Association of changes in HerQLes scores with objective hernia outcomes: an analysis of the ACHQC database.

BACKGROUND: There are both objective and subjective measures of success following ventral hernia repair (VHR). Using the Abdominal Core Health Quality Collaborative (ACHQC) database, we sought to determine if there is an association between 30-day wound events (objective) and changes in the hernia-related quality-of-life (HerQLes) scores, (subjective). We hypothesized that patients who do not experience a 30-day wound event have a greater improvement in their HerQLes score over the short-term. METHODS: All adult patients who underwent VHR with 30-day follow-up data available between 2013 and 2022 were identified within the ACHQC database. The 30-day wound events included surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI). The association between 30-day wound events and changes in HerQLes scores was measured using propensity matched score analysis. Further, regression analysis was used to determine if an improvement in HerQLes score at 30-days postoperatively was associated with the likelihood of experiencing a 30-day wound event. RESULTS: Following a 3:1 matched analysis, 17,796 patients were available for analysis; 4449 (25%) patients experienced a 30-day wound event. The most common SSI was a superficial SSI and the most common SSO was a seroma. A 10-point improvement in the HerQLes score was statistically associated with a 3% decrease in SSI and a 4% decrease in the odds of experiencing an SSO. While not statistically significant, a 10-point improvement in the HerQLes score was associated with a 2.4% decrease in the odds of experiencing an SSOPI. CONCLUSIONS: Subjective and objective measures of success following VHR seem to be correlated with one another over the short-term. Additional studies are needed to determine if this correlation exists with other subjective and objective measures of success and to determine if these correlations persist over the long-term. If present, these associations may help to guide patient counseling as experiencing a postoperative wound event following ventral hernia repair may not be detrimental to their quality-of-life over the long-term.

Current status of resident simulation training curricula: pearls and pitfalls.

BACKGROUND: Residency programs are required to incorporate simulation into their training program. Ideally, simulation provides a safe environment for a trainee to be exposed to both common and challenging clinical scenarios. The purpose of this review is to detail the current state of the most commonly used laparoscopic, endoscopic, and robotic surgery simulation programs in general surgery residency education, including resources required for successful implementation and benchmarks for evaluation. MATERIALS AND METHODS: Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a literature review using PubMed and training websites. Information regarding the components of the most commonly used laparoscopic, endoscopic, and/or robotic simulation curriculum, including both formal and informal benchmarks for evaluating training competence, were collected. RESULTS: Laparoscopic simulation revolves around the Fundamentals of Laparoscopic Surgery (FLS). Proficiency-based as well as virtual simulation have been utilized for FLS training curricula. Challenges include less direct translation to the technical complexities that can arise in laparoscopic surgery. Endoscopic simulation focuses on the Fundamentals of Endoscopic Surgery. There are virtual reality simulation platforms that can be used for skills assessment and training. Challenges include simulator types and access, as well as structured mentoring and feedback. Robotic simulation training curricula have not been standardized. Simulation includes one primary technology, which can be prohibitive based on cost and requirements for onboarding. CONCLUSIONS: While surgical simulation seems to be a fundamental and integrated part of surgical training, it requires a significant number of resources, which can be daunting for residency training programs. Regardless of the barriers outlined, the need for surgical simulation in laparoscopy, endoscopy, and robotics at surgical education training programs is clear.

SAGES guideline for the diagnosis and treatment of appendicitis.

BACKGROUND: Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. METHODS: A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. RESULTS: Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. CONCLUSIONS: These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Diagnosis and treatment of appendicitis: systematic review and meta-analysis.

BACKGROUND: The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS: Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS: 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS: This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD).

BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. METHODS: Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS: The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. CONCLUSION: Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Minimally invasive Heller myotomy with partial posterior fundoplication for the treatment of achalasia: long-term results from a tertiary referral center.

INTRODUCTION: Few studies have reported the long-term results of minimally invasive Heller myotomy (HM) for the treatment of achalasia. Herein, we detail our 17-year experience with HM for the treatment of achalasia from a tertiary referral center. METHODS: All patients undergoing elective HM at our institution from 2000 to 2017 were identified within a prospective institutional database. These patients were sent mail and electronic surveys to capture their symptoms of dysphagia, chest pain, and regurgitation pre- and postoperatively and were asked to evaluate their postoperative gastrointestinal quality of life. Responses from adult patients who underwent minimally invasive Heller myotomy with partial posterior (i.e., Toupet) fundoplication (HM-TF) were analyzed. RESULTS: 294 patients were eligible for study inclusion; 139 (47%) completed our survey. Median time from HM-TF to survey response was 5.6 years. A majority of patients reported improvement in their dysphagia (91%), chest pain (70%), and regurgitation (87%) symptoms. Patients who underwent HM-TF more than 5 years ago were most likely to report heartburn symptoms. One (1%) patient went on to require esophagectomy for ongoing dysphagia and one (1%) patient required revisional fundoplication for their heartburn symptoms. CONCLUSIONS: Minimally invasive Heller myotomy and posterior partial fundoplication is a durable treatment for achalasia over the long term. Additional prospective and multi-institutional studies are needed to validate our results.

Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database.

BACKGROUND: It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use. METHODS: Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression. RESULTS: A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively. CONCLUSIONS: Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

Appropriate patient selection facilitates safe discharge from the PACU after laparoscopic ventral hernia repair: an analysis of the AHSQC database.

BACKGROUND: The postoperative management of patients undergoing laparoscopic ventral hernia repair (VHR) remains relatively unknown. The purpose of our study was to determine if patient and hernia-specific factors could be used to predict the likelihood of hospital admission following laparoscopic VHR using the Americas Hernia Society Quality Collaborative (AHSQC) database. METHODS: All patients who underwent elective, laparoscopic VHR with mesh placement from October 2015 through April 2019 were identified within the AHSQC database. Patients without clean wounds, those with chronic liver disease, and those without 30-day follow-up data were excluded from our analysis. Patient and hernia-specific variables were compared between patients who were discharged from the post-anesthesia care unit (PACU) and patients who required hospital admission. Comparisons were also made between the two groups with respect to 30-day morbidity and mortality events. RESULTS: A total of 1609 patients met inclusion criteria; 901 (56%) patients were discharged from the PACU. The proportion of patients discharged from the PACU increased with each subsequent year. Several patient comorbidities and hernia-specific factors were found to be associated with postoperative hospital admission, including older age, repair of a recurrent hernia, a larger hernia width, longer operative time, drain placement, and use of mechanical bowel preparation. Patients who required hospital admission were more likely than those discharged from the PACU to be readmitted to the hospital within 30 days (4% vs. 2%, respectively) and to experience a 30-day morbidity event (18% vs. 8%, respectively). CONCLUSIONS: Patient- and hernia-specific factors can be used to identify patients who can be safely discharged from the PACU following laparoscopic VHR. Additional studies are needed to determine if appropriate patient selection for discharge from the PACU leads to decreased healthcare costs for laparoscopic VHR over the long-term.

The Role of Bariatric Surgery on Diabetes and Diabetic Care Compliance.

PURPOSE OF REVIEW: Bariatric surgery is a durable and long-term solution to treat both obesity and its associated comorbidities, specifically type 2 diabetes mellitus (T2DM). Many studies have demonstrated the benefits of bariatric surgery on T2DM, but weight recidivism along with recurrence of comorbidities can be seen following these procedures. Patient compliance post-bariatric surgery is linked to weight loss outcomes and comorbidity improvement/resolution. The role of compliance with respect to T2DM medication in bariatric patients specifically has not recently been examined. This article seeks to review the role of bariatric surgery on short- and long-term resolution of T2DM, recurrence, and compliance with T2DM medication following bariatric surgery. RECENT FINDINGS: Seven randomized control trials have examined metabolic surgery versus medical therapy in glycemic control in patients meeting criteria for severe obesity. Six out of seven studies demonstrate a significant advantage in the surgical arms with regards to glycemic control, as well as secondary endpoints such as weight loss, serum lipid levels, blood pressure, renal function, and other parameters. While patient compliance with lifestyle modifications post-bariatric surgery is linked to weight loss outcomes, there are no studies to date that directly evaluate the role of lifestyle modifications and T2DM medication adherence in the management of T2DM post-bariatric surgery. Bariatric surgery is an effective treatment option to achieve long-term weight loss and resolution of obesity-related medical comorbidities, specifically T2DM. Patient compliance to lifestyle modifications post-bariatric surgery is linked to weight loss outcomes and comorbidity resolution. The role of diabetic care compliance in bariatric patient outcomes, however, is poorly understood. Further studies are needed to elucidate the predictors and associated risk factors for non-compliance in this patient population.

Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort.

