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

Inflammatory biomarkers in Alzheimer's disease plasma

Introduction:Plasma biomarkers for Alzheimer’s disease (AD) diagnosis/stratification are a“Holy Grail” of AD research and intensively sought; however, there are no well-established plasmamarkers.Methods:A hypothesis-led plasma biomarker search was conducted in the context of internationalmulticenter studies. The discovery phase measured 53 inflammatory proteins in elderly control (CTL;259), mild cognitive impairment (MCI; 199), and AD (262) subjects from AddNeuroMed.Results:Ten analytes showed significant intergroup differences. Logistic regression identified five(FB, FH, sCR1, MCP-1, eotaxin-1) that, age/APOε4 adjusted, optimally differentiated AD andCTL (AUC: 0.79), and three (sCR1, MCP-1, eotaxin-1) that optimally differentiated AD and MCI(AUC: 0.74). These models replicated in an independent cohort (EMIF; AUC 0.81 and 0.67). Twoanalytes (FB, FH) plus age predicted MCI progression to AD (AUC: 0.71).Discussion:Plasma markers of inflammation and complement dysregulation support diagnosis andoutcome prediction in AD and MCI. Further replication is needed before clinical translatio

Robotic Left Upper Lobectomy

<p>Interest and access to robot thoracic surgery has increased over the last decade. This increased interest from surgeons, hospitals, and patients has led many surgeons to transition from their standard practice of open or thoracoscopic lobectomy to robotic lobectomy. High-volume robotic programs have shown a decrease in the length of hospital stay, 30-day mortality, and postoperative transfusion requirements when lung resection is performed with the robotic technique compared to video-assisted thoracoscopic surgery and thoracotomy (1).<br></p> <p>This video demonstrates a robotic left upper lobectomy. The patient was a 73-year-old woman who was found to have a 12 mm left upper lobe nodule on a screening computed tomography scan. Positron emission tomography demonstrated mild hypermetabolic activity. She was asymptomatic, and she was able to walk one mile and climb two flights of stairs. Her medical history included hypertension and chronic obstructive pulmonary disease, and she had a 10 pack-year history of smoking. The results of her pulmonary function tests were adequate.</p><p>She was taken for a left upper lobe wedge resection, and the frozen section confirmed adenocarcinoma. She then had a completion robotic lobectomy with mediastinal lymph node dissection of stations 5, 6, 7, and L9. At the completion of the procedure, an intercostal nerve block was performed and a 28 Fr chest tube was placed. The chest tube was subsequently removed, and the patient was sent home on postoperative day two. The final pathology revealed a 1.2 cm moderately differentiated adenocarcinoma, with zero out of eight lymph nodes positive for malignancy, stage T1aN0M0 IA. The robotic technique provides excellent exposure and visualization, and it allows for a complete oncologic resection. </p> <p> </p> <p><b>Reference</b></p> <p>1. Farivar AS, Cerfolio RJ, Vallieres E, et al. Comparing robotic lung resection with thoracotomy and video-assisted thoracoscopic surgery cases entered into the Society of Thoracic Surgeons Database. <i><a href="https://doi.org/10.1097/IMI.0000000000000043">Innovations. 2014;9(1):10-15</a></i>.</p

Desaturation during Six-Minute Walk Testing Predicts Major Morbidity Following Anatomic Lung Resection among Patients with COPD

Background: Pulmonary function testing (PFT) is commonly used to risk-stratify patients prior to lung resection. Guidelines recommend that patients with reduced lung function, due to chronic lung conditions such as Chronic Obstructive Pulmonary Disease (COPD), should receive additional physiologic testing to determine fitness for resection. We reviewed our experience with six-minute walk testing (SMWT) to determine the association of test results and post-operative complications. Methods: Consecutive adult patients undergoing segmentectomy, lobectomy, bilobectomy or pneumonectomy between 1 January, 2007 and 1 January, 2017 were identified in a prospectively maintained database. Patients with poor lung function, as defined by percent predicted forced expiratory volume in 1 s (FEV1) or diffusion capacity of carbon monoxide (DLCO) ≤60%, had results of SMWT extracted from their chart. Association of test result to post-operative events was performed. Results: 581 patients had anatomic lung resections with predicted post-operative FEV1 or DLCO values ≤60%, consistent with a diagnosis of COPD. Among them, 50 (8.6%) had preoperative SMWT performed. Patients who received SMWT were more likely to have a FEV1 or DLCO less than 40 percent predicted (24/50 (48.0%) vs 166/531 (31.3%), p = 0.016). Post-operatively, patients who had SMWT performed had higher rates of pneumonia, but similar rates of major morbidity. The post-exercise oxygen saturation and the amount of desaturation correlated with the occurrence of major morbidity. In multivariable regression, oxygen desaturation was an independent risk factor for the occurrence of major morbidity, and desaturation was an excellent predictor of major morbidity by receiver operating characteristic curves analsysis. Conclusions: Among patients with elevated risk, oxygen desaturation during SMWT was independently associated with the occurence of major morbidity in multivariable analysis, while pulmonary function testing was not. SMWT is an important tool for risk-stratification, and may be underutilized