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Background The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy. Methods A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0–4, five-point Likert scale questionnaire) and 24-h pH testing at 6–12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann–Whitney U test, Wilcoxon signed rank test, and Freidman’s test. Results Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6–12 months in 43 patients (72%: Dor n  = 24 and Toupet n  = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) ( p  = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups). Conclusion Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.

Background The objective of this review was to provide an overview of the components that comprise each of the eight barrier mesh prostheses commonly utilized for LVHR and to review the current literature related to the characteristics and effectiveness of these materials to guide the general surgeon in selecting the most appropriate material for LVHR. Methods Composite prostheses with permanent barriers (Bard™ Composix™ E/X, Bard™ Composix™ L/P, and DUALMESH ® Biomaterial) were compared to composite prostheses with absorbable barriers (C-QUR™ Mesh, PROCEED™ Surgical Mesh, Bard™ Sepramesh™ IP Composite, Parietex™ Composite, and PHYSIOMESH™) using scanning electron microscopy and a review of the current preclinical and clinical literature. Results Clinical studies and preclinical animal models have attempted to determine the adhesion characteristics and effectiveness of barrier mesh prostheses available for ventral hernia repair applications. However, it is difficult to make any definitive statements about the adhesion characteristics and effectiveness of these materials because all meshes were not included in all studies and likewise not compared under identical conditions. Overall, Parietex™ Composite and DUALMESH ® Biomaterial were cited most frequently for improvement of adhesion characteristics, followed closely by Bard™ Sepramesh™ IP Composite and C-QUR™ Mesh. Bard™ Composix™, PROCEED™ Surgical Mesh, and uncoated polypropylene were cited most frequently as having the most tenacious and extensive adhesions. Conclusions Differences observed between the various barrier prostheses are likely attributable to the chemical composition of the barrier or the conditions required for resorption and metabolism of the barrier components. It is likely that the components of these barriers incite a wide range of inflammatory responses resulting in the range of adhesion coverage and tenacity observed in the preclinical and clinical studies reviewed. Clinical trials are needed to more appropriately define the clinical effectiveness of these barriers.

Background Risk factors for selecting patients for open adrenalectomy (OA) and for conversion are limited in most series. This study aimed to investigate variables that are important in selecting patients for OA, predict risk of conversion from laparoscopic adrenalectomy (LA), and impact 30-day outcomes of OA and LA. Methods A retrospective cohort study of prospectively collected data was conducted. Patients (≥16 years old) who underwent adrenalectomy in the Division of General Surgery at Barnes-Jewish Hospital (1993–2010) were grouped by operative approach (LA vs. OA) and compared using nonparametric tests and regression analyses ( α  < 0.05). Results In total, 402 patients underwent 422 adrenalectomies. Compared to LA patients, those in the OA group were older ( p  = 0.02), had higher ASA scores ( p  = 0.04), larger tumor size ( p  < 0.01), and fewer functioning lesions ( p  < 0.01). OA patients more often required concurrent procedures ( p  < 0.01), had a longer operative time ( p  = 0.04), more intraoperative complications ( p  = 0.02), higher estimated blood loss (EBL), and larger transfusion requirement. Preoperative factors that predicted selection for OA were higher patient age ( p  = 0.01), higher ASA score ( p  = 0.03), larger tumor size ( p  < 0.01), nonfunctioning lesion ( p  < 0.01), diagnosis of adrenocortical carcinoma ( p  < 0.01), and the need for concomitant procedures ( p  < 0.01). Conversion to open or hand-assisted approach occurred in 6.2 % of LA patients. Preoperative risks for conversion included large tumor size (>8 cm) and need for concomitant procedures ( p  < 0.01). Multivariate analysis revealed that large indeterminate adrenal mass, adrenocortical carcinoma, tumor size (>6 cm), an open operation, conversion, concomitant procedures, operative time >180 min, and EBL >200 mL were predictors of 30-day morbidity. Conclusions Adrenal tumor size and need for concurrent procedures significantly impact the selection of patients for OA, the likelihood of conversion, and perioperative morbidity. These metrics should be considered when assessing operative approach and risks for adrenalectomy.

