength was similar at three days, the interfacial strength of LifeMesh™ remained unchanged, whereas sutured controls increased by day 7. With histologic equivalence, considerably less contraction, and similar early fixation strength, LifeMesh™ is a viable mesh fixation technology.

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.

Short-term strength of non-penetrating mesh fixation: LifeMesh™, Tisseel™, and ProGrip™.

BACKGROUND: Non-penetrating mesh fixation is becoming widely accepted even though little is known about the short-term fixation strength of these techniques. Although clinical outcomes are the ultimate measure of effectiveness, ex vivo biomechanical evaluation provides insights about the load-carrying capacity of the mesh-tissue complex in vivo. As such, the purpose of this study was to compare the short-term fixation strength of three unique non-penetrating methods of fixation: LifeMesh™, ProGrip™, and Tisseel™. Among these, LifeMesh™ is a novel technology where large-pore, mid-weight polypropylene mesh is embedded in a dry matrix of porcine gelatin and microbial transglutaminase enzyme, providing self-fixation without the need for a separate adhesive application. METHODS: Seven mongrel swine underwent implantation of two 4 × 7 cm pieces of either LifeMesh™, ProGrip™, or polypropylene mesh fixated with 2 mL of Tisseel™; 10 min after application, the samples were excised with the abdominal wall and stored for immediate biomechanical testing. The samples underwent lap shear testing to determine the short-term fixation strength of these three technologies. RESULTS: ProGrip™ demonstrated mean fixation strength of 1.3 N/cm (±STE 0.2). Mean fixation for mesh fixated with Tisseel™ was 2.6 N/cm (±STE 0.5). LifeMesh™ samples had mean fixation strength of 8.0 N/cm (±STE 2.1). Analysis of variance testing showed that interfacial strength of LifeMesh™ was significantly greater than that of either ProGrip™ or Tisseel™. ProGrip™ and Tisseel™ were not significantly different from each other (p = 0.06). CONCLUSIONS: Short-term strength of mesh fixation is an undescribed factor in hernia repair, but could have significant implications for early recurrence and mesh contraction. While further investigation is needed to define adequate interfacial strength, this comparison of non-penetrating mesh fixation methods shows that the novel LifeMesh™ technology exhibits greater strength than other non-penetrating fixation techniques.

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.

The effects of aerobic exercise intensity and duration on levels of brain-derived neurotrophic factor in healthy men.

This study examined the combined effects of aerobic exercise intensity and duration on serum brain-derived neurotrophic factor (sBDNF) levels in healthy human adult males aged 18-25 years. Forty five participants were randomly assigned to one of six exercise conditions based on varying intensity (80% or 60% of heart rate reserve, or control) and duration (20 or 40 min). Vigorous (80% heart rate reserve, "Vig") and moderate (60% heart rate reserve, "Mod") exercise was carried out on cycle ergometers. Control subjects remained seated and at rest during the exercise period. Pre- and post-exercise blood draws were conducted and sBDNF measured. Physical exercise caused an average ~ 32% increase in sBDNF levels relative to baseline that resulted in concentrations that were 45% higher than control conditions. Comparing the six conditions, sBDNF levels rose consistently among the four exercise conditions (Vig20 = 26.38 ± 34.89%, Vig40 = 28.48 ± 19.11%, Mod20 = 41.23 ± 59.65%, Mod40 = 30.16 ± 72.11%) and decreased consistently among the controls (Con20 = -14.48 ± 16.50, Con40 = -10.51 ± 26.78). Vig conditions had the highest proportion of subjects that experienced a significant (? 10%) increase in sBDNF levels, followed by Mod and control conditions. An analysis of modeled sBDNF integrals (area under the curve) demonstrated substantially greater values for Vig40 and Mod40 conditions compared to Vig20 and Mod20 conditions. Collectively, these results demonstrate that neither duration (20 vs. 40 min) nor intensity (60 vs. 80% HR reserve) significantly affects the benefits of exercise if only the sBDNF increase at a single post-exercise time point is considered. However, when comparing either the probability of achieving a significant BDNF gain or the integral (i.e. the volume of circulating BDNF over time) the Vig40 condition offers maximal benefits. Thus, we conclude that the future study of aerobic exercise effects on BDNF-mediated neuroprotection should take the volume of BDNF release over time into account. Key PointsAerobic exercise caused a ~32% increase in serum BDNF in adult human males while serum BDNF decreased 13% in sedentary control subjects.Vigorous intensity (80% heart rate reserve), long duration (40 min) exercise offered the greatest probability of a significant BDNF elevation.Long duration exercise offered the greatest numerical benefits in terms of BDNF integral.Neither intensity nor duration affected the mean elevation in BDNF amplitude caused by exercise.

Admission ionized calcium levels predict the need for multiple transfusions: a prospective study of 591 critically ill trauma patients.

