Evan T. Alicuben

Intraoperative Assessment of Perfusion of the Gastric Graft and Correlation With Anastomotic Leaks After Esophagectomy.

Anastomotic complications are a major source of morbidity after esophagectomy with gastric pull-up and are often related to poor graft perfusion. The aim of this study was to evaluate the use of laser-assisted fluorescent-dye angiography to assess perfusion in gastric grafts and determine the relationship between perfusion and anastomotic leaks.

Impact of crural relaxing incisions, Collis gastroplasty, and non-cross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates.

BACKGROUND Hernia recurrence is the leading form of failure after antireflux surgery and may be secondary to unrecognized tension on the crural repair or from a foreshortened esophagus. Mesh reinforcement has proven beneficial for repair of hernias at other sites, but the use of mesh at the hiatus remains controversial. The aim of this study was to evaluate the outcomes of hiatal hernia repair with human dermal mesh reinforcement of the crural closure in combination with tension reduction techniques when necessary. STUDY DESIGN We retrospectively reviewed the records of all patients who had hiatal hernia repair using AlloMax Surgical Graft (Davol), a human dermal biologic mesh. Objective follow-up was with videoesophagram and/or upper endoscopy at 3 months postoperatively and annually. RESULTS There were 82 patients with a median age of 63 years. The majority of operations (85%) were laparoscopic primary repairs of a paraesophageal hernia with a fundoplication. The crura were closed primarily in all patients and reinforced with an AlloMax Surgical Graft. A crural relaxing incision was used in 12% and a Collis gastroplasty in 28% of patients. There was no mesh-related morbidity and no mortality. Median objective follow-up was 5 months, but 15 patients had follow-up at 1 or more years. A recurrent hernia was found in 3 patients (4%). CONCLUSIONS Tension-reducing techniques in combination with human biologic mesh crural reinforcement provide excellent early results with no mesh-related complications. Long-term follow-up will define the role of these techniques and this biologic mesh for hiatal hernia repair.

Laparoscopic wedge fundectomy for collis gastroplasty creation in patients with a foreshortened esophagus.

Objective:To assess the outcome of a laparoscopic wedge-fundectomy Collis gastroplasty for a short esophagus during fundoplication and hiatal hernia repair. Background:The Collis gastroplasty provides a surgical solution for a foreshortened esophagus but has been associated with postoperative dysphagia and esophagitis. Methods:We identified 150 patients who underwent a Collis gastroplasty from 1998 to 2012, and of these, 85 patients underwent laparoscopic procedures using the wedge-fundectomy technique. Results:The median age of the 85 patients (42 men/43 women) was 66 years (range, 37–84 years). A Nissen fundoplication was added to the Collis gastroplasty in 56 patients (66%) and a Toupet fundoplication in 29 patients. No patient had a staple line leak or abscess, and the median hospital stay was 3.5 days (interquartile range, 3–4.5 days). At a median follow-up of 12 months, 93% of patients were free of heartburn. Dysphagia was significantly less common after surgery (preoperative: 58% vs postoperative: 16%; P < 0.0001). New-onset dysphagia developed in only 2 patients. An upper endoscopy was performed in 54 patients at a median of 6 months after surgery, and erosions above the fundoplication were seen in 6 patients (11%). A small (1–2 cm) recurrent hernia was seen in 2 patients (2.4%). Conclusions:The laparoscopic wedge-fundectomy Collis gastroplasty can be performed safely and is associated with a low prevalence of new-onset dysphagia and esophagitis. The addition of a Collis gastroplasty to an antireflux operation is an effective strategy in patients with short esophagus, and its more liberal use is encouraged.

Peroral Endoscopic Myotomy for Achalasia in a Thoracic Surgical Practice

BACKGROUND Peroral endoscopic myotomy (POEM) is a new option in the treatment of achalasia. It has typically been performed by general surgeons and gastroenterologists familiar with advanced endoscopic procedures. Our objective was to assess the initial experience and outcomes with POEM by a thoracic surgeon. METHODS A retrospective chart review was performed of all patients who underwent POEM from October 2012 until December 2014. Pre- and post-POEM evaluation included upper endoscopy, high-resolution manometry, and a timed barium swallow. RESULTS There were 35 patients (18 men and 17 women), with a median age of 53 years. Based on high-resolution manometry, there were 8 patients (23%) with type I, 21 (60%) with type II, and 5 (14%) with type III achalasia, and 1 patient had hypertensive lower esophageal sphincter. Prior therapy had been performed in 18 patients (51%). The POEM procedure was completed in all but 1 patient. On follow-up, dysphagia was improved in all patients. The Eckardt score was significantly reduced from 7 before POEM to 0 after POEM (p < 0.0001), and improved similarly for all manometric types of achalasia. Post-POEM upper endoscopy showed esophagitis in 55% of patients, but this condition resolved in all with acid suppression. Timed barium swallow showed a reduction of esophageal retention at 5 minutes from 63% before POEM to 5% after POEM. Ten patients had follow-up at 12 months or greater after POEM and the improvements persisted. CONCLUSIONS Peroral endoscopic myotomy is a safe and effective therapy for achalasia. It provides reliable and persistent palliation of dysphagia and objective improvement in esophageal emptying. Esophagitis is common but resolves with acid suppression therapy. Thoracic surgeons with an interest in esophageal diseases and experience with endoscopy are encouraged to adopt the procedure.

