Short-Term Outcomes in Patients Undergoing Paraesophageal Hiatal Hernia Repair.

Many patients with hiatal hernias (HH) are asymptomatic; however, symptoms may include heartburn, regurgitation, dysphagia, nausea, or vague epigastric pain depending on the hernia type and severity. The ideal technique and timing of repair remains controversial. This report describes short-term outcomes and readmissions of patients undergoing HH repair at our institution. All patients who underwent HH repair from January 2012 through April 2017 were reviewed. Patients undergoing concomitant bariatric surgery were excluded. 239 patients were identified and 128 were included. Eighty-eight were female (69%) and 40 were male (31%) with a mean age of 59 years (range 20-91 years) and a mean BMI of 29.2 kg/m2 (17-42). Worsening GERD was the most common presenting symptom in 79 (61.7%) patients. Eighty-four laparoscopic cases (65.6%) and 44 robotic assisted (34.4%) procedures were performed. Mesh was used in 59 operations (3 polytetrafluoroethylene; 56 biologic). All hiatal hernia types (I-IV) were collected. Majority were initial operations (89%). Techniques included: Toupet fundoplication in 68 cases (63.0%), Nissen fundoplication in 36 (33.3%), Dor fundoplication in 4 (3.7%), concomitant Collis gastroplasty in 4 (3.1%), and primary suture repair in 20 (15.6%). Outcomes between robotic and laparoscopic procedures were compared. Length of stay was reported as median and interquartile range for laparoscopic and robotic: 1.0 day (1.0-3.0) and 2.0 days (1.0-2.5); p = 0.483. Thirty-day readmission occurred in 9 patients, 7 (8.3%) laparoscopic and 2 (4.6%) robotic; p = 0.718. Two 30-day reoperations occurred, both laparoscopic; p = 0.545. Total of 16 complications occurred; 18.6% had a complication with the use of mesh compared to 8.7% without the use of mesh, p = 0.063. There were no conversion to open modality and no mortalities were reported. Hiatal hernia repair can be performed safely with a low incidence of complications.

Paraesophageal Hiatal Hernia Repair With Urinary Bladder Matrix Graft.

BACKGROUND AND OBJECTIVES: Paraesophageal hiatal hernia repair can be performed with or without mesh reinforcement. The use, technique, and mesh type remain controversial because of mixed reports on mesh-related complications. Short-term outcomes have become important in all forms of surgery. METHODS: From January 2012 through April 2017, all patients who underwent isolated hiatal hernia repair in our center were reviewed. Concomitant bariatric surgery cases were excluded. Repairs reinforced by porcine urinary bladder matrix (UBM) graft were compared to non-UBM repairs. Statistical comparison was based on a Wilcoxon 2-sample test or Fisher's exact test. RESULTS: We reviewed 239 charts; 110 bariatric cases and 8 cases with non-UBM reinforcement were excluded. We identified 121 patients: 56 UBM-reinforced (46.3%) versus 65 non-UBM (53.7%). Sixteen (28.6%) UBM cases were male versus 23 (35.4%) non-UBM cases. The UBM patients were significantly older (63.9 versus 54.3; P = .001). There was no difference in mean BMI (29.6 vs 28.5; P = .28). Cases were performed laparoscopically (60.7% vs 67.7%; P = .45) or robotically (39.3% vs 32.3%; P = .45), with no conversions to open. The UBM group had a longer mean operative time (183 minutes vs 139 minutes; P = .001).There was no difference in median length of stay (2 days vs 2 days; P = .09) or 30-day readmission rate (7.1% vs 7.5%; P =.99). Postoperative complications were graded according to the Clavien-Dindo classification, and there was no difference (19.6% vs 9.2%; P = .12). CONCLUSIONS: Hiatal hernia repair with UBM reinforcement can be performed safely with no increase in postoperative complications.

Optimal Cefazolin Prophylactic Dosing for Bariatric Surgery: No Need for Higher Doses or Intraoperative Redosing.

PURPOSE: The goal of this pharmacokinetic (PK) study was to evaluate whether a single 2-g prophylactic dose of cefazolin given (IV) bolus provides effective protective cefazolin levels for prophylaxis against methicillin-sensitive S. aureus (MSSA), the primary skin pathogen in bariatric surgery. MATERIALS AND METHODS: Thirty-seven patients having gastric bypass or sleeve gastrectomy received cefazolin 2-g preoperative prophylaxis. Serum, subcutaneous adipose tissue, and deep peri-gastric adipose tissue specimens were collected at incision and before skin closure. Cefazolin concentrations in serum and adipose tissue were determined by high-performance liquid chromatography. RESULTS: Penetration of cefazolin, a water soluble antibiotic, into adipose tissue was only 6-8 % of simultaneous serum levels. However, cefazolin tissue concentrations in all adipose tissue specimens, exceeded mean MIC for MSSA. CONCLUSIONS: Prophylactic cefazolin, given as a single 2 g (IV bolus 3-5 min before skin incision) was more than adequate in providing protective cefazolin levels for the duration of bariatric surgery. Cefazolin 2 g (IV dose bolus given just before skin incision) achieves protective adipose tissue levels (> MIC of MSSA) for the duration (usually < 4 h) of bariatric surgical procedures. In this study, cefazolin 2 g (IV bolus) provided protective adipose tissue levels for 4.8 h. Since cefazolin is a water soluble antibiotic (V d = 0.2 L/Kg), penetration into adipose tissue is not V d not dose-dependent. Extremely high-dosed cefazolin, i.e., 3 or 4 g is excessive and unnecessary for bariatric surgery prophylaxis. A single cefazolin 2 g preoperative dose also eliminates the need for intraoperative redosing at 4 h.