BACKGROUND: The advent of newer second-line medical therapies (SLMT) for immune thrombocytopenia (ITP) has contributed to decreased rates of splenectomy, following a trend to avoid or delay surgery. We aimed to characterize the long-term outcomes of laparoscopic splenectomy (LS) for ITP at our institution, examining differences in LS efficiency when performed before or after SLMTs. METHODS: Adults with primary ITP who underwent LS between 2002 and 2016 were identified. Retrospective review of electronic medical records was supplemented with telephone interviews. Treatment response was defined according to current guidelines as complete responders (CR), responders (R), and non-responders (NR). Kaplan-Meier estimates assessed relapse-free rates, and predictors of long-term response were investigated using logistic regression. RESULTS: 109 patients met inclusion criteria, from which 42% were treated with an SLMT before referral to LS. LS was completed in all cases, with no conversions or intraoperative complications. The perioperative morbidity was 7.3%, including 3 deep vein and 2 portal vein thrombosis, one reoperation for bleeding, and no mortalities. Splenectomy was initially effective in 99 patients (CR + R = 90.8%), and 10 patients were NR. At a median 62-month follow-up, 25 patients relapsed, resulting in a 68% CR + R rate. Proportion of CR + R was similar in patients who previously received SLMT and those who did not (61 vs. 76.7%, p = 0.08). CR + R patients were younger (45 vs. 53, p = 0.03), had higher preoperative platelet counts (36 vs. 19, p = 0.01), and experienced a higher increment in platelet counts during hospital stay (117 vs. 38, p < 0.001) as well as 30-days postoperatively (329 vs. 124, p < 0.001). Only a robust response in platelet count at 30-days postoperatively was independently associated with long-term response (OR 1.005, p = 0.006). CONCLUSION: LS was curative in 68% of patients, with no statistically significant difference when performed before or after SLMTs. Outcomes remain challenging to predict preoperatively, with only a robust increase in platelet counts on short term being associated with long-term response.

Development of a Disease-based Hernia Program and the Impact on Cost for a Hospital System.

OBJECTIVE: The aim of this study was to assess the impact of developing a hernia program on mesh utilization. BACKGROUND: With the ongoing changes in healthcare, the value of all interventions will see increased scrutiny. Hernia mesh can be one of the most costly components of hernia repairs. A disease-based institutional hernia program that defines roles for mesh utilization and measures outcomes has the potential to add significant value to hospital systems. METHODS: In August 2014, a disease-based hernia program was initiated across a hospital system. In collaboration with hospital administration, surgical operations, and all surgeons involved in the care of hernia patients, general guidelines for mesh utilization based on CDC wound class were created. All hernia repairs performed between January 2013 and November 2015 were reviewed. RESULTS: Approximately, 13,937 hernias were repaired during the study period. Biologic mesh was used in 0.4% of clean, 7.1% of clean-contaminated, 38.5% of contaminated, and 58.8% of dirty cases. After initiation of the hernia program there was a reduction in biologic mesh utilization across the system (clean: 66% reduction; clean-contaminated: 63% reduction; contaminated: 55% reduction; dirty: 47% reduction). Surgeons who participated in the hernia program used significantly less biologic mesh in clean (P < 0.01), clean-contaminated (P = 0.01) and contaminated (P < 0.01) hernia repairs. CONCLUSIONS: The development of a system-wide hernia program based on collaboration with the hospital administration, operating room purchasing and clinicians resulted in a significant reduction in costly mesh utilization. This collaborative effort from all stakeholders involved in the care of a specific disease process could provide a reproducible model to improve the value equation through cost reduction strategies in today's healthcare environment.

Is It Time to Reconsider Postoperative Epidural Analgesia in Patients Undergoing Elective Ventral Hernia Repair?: An AHSQC Analysis.

OBJECTIVE: We aimed to evaluate the association of epidural analgesia (EA) with hospital length of stay (LOS), wound morbidity, postoperative complications, and patient-reported outcomes in patients undergoing ventral hernia repair (VHR). BACKGROUND: EA has been shown to reduce LOS in certain surgical populations. The LOS benefit in VHR is unclear. METHODS: Patients having VHR performed in the Americas Hernia Society Quality Collaborative (AHSQC) were separated into 2 comparable groups matched on several confounding factors using a propensity score algorithm: one group received postoperative EA, and the other did not. The groups were then evaluated for hospital LOS, 30-day wound morbidity, other complications, and 30-day patient-reported outcomes using pain and hernia-specific quality-of-life instruments. RESULTS: A 1:1 match was achieved and the final analysis included 763 patients receiving EA and 763 not receiving EA. The EA group had an increased LOS (5.49 vs 4.90 days; P < 0.05). The rate of wound events was similar between the groups. There was an increased risk of having any postoperative complication associated with having EA (26% vs 21%; P < 0.05). Pain intensity-scaled scores were significantly higher (worse) in the EA group versus the non-EA group (47.6 vs 44.0; P = 0.04). CONCLUSIONS: The LOS benefit of EA noted for other operations may not apply to patients undergoing VHR. Further study is necessary to determine the beneficial role of invasive pain management procedures in this group of patients with an extremely common disease state.

Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis: Short Term Results From the First 100 Patients at a High Volume Center.

OBJECTIVE: For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center. METHODS: The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0 ±â€Š14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82 ±â€Š0.86 to 2.54 ±â€Š1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP. CONCLUSION: For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.

The effect of resident involvement on bariatric surgical outcomes: an ACS-NSQIP analysis.

BACKGROUND: Surgical residency training programs in the United States are modeled on the principle of graduated responsibility. Residents are given greater responsibility and autonomy in the operating room and during perioperative care as they gain surgical skills and progress through their training. The impact of this method of surgical training on patient outcomes remains unknown. The purpose of this study is to compare early patient morbidity and mortality after bariatric surgery in cases with and without resident participation using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: All patients undergoing bariatric surgery from 2006 through 2010 were identified within the American College of Surgeons National Surgical Quality Improvement Program database. These patients were divided into three groups based on resident involvement in their surgery (no resident, senior-level resident, and junior-level resident). The effect of resident involvement and postgraduate year level on 30-d morbidity and mortality was investigated using composite outcomes, including cardiac events (acute myocardial infarction or cardiac arrest requiring cardiopulmonary resuscitation), pulmonary events (pneumonia, prolonged intubation, or unplanned reintubation), wound (superficial surgical site infection, deep surgical site infection, organ-space infection, or dehiscence), septic events (sepsis and septic shock), clotting events (pulmonary embolism and deep venous thrombosis), and renal events (urinary tract infection and acute kidney injury requiring dialysis). Length of hospital stay, unplanned return to the operating room, and 30-d mortality were also investigated. RESULTS: A total of 19,616 patients underwent bariatric surgery from the year 2006 through 2010; 8960 (45.7%) procedures were performed with resident involvement, with 5406 (36.7%) of these cases involving a senior-level resident. Operations involving a senior-level resident were more likely to experience postoperative cardiac events (P < 0.006), pulmonary events (P = 0.03), wound events (P = 0.01), septic events (P < 0.002), renal events (P ≤ 0.01), prolonged operative time (P < 0.0001), and a prolonged length of hospital stay (P < 0.0001) than those that involved either no resident or a junior-level resident. CONCLUSIONS: Although bariatric operations involving senior-level residents have more statistically significant morbidity outcomes, these morbidity outcomes are related more to perioperative care rather than intraoperative resident involvement. This suggests that more emphasis on perioperative progressive responsibility may be needed to match operative oversight.

Magnetic surgery: first U.S. experience with a novel device.

INTRODUCTION: Magnet-assisted surgery is a new platform within minimally invasive surgery. The Levita™ Magnetic Surgical System, the first magnetic surgical system to receive Food and Drug Administration (FDA) approval, includes a deployable, magnetic grasper and an external magnet that is used to manipulate the grasper within the peritoneal cavity. This system is currently approved for patients undergoing laparoscopic cholecystectomy with a body mass index (BMI) between 21 and 34 kg/m2. Herein, we detail the first United States experience with the Levita™ Magnetic Surgical System during laparoscopic cholecystectomy. METHODS: The Levita™ Magnetic Surgical System was used on consecutive patients undergoing laparoscopic cholecystectomy at our institution from June 2016 through November 2016. Only patients undergoing elective surgery and those with a body mass index (BMI) between 21 and 34 kg/m2 were included. Baseline patient characteristics, operative time, and perioperative details were collected. RESULTS: A total of ten patients underwent laparoscopic cholecystectomy with the Levita™ Magnetic Surgical System during the defined study period. The mean age at the time of surgery was 49.0 years and the average BMI of the cohort was 27.6 kg/m2. The average operative time was 64.4 min. There were no perioperative complications. Seven (70.0%) patients were discharged to home on the day of surgery, while the remaining three (30.0%) patients were discharged to home on postoperative day number one. Surgeons reported that the magnetic grasper was easy to use and provided adequate tissue retraction and exposure. CONCLUSIONS: The Levita™ Magnetic Surgical System is safe and feasible to use in patients undergoing laparoscopic cholecystectomy. Routine use of this system may facilitate a reduction in the total number of laparoscopic trocars used, leading to less tissue trauma and improved cosmesis. Additional studies are needed to determine the applicability and utility of this system for other general surgery cases.

Comparison of laparoscopic jejunostomy tube to percutaneous endoscopic gastrostomy tube with jejunal extension: long-term durability and nutritional outcomes.

