Patrick R. Reardon

Guidelines for surgical treatment of gastroesophageal reflux disease.

GERD was defined according to the Montreal Consensus as “a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.” Symptoms were considered “troublesome” if they adversely affected an individual’s well-being [5]. n nFrom a surgical perspective, GERD is the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus [6]. It is a mechanical disorder, which is caused by a defective lower esophageal sphincter (LES), a gastric emptying disorder, or failed esophageal peristalsis. These abnormalities result in a spectrum of disease, ranging from symptoms only, such as “heartburn,” to esophageal tissue damage with or without subsequent complications including malignancy or airway disease. While the exact nature of the antireflux barrier is incompletely understood, the current view is that the LES, the diaphragmatic crura, and the phrenoesophageal ligament are key components [7, 8].

Class II Major Histocompatibility Complex Plays an Essential Role in Obesity-Induced Adipose Inflammation

Adipose-resident T cells (ARTs) regulate metabolic and inflammatory responses in obesity, but ART activation signals are poorly understood. Here, we describe class II major histocompatibility complex (MHCII) as an important component of high-fat-diet (HFD)-induced obesity. Microarray analysis of primary adipocytes revealed that multiple genes involved in MHCII antigen processing and presentation increased in obese women. In mice, adipocyte MHCII increased within 2 weeks on HFD, paralleling increases in proinflammatory ART markers and decreases in anti-inflammatory ART markers, and preceding adipose tissue macrophage (ATM) accumulation and proinflammatory M1 polarization. Mouse 3T3-L1 and primary adipocytes activated T cells in an antigen-specific, contact-dependent manner, indicating that adipocyte MHCII is functional. HFD-fed MHCII(-/-) mice developed less adipose inflammation and insulin resistance than did wild-type mice, despite developing similar adiposity. These investigations uncover a mechanism whereby a HFD-induced adipocyte/ART dialog involving MHCII instigates adipose inflammation and, together with ATM MHCII, escalates its progression.

Laparoscopic resection of splenic artery aneurysms

BackgroundLaparoscopic techniques used to manage asymptomatic splenic artery aneurysms have been reported infrequently.MethodsA laparoscopic splenic artery aneurysm resection was attempted for six consecutive patients.ResultsOne patient underwent conversion to laparotomy because of a tear in the splenic vein. Among the five successful laparoscopic splenic artery aneurysm resections, the mean estimated blood loss was 37 ± 12.6 ml, the mean operative time was 187.6 ± 79.2 min, and the mean postoperative length of hospital stay was 1.8 ± 1.3 days. The mean time to a clear liquid diet was 5.3 ± 0.5 h, and the mean time to a regular diet was 1 ± 0 day. The mean duration of narcotic analgesic use was 5.4 ± 1.5 days, and the mean time to resumption of regular activities was 12.7 ± 1.6 days.ConclusionsThese cases illustrate the benefit of a laparoscopic approach with brief hospitalizations, early resumption of diet and regular activity, and minimal use of postoperative narcotic analgesics.

Chopstick surgery: a novel technique enables use of the Da Vinci Robot to perform single-incision laparoscopic surgery

IntroductionSingle-incision laparoscopic surgery (SILS) is limited by the coaxial arrangement of the instruments. A surgical robot with “wristed” instruments could overcome this limitation but the “arms” collide when working coaxially. This video demonstrates a new technique of “chopstick surgery,” which enables use of the robotic arms through a single incision without collision.MethodsExperiments were conducted utilizing the da Vinci S® robot (Sunnyvale, CA) in a porcine model with three laparoscopic ports (12xa0mm, 2–5xa0mm) introduced through a single “incision.” Pilot work conducted while performing Fundamentals of Laparoscopic Surgery (FLS) tasks determined the optimal setup for SILS to be a triangular port arrangement with 2-cm trocar distance and remote center at the abdominal wall. Using this setup, an experienced robotic surgeon performed a cholecystectomy and nephrectomy in a porcine model utilizing the “chopstick” technique. The chopstick arrangement crosses the instruments at the abdominal wall so that the right instrument is on the left side of the target and the left instrument on the right. This arrangement prevents collision of the external robotic arms. To correct for the change in handedness, the robotic console is instructed to drive the “left” instrument with the right hand effector and the “right” instrument with the left.ResultsBoth procedures were satisfactorily completed with no external collision of the robotic arms, in acceptable times and with no technical complications. This is consistent with results obtained in the box trainer where the chopstick configuration enabled significantly improved times in all tasks and decreased number of errors and eliminated instrument collisions.ConclusionChopstick surgery significantly enhances the functionality of the surgical robot when working through a small single incision. This technique will enable surgeons to utilize the robot for SILS and possibly for intraluminal or transluminal surgery.