The purpose of this study was to analyze the published perioperative results and outcomes of laparoscopic (LVHR) and open (OVHR) ventral hernia repair focusing on complications and hernia recurrences. Data were compiled from all English-language reports of LVHR published from 1996 through January 2006. Series with fewer than 20 cases of LVHR, insufficient details of complications, or those part of a larger series were excluded. Data were derived from 31 reports of LVHR alone (unpaired studies) and 14 that directly compared LVHR to OVHR (paired studies). Chi-squared analysis, Fisher's exact test, and two-tailed t-test analysis were used. Forty-five published series were included, representing 5340 patients (4582 LVHR, 758 OVHR). In the pooled analysis (combined paired and unpaired studies), LVHR was associated with significantly fewer wound complications (3.8% vs. 16.8%, p < 0.0001), total complications (22.7% vs. 41.7%, p < 0.0001), hernia recurrences (4.3% vs. 12.1%, p < 0.0001), and a shorter length of stay (2.4 vs. 4.3 days, p = 0.0004). These outcomes maintained statistical significance when only the paired studies were analyzed. In the pooled analysis, LVHR was associated with fewer gastrointestinal (2.6% vs. 5.9%, p < 0.0001), pulmonary (0.6% vs. 1.7%, p = 0.0013), and miscellaneous (0.7% vs. 1.9%, p = 0.0011) complications, but a higher incidence of prolonged procedure site pain (1.96% vs. 0.92%, p = 0.0469); none of these outcomes was significant in the paired study analysis. No differences in cardiac, neurologic, septic, genitourinary, or thromboembolic complications were found. The mortality rate was 0.13% with LVHR and 0.26% with OVHR (p = NS). Trends toward larger hernia defects and larger mesh sizes were observed for LVHR. The published literature indicates fewer wound-related and overall complications and a lower rate of hernia recurrence for LVHR compared to OVHR. Further controlled trials are necessary to substantiate these findings and to assess the health care economic impact of this approach.

Background This study aimed to compare the physicomechanical properties of composite prostheses for laparoscopic ventral hernia repair (LVHR) through standard testing and a proposed classification system. Methods Seven prostheses (four with absorbable barriers and 3 with nonabsorbable barriers) were evaluated. The barrier layer was removed, after which the area of the interstices and the diameter of the filaments were determined. The barrier layer was left intact during thickness, density, suture retention strength, tear resistance, uniaxial tensile, and ball-burst testing. Specimens were oriented parallel or perpendicular to their longest dimension during testing. One-way analysis of variance (ANOVA) with Tukey’s posttest or an unpaired, two-tailed t -test was performed to determine whether differences existed due to mesh or orientation, and a p value <0.05 was considered significant. Results Significant differences were observed between mesh types and due to the orientation of the mesh during testing. Of the absorbable barrier meshes, Bard Sepramesh IP Composite demonstrated the greatest suture retention and tear strengths, followed by C-QUR mesh. Of the permanent barrier meshes, DUALMESH demonstrated the greatest suture retention strength in the perpendicular direction, followed by Bard Composix E/X. DUALMESH and Bard Composix E/X demonstrated equivalent suture retention strength in the parallel direction and equivalent tear resistance in both testing directions. All meshes demonstrated tensile strengths greater than the physiologically relevant range of 16–32 N/cm. Conclusions This study provided a basic understanding of how the structural aspects of each mesh design influence functionality. Differences between composite barrier prostheses commonly used for LVHR were observed due to barrier type, mesh type, and orientation. A set of standard testing techniques and a classification system also were presented to define fully the properties of these materials.

Emergency general surgery (EGS) admissions account for more than 3 million hospitalizations in the US annually. We aim to better understand characteristics and mortality risk for EGS interhospital transfer patients compared to EGS direct admissions. Using the 2002–2011 Nationwide Inpatient Sample we identified patients aged ≥18 years with an EGS admission. Patient demographics, hospitalization characteristics, rates of operation and mortality were compared between patients with interhospital transfer versus direct admissions. Interhospital transfers comprised 2% of EGS admissions. Interhospital transfers were more likely to be white, male, Medicare insured, and had higher rates of comorbidities. Interhospital transfers underwent more procedures/surgeries and had a higher mortality rate. Mortality remained elevated after controlling for patient characteristics. Interhospital transfers are at higher risk of mortality and undergo procedures/surgeries more frequently than direct admissions. Identification of contributing factors to this increased mortality may identify opportunities for decreasing mortality rate in EGS transfers. •EGS interhospital transfers have higher rates of mortality than direct admissions.•Direct admissions are less likely to have a procedure or surgery than transfers.•Odds of mortality remain elevated despite controlling for patient characteristics.

Background Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts. Methods Records of 83 patients undergoing laparoscopic ( n  = 16), endoscopic ( n  = 45), and open ( n  = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis. Results There were no significant differences ( p  < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m 2 ), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1–40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher ( p  < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy ( n  = 13), percutaneous drainage ( n  = 3), and repeat endoscopic drainage ( n  = 6). Conclusions Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients.

