Identification of fifty-seven novel loci for abdominal wall hernia development and their biological and clinical implications: results from the UK Biobank.

PURPOSE: Familial aggregation is known for both hernia development and recurrence. To date, only one genome-wide association study (GWAS) limited to inguinal hernia has been reported that identified four risk-associated loci. We aim to investigate polygenic architecture of abdominal wall hernia development and recurrence. METHODS: A GWAS was performed in 367,394 subjects from the UK Biobank to investigate the polygenic architecture of abdominal wall hernia subtypes (inguinal, femoral, umbilical, ventral) and identify specific single nucleotide polymorphisms (SNPs) that are associated with their risk. Expression quantitative trait loci (eQTL) analysis was performed to identify genes whose expression levels are associated with these SNPs. A genetic risk score (GRS) was used to assess the cumulative effect of multiple independent risk-associated SNPs on hernia development and recurrence in independent subjects (n = 82,064). RESULTS: Heritability (h2) was 0.12, 0.06, 0.16, and 0.07 for inguinal, femoral, umbilical, and ventral hernias, respectively. A high-level of genetic correlation (rg) was found among these subtypes of hernia. We confirmed the aforementioned four loci and identified 57 novel loci (P < 5 × 10-8), including 55, 3, 5, and 3 loci for inguinal, femoral, umbilical, and ventral hernias, respectively. Significantly different expression levels between risk/reference alleles of SNPs were found for 145 genes, including TGF-ß2 and AIG1 for inguinal hernia risk and CALD1 for umbilical hernia risk. Finally, higher GRS deciles were significantly associated with increased risk for hernia development (Ptrend = 3.33 × 10-38) and recurrent hernia repair surgery (Ptrend = 3.64 × 10-14). CONCLUSION: These novel results have potential biological and clinical implications for hernia management in high-risk patients.

Comprehensive Analysis of Adverse Events Associated with Gastric Peroral Endoscopic Myotomy: An International Multicenter Study.

BACKGROUND: Gastric peroral endoscopic myotomy (G-POEM) has emerged as an effective management approach for patients with refractory gastroparesis. This study aims to comprehensively study the safety of G-POEM and describe the predictive factors of adverse events (AEs) occurrence. METHODS: This study is a retrospective study involving 13 tertiary care centers (7 USA, 1 South America, 4 Europe, and 1 Asia). Patients who underwent G-POEM for refractory gastroparesis were included. Cases were identified by the occurrence of AEs. For each case, two controls were randomly selected and matched for age (± 10 years), gender, and etiology of gastroparesis. RESULTS: A total of 216 patients underwent G-POEM for gastroparesis. Overall, 31 (14%) AEs were encountered [mild 24 (77%), moderate 5 (16%), and severe 2 (6%)] during the duration of the study. The most common AE was abdominal pain (n = 16), followed by mucosotomy (n = 5) and capnoperitoneum (n = 4), and AEs were most commonly identified within the first 48-h post-procedure 18 (58%). The risk of adverse event occurrence was significantly higher for endoscopists with experience of < 20 G-POEM procedures (OR 3.03 [1.03-8.94], p < 0.05). CONCLUSION: G-POEM seems to be a safe intervention for refractory gastroparesis. AEs are most commonly mild and managed conservatively. Longitudinal mucosal incision, use of hook knife, use of clips for mucosal closure and endoscopist's experience with > 20 G-POEM procedures is significantly associated with decreased incidence of AEs.

Rectus abdominis atrophy after ventral abdominal incisions: midline versus chevron.