Transcriptome analysis of human adipocytes implicates the NOD-like receptor pathway in obesity-induced adipose inflammation

Adipose tissue inflammation increases with obesity, but adipocyte vs. immune cell contributions are unclear. In the present study, transcriptome analyses were performed on highly-purified subcutaneous adipocytes from lean and obese women, and differentially expressed genes/pathways were determined in both adipocyte and stromal vascular fraction (SVF) samples. Adipocyte but not SVF expression of NOD-like receptor pathway genes, including NLRP3 and PYCARD, which regulate caspase-1-mediated IL-1β secretion, correlated with adiposity phenotypes and adipocyte class II major histocompatibility complex (MHCII) gene expression, but only MHCII remained after adjusting for age and body mass index. IFNγ stimulated adipocyte MHCII, NLRP3 and caspase-1 expression, while adipocyte MHCII-mediated CD4(+) T cell activation, an important factor in adipose inflammation, induced IFNγ-dependent adipocyte IL-1β secretion. These results uncover a dialogue regulated by interactions among T cell IFNγ and adipocyte MHCII and NLRP3 inflammasome activity that appears to initiate and escalate adipose tissue inflammation during obesity.

Uptake of enhanced recovery practices by SAGES members: a survey

BackgroundThe SAGES Surgical Multimodal Accelerated Recovery Trajectory (SMART) Enhanced Recovery Task Force aims to increase awareness and provide tools for members to successfully implement enhanced recovery pathways (ERPs) to improve clinical outcomes and patient satisfaction. An initial step was to survey SAGES member on their knowledge, use, and impediments to enhanced recovery.MethodsAn online survey designed by SMART committee members to define SAGES member’s awareness and use of enhanced recovery principles and practice was emailed to all SAGES members. Reminders were sent 2 and 3xa0weeks later, encouraging completion of the survey. The web-based survey included 48 questions and took an estimated 20xa0min to complete.ResultsA total of 229 members completed the survey. Respondents were primarily general/MIS surgeons (82.6%) working in an urban location (85.5%), with a bell-shaped age distribution (median 35–44). Almost half regularly used some elements of ERPs (48.7%), but 30% were unfamiliar with the concept. Wide variety in the specific ERP elements used and discharge criteria were reported. The majority had to create and implement their own plan (70.4%). Roadblocks to implementation were inconsistencies with partners/covering physicians (56.3%), nursing education (46.6%), and resources (34.7%). When implemented, members saw improvements in length of stay (88%), patient satisfaction (54.7%), postoperative pain (53.3%), time to return of bowel function (52.7%), and readmissions (16.7%). A need for education and standardization was especially seen in preoperative care, with 74.4% fasting patients from midnight the night before surgery. Wide variations were also reported in pain management practices. An overwhelming majority (89%) reported that having a protocol endorsed by a national organization, such as SAGES, would help with implementation.ConclusionsFrom this survey of SAGES members, there is a need for education, tools, and standardized protocols to increase awareness, support implementation, and encourage wider utilization of ERP. The overwhelming majority stated having a protocol endorsed by a national organization, such as SAGES, would facilitate implementation.

