David M. Parker

Urgent laparoscopic repair of acutely symptomatic PEH is safe and effective

BackgroundAcute incarceration of paraesophageal hernias (PEHs) requiring urgent or emergent surgery is rare. Patients are often elderly with significant comorbidities and have historically been treated with open abdominal or thoracic incisions. Our study was designed to evaluate the feasibility, safety, and efficacy of laparoscopic paraesophageal hernia repair (LPEHR) in patients with PEH and acute gastric volvulus.MethodsWe reviewed our prospectively maintained database and identified 269 patients who underwent an initial LPEHR between January 2003 and January 2012. Patients were divided into group A (acute), group B (age- and comorbidity-matched 1:3), and group C (all elective repairs). Group A included those admitted with acute symptoms related to PEH and underwent urgent repair. Patient age, Charlson score, operative time, length of stay (LOS), morbidity, mortality, and recurrence rates were compared.ResultsPatients who underwent urgent LPEHR had a higher perioperative morbidity rate than the elective and matched groups. The overall mortality rate was low and no statistical difference was found between groups A, B, and C. LOS in group A was longer than groups B and C. The need for ICU admission was also higher in group A. There was no statistical difference in recurrence rates.ConclusionsHistorically, patients presenting with acute symptoms related to PEH have required open repair, which is associated with significant morbidity and mortality. The acute group was older and sicker than our elective LPEHR patients and had more adverse events resulting in a longer LOS, even when compared with comorbidity-matched elective patients. However, the LOS remained shorter than that reported for open repair and there was no mortality. The recurrence rates in all groups were low and comparable to elective repairs.

Laparoscopic transhiatal esophagectomy for esophageal adenocarcinoma identified at laparoscopic Roux-en-Y gastric bypass

Highlights • Preoperative endoscopy is indicated bariatric patients with history of gastroesophageal reflux.• Laparoscopic transhiatal esophagectomy can be safely performed in patient with history of Roux-en-Y gastric bypass.• The gastric remnant provides a good conduit for reconstruction following esophagectomy in patients with a previous Roux-en-Y gastric bypass.

Multimodal Postoperative Pain Control Is Effective and Reduces Opioid Use After Laparoscopic Roux-en-Y Gastric Bypass

BackgroundOpioids have been the mainstay for postoperative pain relief for many decades. Recently, opioid-related adverse events and death have been linked to postoperative dependency. Multimodal approaches to postoperative pain control may be part of the solution to this health care crisis. The safety and effectiveness of multimodal pain control regimens after laparoscopic Roux-en-Y gastric bypass (LRYGB) has not been well studied. The primary aim of our study was to determine if an evidence-based, multimodal pain regimen during hospitalization could decrease the total oral morphine equivalent (TME) use after LRYGB.Study DesignWe conducted a retrospective cohort study comparing outcomes prior to the implementation of a multimodal pain protocol (December 2010–December 2012) to those after implementation (April 2013–July 2015). The protocol utilized oral celecoxib and scheduled oral acetaminophen for pain control, with opioids used only as needed for breakthrough pain. Data was extracted from an electronic medical record and an institutionally maintained database of all patients undergoing bariatric surgery at a single center.ResultsCompared to controls, the multimodal pain regimen significantly reduced TME used and maximum pain scores with no change in mean pain scores. Multimodal pain protocol patients had a shorter length of stay with no increase in bleeding complications or marginal ulcer rates.ConclusionsAn opioid-sparing multimodal pain regimen adequately controls pain while reducing TME use. The regimen appears to be safe and was associated with a reduced length of stay in patients undergoing LRYGB.