Background This study aimed to review clinical outcomes for patients selected to undergo laparoscopic resection for gastrointestinal stromal tumor (GIST) of the stomach. Methods All 112 laparoscopic gastric resections performed from February 1995 to March 2007 were reviewed. Pre- and postoperative variables were analyzed, and data are given as mean ± standard deviation. Results Laparoscopic gastric resection was attempted for 63 GIST in 61 patients (31 men and 30 women) with a mean age was 59.1 ± 19 years. The tumors were located at the fundus ( n  = 19), antrum ( n  = 18), body ( n  = 17), gastroesophageal junction/cardia ( n  = 7), and pylorus ( n  = 2). Common presentations were upper gastrointestinal bleed ( n  = 29) and incidental finding on esophagogastroduodenoscopy ( n  = 17). The laparoscopic procedures performed were partial gastrectomy ( n  = 52), antrectomy ( n  = 4), esophagogastrectomy ( n  = 3), and endoscopically assisted and/or transgastric resection ( n  = 3). There was one conversion to open procedure for control of bleeding from the spleen. The mean tumor size was 3.8 ± 1.8 cm. Negative surgical margins were achieved in all but one case. The mean operative time was 151.9 ± 67.3 min, and the mean estimated blood loss was 97.4 ± 200.7 ml. A regular diet was resumed at a mean of 2.9 ± 1.6 days, and the mean length of hospital stay was 3.9 ± 2.2 days. The perioperative complication rate was 16.4% including deep vein thrombosis postoperative bleed, anastomotic stricture, and incisional hernia. One mortality occurred, due to respiratory failure. The GISTs included 48 rated as low risk, six rated as intermediate risk, and nine rated as high malignant potential. At a mean follow-up period of 15 ± 21.8 months (range, 0–103 months), three of nine patients with high malignant potential GIST experienced, respectively, metastatic disease to the liver, liver and lung, and peritoneum. At this writing, all the other patients are disease free. Conclusions Laparoscopic gastric resection for GIST is a feasible option. Adequate oncologic resection was achieved with 98.4% of patients chosen for laparoscopic resection. Resection margin positivity and recurrence rates are low after laparoscopic approaches for appropriately selected patients with GIST, demonstrating favorable characteristics.

Due to the COVID-19 pandemic, post-discharge virtual visits transitioned from a novel intervention to standard practice. Our aim was to evaluate participation in and outcomes of virtual post-discharge visits in the early-pandemic timeframe. Pandemic cohort patients were compared to historical patients. Patient demographics, clinical information, and post-discharge 30-day hospital encounters were compared between groups. The historical cohort included 563 patients and the pandemic cohort had 823 patients. There was no difference in 30-day hospital encounters between patients who completed a video vs. telephone visit in the pandemic cohort (3.8% vs. 7.6%, p = 0.11). There was a lower 30-day hospital encounter rate in pandemic video and telephone visits compared to similar historical sub-groups. Expansion of virtual post-discharge visits to include all patients and telephone calls did not negatively impact rates of 30-day post-discharge hospital encounters. Offering telehealth options for post-discharge follow-up does not appear to have negative impact on healthcare utilization. [Display omitted] •Telephone visits had a higher proportion of minority and underinsured patients.•No difference in 30-day hospital encounters for video vs. telephone visits.•Lower 30-day hospital encounter rate for pandemic vs. historical video visits.•Patients who did not meet study inclusion criteria did not have worse outcomes.

Background The purpose of this study was to evaluate the associations between patient characteristics or surgical site classifications and the histologic remodeling scores of synthetic meshes biopsied from their abdominal wall repair sites in the first attempt to generate a multivariable risk prediction model of non-constructive remodeling. Methods Biopsies of the synthetic meshes were obtained from the abdominal wall repair sites of 51 patients during a subsequent abdominal re-exploration. Biopsies were stained with hematoxylin and eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell infiltration, cell types, extracellular matrix deposition, inflammation, fibrous encapsulation, and neovascularization) and a mean composite score (CR). Biopsies were also stained with Sirius Red and Fast Green, and analyzed to determine the collagen I:III ratio. Based on univariate analyses between subject clinical characteristics or surgical site classification and the histologic remodeling scores, cohort variables were selected for multivariable regression models using a threshold p value of ≤0.200. Results The model selection process for the extracellular matrix score yielded two variables: subject age at time of mesh implantation, and mesh classification (c-statistic = 0.842). For CR score, the model selection process yielded two variables: subject age at time of mesh implantation and mesh classification ( r 2  = 0.464). The model selection process for the collagen III area yielded a model with two variables: subject body mass index at time of mesh explantation and pack-year history ( r 2  = 0.244). Conclusion Host characteristics and surgical site assessments may predict degree of remodeling for synthetic meshes used to reinforce abdominal wall repair sites. These preliminary results constitute the first steps in generating a risk prediction model that predicts the patients and clinical circumstances for which non-constructive remodeling of an abdominal wall repair site with synthetic mesh reinforcement is most likely to occur.