Laparoscopic paraesophageal hernia repair with absorbable mesh: a systematic review

Background: Laparoscopic repair is the standard of care for patients with paraesophageal hernia (PEH). Different prosthetic materials have been proposed to bolster the hiatus thus theoretically minimizing the probability for hernia recurrence. The use of non-absorbable mesh has been reported however, their safety profile has been questioned because the noteworthy mesh-related complication rate. Opposite, absorbable mesh (synthetic and biologic) seems associated with mitigated mesh-related complications and comparable hernia recurrence in the short- and medium-term. Methods: PubMed, MEDLINE, EMBASE, Scopus, Google Scholar, and ClinicalTrials.gov were executed according to the PRISMA statement until May 2022. Primary endpoints were technical details and surgical outcomes of adult patients (>= 18 years old) that underwent laparoscopic PEH repair and crural reinforcement with absorbable mesh. The ROBINS-I tool was used to assess the methodological quality of included studies. Results: Thirty-nine studies (3,103 patients) were included. The age of the patient population ranged from 18 to 93 years old and 62.8% were females. Posterior cruroplasty was performed in all patients. U-shape (83.7%), circumferential (8.1%), keyhole (5.4%) and starburst (2.8%) mesh configuration were described. Different methods for mesh fixation (sutures vs. fibrin glue vs. absorbable tacks) were adopted while Nissen (75.1%) and Toupet (21.1%) fundoplication were mainly fashioned. The overall postoperative complication rate was 2.5%. Pulmonary and cardiac complication rates were 1.8% and 0.9%, respectively while in-hospital mortality was 0.2%. Postoperative follow-up ranged from 12 to 166 months. Mesh-related complication rate was 0.06% (esophageal stricture related to fibrosis). Hernia recurrence rate was 12.7% while re-do surgery was required in 1.9% of patients. Postoperative dysphagia rate was 5.1%. Discussion: Consensus concerning the optimal mesh material for crural buttressing is lacking. Given the potential for tissue ingrowth rather than encapsulation and reduced degree of perivisceral inflammation, absorbable meshes are mostly preferred over non-absorbable meshes. The use of absorbable mesh seems safe and effective with low overall and mesh-related complications, acceptable recurrence rate and low need for re-do surgery in the short/medium-term. Because heterogeneity related to different hernia characteristics, intraoperative technical variations (i.e., method for mesh fixation, etc.), definition of hernia recurrence and diverse follow-up, a conclusive evidence is still to be defined

Late histological findings in symptomatic COVID-19 patients: A case report

RATIONALE: Although there have been several studies describing clinical and radiographic features about the novel coronavirus (COVID-19) infection, there is a lack of pathologic data conducted on biopsies or autopsies. PATIENT CONCERNS: A 56-year-old and a 70-year-old men with fever, cough, and respiratory fatigue were admitted to the intensive care unit and intubated for respiratory distress. DIAGNOSIS: The nasopharyngeal swab was positive for COVID-19 and the chest Computed Tomography (CT) scan showed the presence of peripheral and bilateral ground-glass opacities. INTERVENTIONS: Both patients developed pneumothoraces after intubation and was managed with chest tube. Due to persistent air leak, thoracoscopies with blebs resection and pleurectomies were performed on 23rd and 16th days from symptoms onset. OUTCOMES: The procedures were successful with no evidence of postoperative air-leak, with respiratory improvement. Pathological specimens were analyzed with evidence of diffuse alveolar septum disruption, interstitium thickness, and infiltration of inflammatory cells with diffuse endothelial dysfunction and hemorrhagic thrombosis. LESSONS: Despite well-known pulmonary damages induced by the COVID-19, the late-phase histological changes include diffused peripheral vessels endothelial hyperplasia, in toto muscular wall thickening, and intravascular hemorrhagic thrombosis

Dor versus Toupet fundoplication after Laparoscopic Heller Myotomy: Systematic review and Bayesian meta-analysis of randomized controlled trials

Laparoscopic Heller Myotomy (LHM) with partial fundoplication has become the treatment of choice for esophageal achalasia. However, the choice of the partial fundoplication is debated. The aim of this study was to compare outcomes for Dor and Toupet fundoplication after LHM. A systematic search of randomized controlled trials comparing Dor and Toupet fundoplication was performed using PubMed, EMBASE and Web of Science. Three studies met the inclusion criteria. Overall, 174 patients were included in the analysis. The postoperative abnormal acid reflux [pooled Risk Ratio 0.98 (95% HPD 0.54-1.80)] and dysphagia [pooled Risk Ratio 1.03 (95% HPD 0.51-2.05)] were similar comparing Dor and Toupet fundoplication. The % total time pH  64 4 [estimated pooled mean difference -0.08 (95% HPD -1.04-0.90)] and DeMeester score [estimated pooled mean difference 0.51 (95% HPD -0.90-1.94)] were comparable. Additionally, the operative time [estimated pooled mean difference 0.02 (95% HPD -0.53-0.52)] and iatrogenic esophageal perforation [pooled Risk Ratio 1.05 (95% HPD 0.52-2.10)] were similar in the two groups. Dor and Toupet fundoplication after laparoscopic Heller myotomy seem comparable in term of postoperative abnormal acid exposure and dysphagia. The choice of the partial fundoplication should be left to surgeon experience and tailored on each patient

Intraoperative endomanometric laparoscopic Nissen fundoplication improves postoperative outcomes in large sliding hiatus hernia with severe gastroesophageal reflux disease. A retrospective cohort study

Background: Laparoscopic Nissen Fundoplication (LNF) is the gold standard surgical intervention for gastroesophageal reflux disease (GERD). LNF can be followed by recurrent symptoms or complications affecting patient satisfaction. The aim of this study is to assess the value of the intraoperative endomanometric evaluation of esophagogastric competence and pressure combined with LNF in patients with large sliding hiatus hernia (> 5 cm) with severe GERD (DeMeester score >100). Materials and methods: This is a retrospective, multicenter cohort study. Baseline characteristics, postoperative dysphagia and gas bloat syndrome, recurrent symptoms, and satisfaction were collected from a prospectively maintained database. Outcomes analyzed included recurrent reflux symptoms, postoperative side effects, and satisfaction with surgery. Results: 360 patients were stratified into endomanometric LNF (180 patients, LNF+) and LNF alone (180 patients, LNF). Recurrent heartburn (3.9% vs. 8.3%) and recurrent regurgitation (2.2% vs. 5%) showed a lower incidence in the LNF+ group (P=0.012). Postoperative score III recurrent heartburn and score III regurgitations occurred in 0% vs. 3.3% and 0% vs. 2.8% cases in the LNF+ and LNF groups, respectively (P=0.005). Postoperative persistent dysphagia and gas bloat syndrome occurred in 1.75% vs. 5.6% and 0% vs. 3.9% of patients (P=0.001). Score III postoperative persistent dysphagia was 0% vs. 2.8% in the two groups (P=0.007). There was no redo surgery for dysphagia after LNF+. Patient satisfaction at the end of the study was 93.3% vs. 86.7% in both cohorts, respectively (P=0.05). Conclusions: Intraoperative high-resolution manometry (HRM) and endoscopic were feasible in all patients, and the outcomes were favorable from an effectiveness and safety standpoint