Mesh fixation with a barbed anchor suture results in significantly less strangulation of the abdominal wall

BackgroundLaparoscopic ventral hernia repair using an underlay mesh frequently requires suture fixation across the abdominal wall, which results in significant postoperative pain. This study investigates the utility of a novel mesh fixation technique to reduce the strangulation force on the abdominal wall.MethodsMultiple 2-cm2 pieces of polyester mesh (Parietex Composite, Covidien) were placed as an underlay against a porcine abdominal wall. Fixation was accomplished using either the standard 0-polyglyconate or the 0-polyglyconate barbed anchor suture designed to hold in tissue without the need to tie a knot (V-Loc 180; Covidien). Suture fixation began with a stab wound incision in the skin. A suture-passing device then was used to pass the suture across the abdominal wall and through the mesh. The suture passer was removed and reintroduced through the same stab wound incision but at a different fascial entry point 1.5xa0cm away. The tail of the suture was grasped and pulled up through both the mesh and the abdominal wall, creating a full-thickness U-stitch. One tail of the suture was attached to a tensiometer, and the strangulation force on the abdominal wall was measured while the suture was tied (standard) or looped (barbed). To compare pullout force, the tensiometer was attached to either the mesh or the suture, and traction was applied until material failure or suture pull through. Results are expressed as meanxa0±xa0standard deviation. Comparisons were performed using Student’s t-test.ResultsEight pieces of mesh were placed for each suture. The average force required to secure the barbed suture (0.59 ± 0.08xa0kg) was significantly less than the force needed to secure the standard suture (2.17xa0±xa00.58xa0kg) (Pxa0<xa00.0001). Tablexa01 compares the suture pullout forces with the mesh failure forces. Although the pullout force for the standard suture is significantly greater than for the barbed suture, both sutures have a pullout strength significantly greater than the mesh failure force.Tablexa01Suture fixation forces for standard and barbed suturesSuture fixation force (kg)Standard suture2.17 ± 0.58Barbed suture0.59 ± 0.08Pxa0<xa00.0001ConclusionsA barbed anchor suture used to secure mesh to the abdominal wall requires nearly 75% less strangulation force than a standard monofilament suture while still providing significantly greater pullout force than that required for the mesh to tear and fail. This method of mesh fixation should result in less postoperative pain and warrants a clinical trial.

A modest proposal [1]

I read with interest the article by Granderath et al. [1] discussing the role of hiatus closure in postoperative dysphagia after laparoscopic 360 fundoplication. I commend this group for their constant efforts to improve this operation. One problem I had with this article is that it is impossible to tell exactly how tightly the crura were closed in the initial or subsequent operations. Accurate descriptions usually are given regarding the type of sutures used, the presence or absence of mesh, the shape of the mesh, and so on. For an accurate comparison of whether the crural closure performed by two different surgeons is more or less likely to cause dysphagia, we need a common method for gauging both the starting size of the hiatal hernia (or hiatus) repaired and the final size of the hiatus after closure. Concerning how tight to close the hiatus, it seems intuitive that the tighter you close the crura, the less likely you are to have postoperative intrathoracic migration of the wrap. The most frequent anatomic morphologic complication leading to recurrent or persistent symptoms after antireflux surgery is intrathoracic wrap migration [1]. Equally intuitive, and borne out by this article, is that the tighter you close the hiatus, the more likely you are to cause dysphagia by direct obstruction of the esophagus by the crural sling. The ideal crural closure is the tightest closure that does not lead to long-term dysphagia. This ideal should be associated as well with the lowest acceptable incidence of intrathoracic wrap migration. It also seems intuitive that the larger the diameter of the hiatus before closure, the more likely are the chances of subsequent disruption to the posterior crural repair. Unless some sort of measurements are recorded to document such differences before and after crural closure, understanding the import of the subsequent outcomes is very difficult. I propose that to alleviate this problem, all surgeons performing closure of the hiatus as part of a hiatal hernia repair or fundoplication should measure the diameter of the hiatus both before and after closure. Currently, I measure the anteroposterior dimensions of the hiatus, in centimeters, along the length of the right crus. The anteriormost point of the right crus is measured down to the point at which the left crus and right crus join posteriorly using a flexible plastic ruler (DeRoyal Surgical, Powell, TN, USA). These data are recorded in the operative report under the ‘‘Findings’’ header. I believe, on the basis of prior experience with closure of the hiatus over a 60-Fr. bougie, that the appropriate final anteroposterior diameter for closure of the hiatus is 18 to 20 mm. This was the consistent diameter measured after gentle closure of the crura snug over a 60-Fr. bougie, removal of the Bougie, and placement of a single additional suture to the closure. It should leave adequate room for passage of a food bolus. Long-term dysphagia has been minimal. Whether 18 to 20 mm is indeed the ‘‘ideal diameter’’ for closure of the hiatus or not can be determined only by knowing what the actual final anteroposterior diameter of the hiatal closure is and comparing it with the results of others. Studies would be required that kept all other aspects of the operation the same including mesh use, wrap length and tightness, and so forth, and that gradually diminished the diameter of the hiatal closure until an unacceptable level of dysphagia was reached. Accurate tracking of postoperative intrathoracic migration of the wrap would be required, and this outcome would have to be balanced against dysphagia caused by tight crural closure. As I was just starting to perform laparoscopic 360 fundoplications and repairs of hiatal hernias, I read as much as I could and attended as many lectures by experts as I could in an attempt to learn the precise ‘‘details’’ of a correctly performed operation. I was immensely frustrated when I asked experts exactly how tight to close the crura and got vague answers such as ‘‘just tight enough to prevent a postoperative hiatal hernia, but not so tight as to cause dysphagia.’’ I make this ‘‘modest proposal’’ in the hope that through accurate recording of the exact details of the operations we perform, we not only can advance the science of surgery and improve our outcomes, but also can pass accurate information on to all surgeons concerning the technical details of how to perform these operations correctly.