INTRODUCTION: Enteral access through the jejunum is indicated when patients cannot tolerate oral intake or gastric feeding. While multiple approaches for feeding jejunal access exist, few studies have compared the efficacy of these techniques. The purpose of this study was to investigate the long-term durability, re-intervention rates, and nutritional outcomes following percutaneous endoscopic gastrostomy tubes with jejunal extension tubes (PEG-JET) versus laparoscopic jejunostomy tubes (j-tubes). METHODS: Retrospective chart review was performed on all patients who underwent PEG-JET or laparoscopic jejunostomy tube placement from January 2005 through December 2015 at our institution. Thirty-day and long-term outcomes were compared between the two groups. RESULTS: A total of 105 patients underwent PEG-JET and 307 patients underwent laparoscopic j-tube placement during the defined study period. In terms of 30-day outcomes, patients who underwent PEG-JET placement were significantly more likely to experience a tube dislodgement event (p = 0.005) and undergo a re-intervention (p < 0.001). Patients who had a laparoscopic j-tube placed were significantly more likely to meet their enteral feeding goals (p = 0.002) and less likely to require nutritional supplementation with total parenteral nutrition (TPN) (p < 0.001). With regard to long-term outcomes, patients who underwent PEG-JET placement were significantly more likely to experience tube occlusion (p < 0.001) and require an endoscopic or surgical tube re-intervention (p < 0.001). Patients who underwent laparoscopic j-tube placement were significantly more likely to experience a tube site leak (p = 0.015) but were less likely to require nutritional supplementation with TPN (p = 0.001). CONCLUSION: Laparoscopic jejunostomy tubes provide more durable long-term enteral access compared to PEG-JET. Consideration should be given to laparoscopic jejunostomy tube placement in eligible patients who cannot tolerate oral intake or gastric enteral feeding.

Development of a critical-sized ventral hernia model in the pig.

BACKGROUND: The pig is commonly used as a preclinical model for ventral hernia repair. However, no study has verified that an unrepaired surgically induced hernia (control) in the pig does not heal spontaneously but rather develops a persistent hernia. Without such verification in any given model, one cannot draw conclusions on the efficacy of the repair technique investigated. MATERIALS AND METHODS: Three surgically induced hernia models with increasing severity were created in eight pigs. These included 10-cm retrorectus partial-thickness (model 1) and 15-cm preperitoneal full-thickness (model 2) incisional defects and an 8 × 8 cm preperitoneal full-thickness excisional defect (model 3). Postoperative management included use of an abdominal binder, and in some cases, suction drainage, for 2 wk to support the repair and prevent seroma. Models were evaluated for persistence of hernia at 5 wk using clinical and radiographic assessments. RESULTS: All pigs developed clinical hernias after 2 wk of defect creation, but only models 1 and 3 had clinically persistent hernias at 5 wk. At 5 wk, the average defect area was 97 cm2 in model 1, 66 cm2 in model 2, and 245 cm2 in model 3. Dense fibrotic scarring was observed in the models with resolved hernias. CONCLUSIONS: Our results highlight the need to verify an unrepaired hernia injury model does not heal spontaneously prior to using it for hernia repair studies. The partial-thickness incisional model 1 and full-thickness excisional model 3 formed persistent hernias in pigs at 5 wk and should be further explored as models for investigating hernia repair strategies.

Median arcuate ligament syndrome in athletes.

BACKGROUND: Exercise-related transient abdominal pain (ETAP) is a common entity in young athletes. Most occurrences are due to a "cramp" or "stitch," but an uncommon, and often overlooked, etiology of ETAP is median arcuate ligament syndrome (MALS). The initial presentation of MALS typically includes postprandial nausea, bloating, abdominal pain, and diarrhea, but in athletes, the initial presentation may be ETAP. METHODS: We present a case series of three athletes who presented with exercise-related transient abdominal pain and were ultimately diagnosed and treated for MALS. Unlike other patients with median arcuate ligament syndrome, these athletes presented with exercise-induced pain, rather than the common postprandial symptoms. These symptoms persisted despite conservative measures. Work-up of patients with suspected MALS include a computed tomography or magnetic resonance angiography showing compression of the celiac artery with post-stenotic dilation, or a celiac artery ultrasound demonstrating increased velocities (>200 cm/s2) with deep exhalation. RESULTS: All patients underwent a laparoscopic median arcuate ligament release. Postoperatively, there were no complications, and all were discharged home on postoperative day #2. All patients have subsequently returned to athletics with resolution of their symptoms. CONCLUSION: ETAP is common in athletes and often resolves with preventative or conservative strategies. When ETAP persists despite these methods, alternative causes, including MALS, should be considered. A combination of a thorough history and physical exam, as well as radiographic data, is essential to make the appropriate diagnosis and treatment strategy.