PURPOSE: Although many outcomes have been compared between a midline and chevron incision, this is the first study to examine rectus abdominis atrophy after these two types of incisions. METHODS: Patients undergoing open pancreaticobiliary surgery between 2007 and 2011 at our single institution were included in this study. Rectus abdominis muscle thickness was measured on both preoperative and follow-up computed tomography (CT) scans to calculate percent atrophy of the muscle after surgery. RESULTS: At average follow-up of 24.5 and 19.0 months, respectively, rectus abdominis atrophy was 18.9% greater in the chevron (n = 30) than in the midline (n = 180) group (21.8 vs. 2.9%, p < 0.0001). Half the patients with a chevron incision had >20% atrophy at follow-up compared with 10% with a midline incision [odds ratio (OR) 9.0, p < 0.0001]. No significant difference was observed in incisional hernia rates or wound infections between groups. CONCLUSION: In this study, chevron incisions resulted in seven times more atrophy of the rectus abdominis compared with midline incisions. The long-term effects of transecting the rectus abdominis and disrupting its innervation creates challenging abdominal wall pathology. Atrophy of the abdominal wall can not be readily fixed with an operation, and this significant side effect of a transverse incision should be factored into the surgeon's decision-making process when choosing a transverse over a midline incision.

Six month outcomes in patients experiencing weight gain after gastric bypass who underwent gastrojejunal revision using an endoluminal suturing device.

BACKGROUND: Weight gain after Roux-en-Y gastric bypass occurs in approximately 25 % of cases, and this may contribute to recurrence of comorbid conditions. Currently, adequate treatment strategies for this group of patients are limited. Endoscopic narrowing of the gastrojejunal anastomosis may result in a low-risk, minimally invasive treatment alternative compared to standard surgical revision. We assessed short-term outcomes in patients undergoing endoscopic gastrojejunal revisions (EGJR) using an endoluminal suturing device. METHODS: We performed an institutional review board-approved retrospective analysis of 25 consecutive patients who underwent EGJR. Patients preoperatively presented with a dilated gastrojejunal anastomosis of greater than 15 mm and weight gain. An endoluminal suturing device (Overstitch(TM), Apollo Endosurgery, Austin TX) was used to reduce the diameter of the anastomosis. Follow-up occurred at 2 and 6 weeks, 3 and 6 months, and 1 year RESULTS: Prior to EGJR, patients regained an average of 23.4 ± 13.2 kg from their weight loss nadir and had a mean body mass index of 42.2 ± 6.6 kg/m(2). At 6 weeks, 100 % of patients experienced weight loss (average 5.8 ± 4.4 kg; p < .001). At 3 months, 94 % had weight loss (average 7.0 ± 6.2 kg; p < .001). At 6 months, 91 % maintained weight loss (average 5.6 ± 6.2 kg; p = 0.013). Lastly, at 1 year following EGJR, 100 % of available cases maintained weight loss (average 7.5 ± 6.4 kg; p = 0.057). The average percent excess weight loss was 12.5, 15.4, 12.4, and 17.1 % at 6 weeks, 3 and 6 months, and 1 year, respectively. There was a negative time effect in the mixed effect model using both on-treatment and intent-to-treat analyses, illustrating a significant weight reduction over time. The average follow-up per patient was 146 days. There were no complications reported during the follow-up period. CONCLUSIONS: Six month follow-up for EGJR patients demonstrated a low-risk, minimally invasive treatment option to reverse weight gain subsequent to a failed gastric bypass. Procedures presented no complications and may provide an attractive alternative to standard surgical revision.

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy.

Several complications after esophagectomy with gastric pull-up are associated with ischemia within the gastric conduit. The aim of this study is to assess the feasibility of laparoscopic ischemic preconditioning of the stomach prior to thoracotomy, esophagectomy, and gastric pull-up with an intrathoracic anastomosis. A retrospective review of 24 consecutive patients between October 2008 and July 2011 with esophageal adenocarcinoma (stage I-III) undergoing laparoscopic gastric ischemic conditioning prior to esophagectomy was conducted. Conditioning included laparoscopic ligation of the left and short gastric arteries, celiac node dissection, and jejunostomy tube placement. Formal resection and reconstruction was then performed 4-10 days later. Of the 24 patients, 88% received neoadjuvant chemotherapy/radiation therapy. Twenty-three of the 24 patients underwent successful laparoscopic ischemic conditioning and subsequent esophagectomy. Total mean number of lymph nodes harvested was 21.8 (±8.0), and a mean of 5.3 (±2.4) celiac lymph nodes identified. There were no conversions to an open procedure. Length of stay was 3.8 (±4.8) days with a median length of stay of 2 (1-24) days. Three patients experienced anastomotic leak, six patients experience delayed gastric emptying, and two patients developed anastomotic stricture. There were no surgical site infections. R0 resection was achieved in all patients who underwent laparoscopic ischemic conditioning followed by esophagectomy. Laparoscopic ischemic conditioning of the gastric conduit has been shown to be feasible and safe.

