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

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

Diverse Beliefs and Time Variability of Risk Premia

Why do risk premia vary over time? We examine this problem theoretically and empirically by studying the effect of market belief on risk premia. Individual belief is taken as a fundamental primitive state variable. Market belief is observable; it is central to the empirical evaluation and we show how to measure it. Our asset pricing model is familiar from the noisy REE literature but we adapt it to an economy with diverse beliefs. We derive equilibrium asset prices and implied risk premium. Our approach permits a closed form solution of prices; hence we trace the exact effect of market belief on the time variability of asset prices and risk premia. We test empirically the theoretical conclusions. Our main result is that, above the effect of business cycles on risk premia, fluctuations in market belief have significant independent effect on the time variability of risk premia. We study the premia on long positions in Federal Funds Futures, 3- and 6-month Treasury Bills (T-Bills). The annual mean risk premium on holding such assets for 1-12 months is about 40-60 basis points and we find that, on average, the component of market belief in the risk premium exceeds 50% of the mean. Since time variability of market belief is large, this component frequently exceeds 50% of the mean premium. This component is larger the shorter is the holding period of an asset and it dominates the premium for very short holding returns of less than 2 months. As to the structure of the premium we show that when the market holds abnormally favorable belief about the future payoff of an asset the market views the long position as less risky hence the risk premium on that asset declines. More generally, periods of market optimism (i.e. "bull" markets) are shown to be periods when the market risk premium is low while in periods of pessimism (i.e. "bear" markets) the market's risk premium is high. Fluctuations in risk premia are thus inversely related to the degree of market optimism about future prospects of asset payoffs. This effect is strong and economically very significant

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

Kupffer Cells Hasten Resolution of Liver Immunopathology in Mouse Models of Viral Hepatitis

Kupffer cells (KCs) are widely considered important contributors to liver injury during viral hepatitis due to their pro-inflammatory activity. Herein we utilized hepatitis B virus (HBV)-replication competent transgenic mice and wild-type mice infected with a hepatotropic adenovirus to demonstrate that KCs do not directly induce hepatocellular injury nor do they affect the pathogenic potential of virus-specific CD8 T cells. Instead, KCs limit the severity of liver immunopathology. Mechanistically, our results are most compatible with the hypothesis that KCs contain liver immunopathology by removing apoptotic hepatocytes in a manner largely dependent on scavenger receptors. Apoptotic hepatocytes not readily removed by KCs become secondarily necrotic and release high-mobility group box 1 (HMGB-1) protein, promoting organ infiltration by inflammatory cells, particularly neutrophils. Overall, these results indicate that KCs resolve rather than worsen liver immunopathology