Laparoscopic Pancreaticoduodenectomy for Cancer: Margin Status, Adequacy of Resection and 90 Day Outcomes

BACKGROUND: Morbidity and mortality rates for major surgical procedures are improved in high volume hospitals. Additionally, high volume centers are often leaders in the utilization of novel surgical technology such as minimally invasive surgery (MIS) for colorectal disease. Although high volume centers often serve diverse patient populations, it is unknown if there are disparities in the application of new surgical technologies within these hospitals. We sought to determine if ethnic and socioeconomic disparities in the use of MIS for colorectal disease exist at high volume centers. METHODS: Using the 2008 National Inpatient Sample database, a retrospective review of laparoscopic colectomies performed at high volume centers (case volume >200 year) was conducted. ICD-9 codes were used to identify minimally invasive (MIS) colorectal resections. Multivariate logistic regression including ethnic and socioeconomic variables was used to identify independent predictive factors for undergoing MIS. RESULTS: A total of 98,047 colorectal resections were performed at high volume centers in 2008. Overall, only 7950 (8.1%) colorectal resections were performed using a minimally invasive approach. Patients with malignant neoplasms were three times more likely to undergo MIS and those receiving elective resections were twice as likely (Table1). When evaluating racial and socioeconomic factors, patients within the highest income quartile were more likely to undergo minimally invasive surgery than those in the lowest income groups. In addition, Medicaid and Medicare patients were significantly less likely to undergo MIS. Lastly, race was not a significant predictive factor for undergoing MIS for colorectal disease at a high volume center. CONCLUSION: There are significant socioeconomic disparities in the use of minimally invasive surgery for colorectal disease at high volume centers. Future studies should be aimed at identifying access barriers to MIS in the treatment of colorectal disease.

Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae

BackgroundPrimary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair.MethodsUtilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closurexa0+xa0absorbable or non-absorbable mesh and fundoplication with hiatal closure alone.ResultsA total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29xa0years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the ‘Mesh’ cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the ‘No Mesh’ cohort (pxa0=xa00.362). A reoperation was necessary in 6 patients (6.7%) in the ‘Mesh’ cohort as compared to 3 patients (3.5%) in the ‘No Mesh’ cohort (pxa0=xa00.543).ConclusionsOnlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.