Impact of Crural Relaxing Incisions, Collis Gastroplasty, and Non–Cross-linked Human Dermal Mesh Crural Reinforcement on Early Hiatal Hernia Recurrence Rates

BackgroundHernia 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 DesignWe 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.ResultsThere 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%).ConclusionsTension-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

Data from: 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, a behavioral process not generally incorporated into discussions of population-level diversity effects. Here, we examine how maternal decisions that determine group genetic diversity influence the viability of Drosophila melanogaster larvae. Our groups contained wildtype larvae, whose genetic diversity we manipulated; and genetically-marked “tester” larvae, whose genotype and frequency were identical in all trials. We measured wildtype and tester viability for each group. Surprisingly, the viability of wildtype larvae did not depend on group genetic diversity. 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 wildtype genotypes were deleterious to tester viability, while other groups of the same diversity—but containing different wildtype genotypes—were not deleterious. These deleterious combinations of wildtype genotypes could not be predicted by observing the performance of the same tester and wildtype genotypes in low-diversity groups. Taken together, these results suggest that non-additive 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

State of the Art in Lung Nodule Localization

Lung nodule and ground-glass opacity localization for diagnostic and therapeutic purposes is often a challenge for thoracic surgeons. While there are several adjuncts and techniques in the surgeon’s armamentarium that can be helpful, accurate localization persists as a problem without a perfect solution. The last several decades have seen tremendous improvement in our ability to perform major operations with minimally invasive procedures and resulting lower morbidity. However, technological advances have not been as widely realized for lung nodule localization to complement minimally invasive surgery. This review describes the latest advances in lung nodule localization technology while also demonstrating that more efforts in this area are needed

data for dryad

The attending spreadsheet contains data from all 3 levels of diversity and 2 group sizes. Data were collected by JBS, ETA, JG, MH, and NM. The “diversity” column refers to the level of wildtype genetic diversity in the group (L= low, M= medium, H= high). “Number of tester survivors” and “number of wildtype survivors” are the number of tester and wildtype individuals, respectively, who eclosed from that group. Groups in which either the number of wildtype or tester survivors was 0 were excluded from the analysis. “Date” is the date the vial was created. “Genotype combination” describes the complement of wildtype genotypes present in the group; information about specific genotype combinations is available in the Supplemental Information to the paper. “Group size” is the number of first-instar larvae originally added to the vial (72 for small groups, 144 for large groups)

Exploring the Potential Different Outcomes Associated With the Different Phenotypes Under the Shared Pathologic T3N0 Designation

Introduction: The objective of this study was to compare overall survival (OS) between patients with pT1-2N1 versus pT3N0 NSCLC and various subtypes of pT3N0 NSCLC. Methods: The National Cancer Database was queried to identify treatment-naive patients with pathologic stage IIB primary NSCLC. Patients were included if they were diagnosed with pT3N0 or pT1-2N1 NSCLC and received definitive surgery within 4 months of diagnosis. The pT3N0 cohort was subdivided by single versus multiple concurrent T3 descriptors and single-T3 subtypes. The 5-year OS was compared using the Kaplan-Meier method, and the Cox proportional-hazards model was used to identify prognostic factors for death. Results: A total of 16,770 patients were included (pT3N0: 7179; pT1-2N1: 9591). pT3N0 NSCLC was associated with greater 5-year OS than pT1-2N1 NSCLC (52.4% versus 47.8%, p < 0.0001). Among patients receiving adjuvant chemotherapy after surgery, multiple-T3 pT3N0 NSCLC was associated with lower 5-year OS than single-T3 pT3N0 NSCLC (49.0% versus 63.3%, p < 0.0001), and chest wall-only pT3N0 NSCLC was associated with the lowest 5-year OS across single-T3 subtypes (additional nodule: 68.3%; size: 64.5%; chest wall: 52.2%, p < 0.0001). Adjuvant chemotherapy was associated with decreased risk of death in the pT3N0 cohort (hazard ratio = 0.65, confidence interval: 0.59–0.71, p < 0.0001). Conclusions: Patients with pT3N0 NSCLC experience greater 5-year OS after surgery compared with those with pT1-2N1 NSCLC. Multiple-T3 and chest wall-only pT3N0 NSCLC are associated with worse 5-year OS and increased risk of death relative to other T3 subtypes. Future staging systems should consider including notation distinguishing multiple T3 descriptors in pT3N0 NSCLC

Safety and efficacy of magnetic sphincter augmentation dilation.

BACKGROUND: The magnetic sphincter augmentation device (MSA) provides effective relief of gastroesophageal reflux symptoms. Dysphagia after MSA implantation sometimes prompts endoscopic dilation. The manufacturer\u27s instructions are that it be performed 6 or more weeks after implantation under fluoroscopic guidance to not more than 15 mm keeping 3 or more beads closed. The purpose of this study was to assess adherence to these recommendations and explore the techniques used and outcomes after MSA dilation. METHODS AND PROCEDURES: We conducted a multicenter retrospective review of patients undergoing dilation for dysphagia after MSA placement from 2012 to 2018. RESULTS: A total of 144 patients underwent 245 dilations. The median size of MSA placed was 14 beads (range 12-17) and the median time to dilation was 175 days. A second dilation was performed in 67 patients, 22 patients had a third dilation and 7 patients underwent 4 or more dilations. In total, 17 devices (11.8%) were eventually explanted. The majority of dilations were performed with a balloon dilator (81%). The median dilator size was 18 mm and 73.4% were done with a dilator larger than 15 mm. There was no association between dilator size and need for subsequent dilation. Fluoroscopy was used in 28% of cases. There were no perforations or device erosions related to dilation. DISCUSSION: There is no clinical credence to the manufacturer\u27s recommendation for the use of fluoroscopy and limitation to 15 mm when dilating a patient for dysphagia after MSA implantation. Use of a larger size dilator was not associated with perforation or device erosion, but also did not reduce the need for repeat dilation. Given this, we would recommend that the initial dilation for any size MSA device be done using a 15 mm through-the-scope balloon dilator. Dysphagia prompting dilation after MSA implantation is associated with nearly a 12% risk of device explantation