Urinary Bladder Matrix Reinforcement for Laparoscopic Hiatal Hernia Repair.

BACKGROUND AND OBJECTIVES: Synthetic mesh reinforcement during laparoscopic hiatal hernia repair (LHHR) reduces recurrence. Biologically derived mesh is also associated with reduced recurrence. Urinary bladder matrix (UBM), a biologically derived extracellular matrix mesh, has shown clinical success. We wanted to determine the safety and efficacy of LHHR with porcine UBM reinforcement. METHODS: This retrospective, single-surgeon study reviewed clinical data on patients who underwent LHHR from August 2009 through May 2014, with diaphragmatic reinforcement with porcine UBM mesh. Primary outcomes were (1) recurrence-a >2-cm defect above the diaphragm at 3 months; (2) intra- and postoperative complications; (3) pre- and postoperative esophageal reflux (GERD) or dysphagia; and (4) cessation of proton pump inhibitor (PPI). RESULTS: Sixty-two patients who had LHHR with UBM mesh were studied (mean age, 62 years, 53 women, mean body mass index 32.7 kg/m2) Before surgery 98% had GERD, 19% had dysphagia, and 98% were on PPI. Postoperative UGIS was performed on 66% 3 months after surgery, and 19% had a recurrence of >2 cm; 56% remained on PPI, and 16% (P < .001) remained symptomatic. Dysphagia improved in 75% (P = .05). No intraoperative complications were recorded. One postoperative mortality occurred secondary to an unrelated cardiac event. CONCLUSIONS: UBM mesh was effective and safe for LHHR. In addition to reducing the rate of recurrence compared to unreinforced primary repair, the properties of UBM, including site-specific constructive tissue remodeling, may add benefits over other biologic products. This study represents an evaluation of UBM mesh in a large cohort of patients who underwent LHHR.

A rare presentation of triple-negative apocrine breast carcinoma with metastases.

Apocrine breast carcinoma is a rare subtype of the invasive ductal carcinoma and accounts for as little as 0.3-1% of all breast cancers. It is usually positive for human epidermal growth factor receptor 2 (HER-2) and negative for both estrogen receptor and progesterone receptor. Here we present an exceptionally rare case of apocrine breast carcinoma that is a triple receptor negative with metastases and to our knowledge this is the first published case. This is a significant finding because it implies that the tumor would not respond to the typical hormonal agents. This case highlights the need for studies to elucidate better treatment strategies for these types of patients.

Is surgical intervention avoidable in cases of emphysematous gastritis? A case presentation and literature review.

INTRODUCTION: Gas located within the gastric wall is a rare finding that is associated with a mortality rate of 50%. It confers two main diagnoses: gastric emphysema and emphysematous gastritis. Due to its high mortality rate, emphysematous gastritis must be differentiated from gastric emphysema early to avoid adverse outcomes and plan the management of these patients. PRESENTATION OF CASE: We introduce a 55 year-old male who presents with diffuse abdominal pain associated with fever, nausea, vomiting, and diarrhea. Patient has positive peritoneal signs with fever and leukocytosis. Air in the gastric wall and portal venous system was visualized on Computed Tomography (CT). The patient underwent emergent laparotomy which showed normal bowel with few adhesions. DISCUSSION: Various etiologies can cause gas within the gastric wall but concomitant air in the hepatic venous system is highly suspicious for emphysematous gastritis. CT imaging is the most sensitive and specific way to differentiate emphysematous gastritis versus gastric emphysema. Although rare, there are many cases of emphysematous gastritis that undergo prompt surgical exploration. Recently, however, medical treatment has become more common and surgical management reserved for complications. CONCLUSION: We conclude by stating that this case of emphysematous gastritis, due to gastric ulcers, would have no difference in outcome if treated medically instead of surgically. Historically, patients with emphysematous gastritis warranted surgical intervention. More recently, case reports of emphysematous gastritis are favoring conservative management. The consensus still remains that there is no standard approach for these patients and most patients in extremis are undergoing surgical intervention.