Nonadditive indirect effects of group genetic diversity on larval viability in Drosophila melanogaster imply key role of maternal decision‐making

Genetic variation can have important consequences for populations: high population genetic diversity is typically associated with ecological success. Some mechanisms that account for these benefits assume that local social groups with high genetic diversity are more successful than low‐diversity groups. At the same time, active decision‐making by individuals can influence group genetic diversity. Here, we examine how maternal decisions that determine group genetic diversity influence the viability of Drosophila melanogaster larvae. Our groups contained wild‐type larvae, whose genetic diversity we manipulated, and genetically marked ‘tester’ larvae, whose genotype and frequency were identical in all trials. We measured wild‐type and tester viability for each group. Surprisingly, the viability of wild‐type larvae was neither augmented nor reduced when group genetic diversity was altered. However, the viability of the tester genotype was substantially depressed in large, high‐diversity groups. Further, not all high‐diversity groups produced this effect: certain combinations of wild‐type genotypes were deleterious to tester viability, while other groups of the same diversity—but containing different wild‐type genotypes—were not deleterious. These deleterious combinations of wild‐type genotypes could not be predicted by observing the performance of the same tester and wild‐type genotypes in low‐diversity groups. Taken together, these results suggest that nonadditive interactions among genotypes, rather than genetic diversity per se, account for between‐group differences in viability in D. melanogaster and that predicting the consequences of genetic diversity at the population level may not be straightforward.

Kidney transplantation in the Hispanic population

Hispanic race and low socioeconomic status are established predictors of disparity in access to kidney transplantation. This single‐center retrospective review was undertaken to determine whether Hispanic race predicted kidney transplant outcomes. A total of 720 patients underwent kidney transplantation from January 1, 2004 to December 31, 2013, including 398 Hispanic patients and 322 non‐Hispanic patients. Hispanic patients were significantly younger (p < 0.0001), on hemodialysis for longer (p = 0.0018), had a greater percentage with public insurance (p < 0.0001), more commonly had diabetes as the cause of end‐stage renal disease (p = 0.0167), and had a lower percentage of living donors (p = 0.0013) compared to non‐Hispanic patients. There was no difference in one‐, five‐, and 10‐yr graft (97%, 81%, and 61% vs. 95%, 76%, and 42% p = 0.18) or patient survival (98%, 90%, and 84% vs. 97%, 87%, and 69% p = 0.11) between the Hispanic and non‐Hispanic recipients. Multivariate analysis identified increased recipient age and kidney donor profile index to be predictive of lower graft survival and increasing recipient age to be predictive of lower patient survival. In the largest single‐center study on kidney transplantation outcomes in Hispanic patients, there is no difference in graft and recipient survival between Hispanic and non‐Hispanic kidney transplant patients, and in multivariate analysis, Hispanic race is not a risk factor for graft or patient survival.

Inguinal Hernia Repair: Laparoscopic

Abstract Symptomatic inguinal hernias are a commonly encountered surgical problem. Repair can be performed with an open or minimally invasive approach. Laparoscopic inguinal hernia repair is now widely performed, especially in the setting of bilateral or recurrent inguinal hernias. This chapter reviews the anatomy, benefits, and possible complications of laparoscopic inguinal hernia repair. Laparoscopic inguinal hernia repair is also compared with the traditional anterior approach, and the operative techniques of both the transabdominal preperitoneal repair and the totally extraperitoneal repair are reviewed. The outcomes of these two procedures are also examined.

Routine esophageal manometry is not useful in patients with normal videoesophagram

BackgroundVideoesophagram (VEG) and esophageal manometry (EM) are components of the preoperative evaluation for foregut surgery. EM is able to identify motility disorders and diminished contractility that may alter surgical planning. However, there are no clearly defined criteria to guide this. Reliable manometry is not always easily obtained, and therefore its necessity in routine preoperative evaluation is unclear. We hypothesized that if a patient has normal videoesophagram, manometry does not reveal clinically significant esophageal dysfunction.MethodsWe reviewed patients who underwent protocolized videoesophagram and manometry at our institution. Measures of esophageal motility including the mean distal contractile integral (DCI), mean wave amplitude (MWA), and percent of peristaltic swallows (PPS) were analyzed. The Chicago Classification was used for diagnostic criteria of motility disorders. Normal VEG was defined as stasis of liquid barium on less than three of five swallows.ResultsThere were 418 patients included. 231 patients (55%) had a normal VEG, and 187 patients (45%) had an abnormal VEG. In the normal VEG group, only 2/231 (0.9%) patients had both abnormal DCI and PPS, 1/231 (0.4%) patients had both abnormal DCI and MWA and no patients had both abnormal MWA and PPS. There were no patients with achalasia or absent contractility and 1 patient with ineffective esophageal motility (IEM) in the normal VEG group. This was significantly different from the abnormal VEG group which included 4 patients with achalasia, 1 with absent contractility and 22 with IEM (p < 0.0001). The negative predictive value of VEG was 99.6% and the sensitivity was 96.4%.ConclusionsA normal videoesophagram reliably excluded the presence of clinically significant esophageal dysmotility that would alter surgical planning. Routine manometry is not warranted in patients with normal videoesophagram, and should be reserved for patients with abnormal VEG.