Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus.

AIMS: There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology. METHODS: We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as "recommended" or "discouraged" if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled "acceptable" (neither recommended nor discouraged). RESULTS: Seventy-two surgeons with a median (IQR) experience of 23 (14-30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15-36) and 40 (28-60) pHH-surgeries, respectively. After Delphi round 2, "recommended" strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified "discouraged" strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were "acceptable". CONCLUSIONS: This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.

Results of robotic TAPP and conventional laparoscopic TAPP in an outpatient setting: a cohort study in Switzerland.

PURPOSE: Recently, robotic surgery has been increasingly performed in hernia surgery. Although feasibility and safety of robot-assisted inguinal hernia repair in an inpatient setting have been already shown, its role in outpatient hernia surgery has not yet been investigated. Thus, this study aimed to compare robot-assisted TAPP (r-TAPP) and conventional laparoscopic TAPP (l-TAPP) in an outpatient setting. METHODS: A prospective database of patients with inguinal hernia treated by l-TAPP or r-TAPP in an outpatient setting during a 1-year period was analyzed in a comparative cohort study. All patients underwent a check-up appointment with their surgeon within 3 days and 6 weeks postoperatively. Data on surgical time, perioperative complications, and postoperative pain were collected. Pain was recorded by using a Verbal Rating Scale (VRS). RESULTS: Overall, outpatient laparoendoscopic inguinal hernia repair was performed in 58 patients (29 l-TAPP; 29 r-TAPP). Mean age was 57 years (21-81), mean BMI 24.5 kg/m2 (19-33) with no differences between both groups. Most patients reported none or only a low postoperative pain level in both groups (89.6% in l-TAPP group; 100% in r-TAPP), while there was a trend for less pain after r-TAPP. In both groups, there was one case of postoperative hematoma, which was successfully treated by conservative means. No other complications occurred during follow-up in either group and there was no 30-day-readmission, no unplanned overstay or any 30-day mortality in the cohort. CONCLUSION: Robot-assisted inguinal hernia surgery can be safely performed in an outpatient setting with a tendency to less pain when compared to the conventional laparoscopic technique. Cost-effectiveness and cost-coverage of outpatient robot-assisted inguinal hernia surgery must be further investigated in times of limited health cost resources and diagnosis-related medical reimbursements.

Current surgical concepts for type III hiatal hernia: a survey among members of the Swiss Society of Visceral Surgery.

AIMS OF THE STUDY: Surgery for large hiatal hernias has greatly evolved over the last decade, but there is an ongoing controversy regarding many technical aspects, such as the use of meshes or the necessity to add a fundoplication. The purpose of this survey was to assess the current spectrum of surgical care for mixed axial and paraoesophageal hiatal hernias (type III hiatal hernia) in Switzerland. METHODS: In April 2020, we conducted a web-based survey comprising 25 questions on surgical management of type III hiatal hernia among members of the Swiss Society for Visceral Surgery. The survey focused exclusively on primary hernias in an elective setting. Responses were graded on a five-point Likert scale and analysed using descriptive statistics. Consensus was defined as agreement (agree or strongly agree) ≥75%. RESULTS: Forty-seven visceral surgeons with a median annual institutional caseload of 15 (interquartile range 10-30) type III hiatal hernia participated in the survey (response rate 15%). Agreement ≥75% was found for several basic technical steps (access via laparoscopy, hernia sac resection, preservation of vagus nerves, preservation of aberrant left hepatic artery, single-stitch posterior suture repair of hiatus with braided, non-resorbable material, complementary antireflux procedure). In contrast, consensus was not achieved for several important surgical details (mesh hiatoplasty, type of antireflux procedure, gastropexy, management of short oesophagus). A high percentage of participating surgeons experienced mesh related complications in their own or assigned patients: erosions (15% and 36%, respectively), stenoses (26% and 24%, respectively) and pericardial tamponades (9% and 15%, respectively). Nevertheless, hiatal reinforcement with mesh (in all or in selected cases) was reported by 91% of participants without consensus regarding mesh type, shape, placement and fixation technique. CONCLUSIONS: Apart from a few generally accepted technical steps, surgical management of type III hiatal hernia is highly variable amongst visceral surgeons in Switzerland. Although mesh-related complications appear to be common, most Swiss surgeons report routine mesh use for hiatal reinforcement.

Procalcitonin as preoperative marker for surgery in advanced parapneumonic empyema.

BACKGROUND: The optimal time point for surgical management of advanced parapneumonic empyema in need of open pleurectomy and decortication remains unclear. We hypothesized that surgical outcomes will be better when procalcitonin (PCT) levels have dropped to normal ranges as evidence for resolution of the underlying pneumonia. METHODS: We retrospectively analyzed outcomes of 38 patients with advanced parapneumonic empyema who underwent open decortication and pleurectomy with available preoperative PCT (pPCT) values. Patients were divided into two groups based on the pPCT cut-off of 0.25 µg/L. Total length of stay was the primary endpoint. Secondary endpoints included postoperative length of stay, surgery-related complications and death. RESULTS: Patients with a pPCT ≥0.25 µg/L had a significantly longer total length of stay compared to patients with a pPCT level <0.25 µg/L [mean 22.4 vs. 15.0 days, difference -7.4 days (95% CI: -12.8 to -2.0), P=0.009]. This was also confirmed in linear regression analysis adjusting for age, gender and comorbidities [adjusted regression coefficient for log-transformed length of stay -0.27, 95% CI: -0.02 to -0.52, P=0.037]. Results for postoperative length of stay were similar. Eight patients in the pPCT ≥0.25 µg/L group had postoperative complications with two deaths while no complications occurred in the PCT <0.25 µg/L group (38% vs. 0%, P=0.004). CONCLUSIONS: These data suggest better surgical outcomes in advanced parapneumonic empyema when pneumonia has resolved with a pPCT drop of <0.25 µg/L. A larger, prospective study is needed to confirm these results.

Sampling the Mouse Hippocampal Dentate Gyrus.

Sampling is a critical step in procedures that generate quantitative morphological data in the neurosciences. Samples need to be representative to allow statistical evaluations, and samples need to deliver a precision that makes statistical evaluations not only possible but also meaningful. Sampling generated variability should, e.g., not be able to hide significant group differences from statistical detection if they are present. Estimators of the coefficient of error (CE) have been developed to provide tentative answers to the question if sampling has been "good enough" to provide meaningful statistical outcomes. We tested the performance of the commonly used Gundersen-Jensen CE estimator, using the layers of the mouse hippocampal dentate gyrus as an example (molecular layer, granule cell layer and hilus). We found that this estimator provided useful estimates of the precision that can be expected from samples of different sizes. For all layers, we found that a smoothness factor (m) of 0 generally provided better estimates than an m of 1. Only for the combined layers, i.e., the entire dentate gyrus, better CE estimates could be obtained using an m of 1. The orientation of the sections impacted on CE sizes. Frontal (coronal) sections are typically most efficient by providing the smallest CEs for a given amount of work. Applying the estimator to 3D-reconstructed layers and using very intense sampling, we observed CE size plots with m = 0 to m = 1 transitions that should also be expected but are not often observed in real section series. The data we present also allows the reader to approximate the sampling intervals in frontal, horizontal or sagittal sections that provide CEs of specified sizes for the layers of the mouse dentate gyrus.