BACKGROUND: Deaths from uncontrolled exsanguinating hemorrhage occur rapidly postinjury. Any successful resuscitation strategy must also occur early, underscoring the importance of rapid identification of patients at risk for multiple transfusions. Previous studies have shown low ionized calcium (iCa) levels to be associated with hypotension and function as a predictor of mortality. We hypothesized that admission iCa levels could potentially predict the need for multiple transfusions in critically ill trauma patients. METHODS: Admission iCa was collected prospectively on all trauma activations during a 9-month period. Youden's index was used to determine the appropriate cutpoint for iCa. Outcomes (mortality, multiple transfusions [≥5 units packed red blood cells in 24 hours] and massive transfusion [≥10 units packed red blood cells in 24 hours]) were compared using Wilcoxon rank-sum and χ tests where appropriate. Multivariable logistic regression was performed to determine whether iCa was an independent predictor of multiple transfusions. RESULTS: A total of 591 patients were identified: 461 (78%) men and 130 (22%) women. Cutpoint was identified as 1.00. iCa was <1.00 (lo-Cal) in 332 patients and≥1.00 (hi-Cal) in 259 patients. Mortality was significantly increased in the lo-Cal group (15.5% vs. 8.7%, p=0.036). In addition, both multiple transfusions (17.1% vs. 7.1%, p=0.005) and massive transfusion (8.2% vs. 2.2%, p=0.017) were significantly increased in the lo-Cal group. Multivariable logistic regression analysis identified iCa<1 as an independent predictor of the need for multiple transfusions after adjusting for age and injury severity (odds ratio=2.294, 95% confidence interval=1.053-4.996). CONCLUSIONS: Low iCa levels at admission were associated with increased mortality as well as an increased need for both multiple transfusions and massive transfusion. In fact, multivariable logistic regression analysis identified low iCa levels as an independent predictor of multiple transfusions. Admission iCa levels may facilitate the rapid identification of patients requiring massive transfusion, allowing for earlier preparation and administration of appropriate blood products.

Comparison of a real-time reverse transcriptase PCR assay and a culture technique for quantitative assessment of viral load in children naturally infected with respiratory syncytial virus.

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory infection of children. Understanding RSV pathogenesis and evaluating interventions requires quantitative RSV testing. Previous studies have used the plaque assay technique. Real-time reverse transcriptase PCR (RTrtPCR) offers possible greater sensitivity, stability after freeze/thaw, and lower cost, thus facilitating multicenter studies. We developed RTrtPCR assays based upon the RSV N and F genes. The N-gene assay detected greater RSV quantity and was further evaluated. Standard curves utilized both extractions from RSV culture supernatants of known quantity and cloned purified copies of the target DNA. In vitro, the ratio of RSV subgroup A (RSV-A) genome copies to PFU was 153:1. A total of 462 samples collected quantitatively from 259 children were analyzed in duplicate by RTrtPCR. Results were compared with those of RSV plaque assays performed on fresh aliquots from the same children. Duplicate RTrtPCR results were highly correlated (r2 = 0.9964). The mean viral load from nasal washes obtained on the first study day was 5.75 +/- standard error of the mean 0.09 log PFU equivalents (PFUe)/ml. Viral load by RTrtPCR correlated with plaque assay results (r2 = 0.158; P < 0.0001). Within individuals, upper and lower respiratory tract secretions contained similar viral concentrations. RSV-A-infected children had 1.17 log PFUe higher viral loads than did those with RSV-B (P < 0.0001). RSV quantification by RTrtPCR of the N gene is precise and has significant, though limited, correlation with quantitative culture. The utility of the RTrtPCR quantification technique for clinical studies would be solidified after its correlation with RSV disease severity is established.

Heme oxygenase-1 messenger RNA expression is induced in peripheral blood mononuclear cells of pediatric cancer patients with systemic inflammatory response syndrome.

OBJECTIVE: To determine whether heme oxygenase-1 messenger RNA expression in peripheral blood mononuclear cells is induced in pediatric cancer patients with the systemic inflammatory response syndrome (SIRS) and whether this expression correlates with the heme oxygenase-1 products, bilirubin and carboxyhemoglobin. DESIGN: Prospective, controlled study. SETTING: A tertiary care pediatric oncology hospital. PATIENTS: Fourteen patients admitted to the intensive care unit with a diagnosis of SIRS by American College of Chest Physicians/Society for Critical Care Medicine consensus criteria and 17 control patients (off therapy, no acute illness). INTERVENTIONS: Blood for bilirubin, carboxyhemoglobin, and heme oxygenase-1 messenger RNA expression was collected at study entry. SIRS patients continued to have samples collected every 12 hrs for 1 wk or until intensive care unit discharge. Heme oxygenase-1, bilirubin, and carboxyhemoglobin levels of SIRS patients were compared with controls, and correlation between heme oxygenase-1 and products was assessed. MEASUREMENTS AND MAIN RESULTS: Within 48 hrs of study entry, maximum heme oxygenase-1 expression for all SIRS patients compared with controls was 5.5 +/- 1.0 vs. 1.1 +/- 0.1 (p < .0006). Maximum expression was > or =2.3-fold in 13 of 14 SIRS patients. Maximum heme oxygenase-1 expression also differed from minimum (5.5 +/- 1.0 vs. 1.6 +/- 0.3, p < .003). Maximum bilirubin and carboxyhemoglobin levels within 48 hrs of study entry differed between SIRS patients and controls (3.0 +/- 0.8 vs. 0.3 +/- 0.1, p = .006; and 1.2 +/- 0.2 vs. 0.6 +/- 0.1, p = .001, respectively). Bilirubin, but not carboxyhemoglobin, correlated with heme oxygenase-1 expression (p = .0013). CONCLUSIONS: Heme oxygenase-1 messenger RNA, bilirubin, and carboxyhemoglobin levels were increased within 48 hrs of admission in pediatric cancer patients with SIRS. Heme oxygenase-1 expression correlated with serum bilirubin levels. The increase in heme oxygenase-1 expression may add to the understanding of the increase in serum bilirubin observed in patients with SIRS/sepsis. These findings support a role for heme oxygenase-1 in the physiologic response to inflammatory stress.