Should We Operate Nonagenarians with Symptomatic Giant Paraesophageal Hernias?

Introduction: Hiatal hernia (HH) is a common disorder of the upper gastrointestinal (UGI) tract that general surgeons encounter. Giant paraesophageal is a subtype of HH in which more than 30% of the stomach is located in the chest. It can cause symptoms such as dysphagia, UGI bleeding, gastroesophageal reflux disease, and vomiting. As the life expectancy of the general population increases, the incidence of giant HH increases and can cause morbidity, including recurrent admissions and prolonged length of hospitalization. In this article, we describe a cohort of nonagenarian patients with HH who were admitted to our institution and were treated either surgically or medically. Methods: We retrospectively reviewed our prospectively maintained database of all nonagenarians who were admitted to our center between 2018 and 2022 with the diagnosis of HH. We compared the demographic data, clinical data, and outcomes between patients undergoing operative and nonoperative management. Results: Twenty patients of age over 90 years were hospitalized with HH-related symptoms. Six underwent surgery, whereas 14 received medical management. Surgical patients had fewer overall hospitalization days, shorter length of stay, and less blood product requirements. Notably two cases of in-hospital mortality occurred in the nonoperative group, whereas none occurred in the operative group. All surgical procedures were performed laparoscopically, with two minor perioperative complications. Conclusion: In selected nonagenarian patients, laparoscopic HH repair is safe and should be considered favorably. It can reduce hospitalization time and can mitigate morbidity.

TFEB drives mTORC1 hyperactivation and kidney disease in Tuberous Sclerosis Complex.

Tuberous Sclerosis Complex (TSC) is caused by TSC1 or TSC2 mutations, leading to hyperactivation of mechanistic target of rapamycin complex 1 (mTORC1) and lesions  in multiple organs including lung (lymphangioleiomyomatosis) and kidney (angiomyolipoma and renal cell carcinoma). Previously, we found that TFEB is constitutively active in TSC. Here, we generated two mouse models of TSC in which kidney pathology is the primary phenotype. Knockout of TFEB rescues kidney pathology and overall survival, indicating that TFEB is the primary driver of renal disease in TSC. Importantly, increased mTORC1 activity in the TSC2 knockout kidneys is normalized by TFEB knockout. In TSC2-deficient cells, Rheb knockdown or Rapamycin treatment paradoxically increases TFEB phosphorylation at the mTORC1-sites and relocalizes TFEB from nucleus to cytoplasm. In mice, Rapamycin treatment normalizes lysosomal gene expression, similar to TFEB knockout, suggesting that Rapamycin's benefit in TSC is TFEB-dependent. These results change the view of the mechanisms of mTORC1 hyperactivation in TSC and may lead to therapeutic avenues.

Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report.

BACKGROUND: Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system. METHODS: Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times. RESULTS: Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2. CONCLUSION: The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.

The Angle of His as a Measurable Element of the Anti-reflux Mechanism.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux. OBJECTIVES: Our aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model. METHODS: The study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented. RESULTS: Each group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as "beyond - 30°". A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively). CONCLUSIONS: In this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.

Health Literacy Levels and Predictors Among Lebanese Adults Visiting Outpatient Clinics in Beirut.

BACKGROUND: To date, there has been a dearth of research on health literacy in the Eastern Mediterranean Region and in particular Lebanon. OBJECTIVES: This cross-sectional study assessed the levels and correlates of health literacy in Lebanese adults. METHODS: A total of 587 participants (54.5% women) were recruited from the outpatient clinics of five health facilities in Beirut. The questionnaire consisted of the Arabic version of the Functional Health literacy Scale, the Arabic short version of the European Health Literacy Survey, and questions on sociodemographic and health-related factors. Descriptive and inferential statistics were performed to assess the association of these factors with functional health literacy (FHL) and comprehensive health literacy (CHL) levels. KEY RESULTS: About 65.8% had inadequate or problematic FHL and 43.8% had inadequate or problematic CHL. Although FHL was negatively correlated with long-term illness, it was positively correlated with ability to pay and health status. CHL was positively correlated with education, income, ability to pay for treatment, health status, and FHL level, whereas it was negatively correlated with long-term illness. Binary logistic regression showed that low education, low socioeconomic status, and being a widow were predictive of inadequate FHL. Moreover, having inadequate FHL and low income increased the likelihood of having inadequate CHL. CONCLUSION: This study has identified those with risk factors for inadequate health literacy and unfavorable health outcomes. A national action plan can guide the promotion of health literacy and its embeddedness in society to instill competencies and the environment that would eliminate health inequities and sustain health in Lebanon. [HLRP: Health Literacy Research and Practice. 2021;5(4):e295-e309.] Plain Language Summary: This study examined health literacy levels and correlates in 587 Lebanese adults using two recognized screening tools. The first tool measured functional health literacy (FHL), which represents the ability of a person to acquire information on health through reading or writing. The second tool assessed comprehensive health literacy (CHL), which encompasses the ability of a person to use their social skills to acquire health information from different media and make appropriate health decisions based on this information. Close to two-thirds of the participants had inadequate or problematic FHL. More specifically, low education, low socioeconomic status, and widowhood were predictive of inadequate FHL. Nearly one-half of the participants had inadequate or problematic CHL with an increased likelihood of inadequate levels in people with low FHL and low income.

Psoas Attenuation and Mortality of Elderly Patients Undergoing Nontraumatic Emergency Laparotomy.

BACKGROUND: Emergency laparotomy (EL) is an increasingly common procedure in the elderly. Factors associated with mortality in the subpopulation of frail patients have not been thoroughly investigated. Sarcopenia has been investigated as a surrogate for frailty and poor prognosis. Our primary aim was to evaluate the association between easily measured sarcopenia parameters and 30-day postoperative mortality in elderly patients undergoing EL. Length of stay (LOS) and admission to an intensive care unit were secondary end points. METHODS: We conducted a retrospective cohort study, over a 5-year period, of patients aged 65 y and older who underwent EL at a tertiary university hospital. Sarcopenia was evaluated on admission computed tomography scan by two methods, first by psoas muscle attenuation and second by the product of perpendicular cross-sectional diameters (PCSDs). The lowest quartile of PCSDs and attenuation were defined as sarcopenic and compared with the rest of the cohort. Attenuation was stratified for the use of contrast enhancement. Multivariant logistic regression was performed to determine independent risk factors. RESULTS: During the study period, 403 patients, older than 65 y, underwent EL. Of these, 283 fit the inclusion criteria and 65 (23%) patients died within 30 d of surgery. On bivariate analysis, psoas muscle attenuation, but not PCSDs, was found to be associated with 30-day mortality (OR = 2.43, 95% CI = 1.34-4.38, P = 0.003) and longer LOS (35.7 d versus 22.2 d, Δd 13.5, 95% CI = 6.4-20.7, P < 0.001). In a multivariate analysis, psoas muscle attenuation, but not PCSDs, was an independent risk factor for 30-day postoperative mortality (OR = 2.35, 95% CI = 1.16-4.76, P = 0.017) and longer LOS (Δd = 14.4, 95% CI = 7.7-21.0, P < 0.001). Neither of the sarcopenia parameters was associated with increased admission to an intensive care unit. DISCUSSION: Psoas muscle attenuation is an independent risk factor for 30-day postoperative mortality and LOS after EL in the elderly population. This measurement can inform clinicians about the operative risk and hospital resource utilization.