Biomesh placement in laparoscopic repair of paraesophageal hernias.

The placement of mesh in the crural closure of paraesophageal hiatal hernia repairs has been shown to decrease hernia recurrence rates. Typical synthetic mesh are easy to use but have high rate of erosion into the esophagus. Alternatively, biologic mesh decrease the risk of erosion, but are more difficult to manipulate, and there is currently no well-described method for securing them. Current fixation techniques of mesh are difficult, cumbersome, incur extra expense, and are not without complications. A method that requires no additional sutures or staples and achieves excellent contact and reinforcement of the crural closure is presented.

Outcomes after pancreatectomy for intraductal papillary mucinous neoplasms of the pancreas: an institutional experience.

PURPOSE: To evaluate the experience with pancreatectomy for intraductal papillary mucinous neoplasm (IPMN) at a single academic institution. METHODS: A prospective pancreatic database was reviewed and identified 43 patients with IPMN who were managed operatively. Clinicopathologic features and predictors of outcome were examined. The World Health Organization pathologic classification of IPMN was utilized. RESULTS: IPMN was diagnosed in 21% of patients who underwent pancreatic resection for solid or cystic mass lesions. Ninety-five percent of patients were symptomatic. Patients were managed with total pancreatectomy, pancreaticoduodenectomy, distal pancreatectomy, central pancreatectomy, or enucleation. Nine patients had adenomas, 14 had borderline neoplasms, 10 had carcinoma in situ, and 9 had invasive carcinoma. Overall, 23 patients (53%) had lesions with main duct involvement. Frozen section transection margins were positive for malignancy in 2 patients. With a mean follow-up of 17 months, the 5-year disease-specific survival for patients with main duct involvement was 67%. The 5-year disease-specific survival for patients with benign lesions was 100%, and 61% for patients with malignant lesions (P = .02). The presence of symptoms, increased CA 19-9, and tumor size were not predictive of malignancy. Increased serum bilirubin concentrations were predictive of malignancy (P = .03). Main duct involvement was also associated with malignancy (P < .02). CONCLUSIONS: Cancer is found in 65% of patients with IMPN involving the main duct. Based on our data, patients with symptomatic, main duct involvement, especially those with an increased serum bilirubin, should be offered resection. Alternatively, patients with side branch IPMN may be managed conservatively.

The importance of surgeon volume and training in outcomes for vascular surgical procedures.

PURPOSE: Mortality and morbidity rates after vascular surgical procedures have been related to hospital volume. Hospitals in which greater volumes of vascular surgical procedures are performed tend to have statistically lower mortality rates than those hospitals in which fewer procedures are performed. Only a few studies have directly assessed the impact of the surgeon's volume on outcome. Therefore, the purpose of this study was to review a large state data set to determine the impact of surgeon volume on outcome after carotid endarterectomy (CEA), lower extremity bypass grafting (LEAB), and abdominal aortic aneurysm repair (AAA). METHODS: The Florida Agency for Health Care Administration state admission data from 1992 to 1996 were obtained. The data included all nonfederal hospital admissions. Frequencies were calculated from first-listed International Classification of Diseases-9 codes. Multiple logistic regression was used to test the significance on outcome of surgeon volume, American Board of Surgery certification for added qualifications in general vascular surgery, hospital size, hospital volume, patient age, and gender. RESULTS: During this interval, there were 31,172 LEABs, 45,744 CEAs, and 13,415 AAAs performed. The in-hospital mortality rate increased with age. A doubling of surgeon volume was associated with a 4% reduction in risk for adverse outcome for CEA (P =.006), an 8% reduction for LEAB, and an 11% reduction for AAA ( P =.0002). However, although hospital volume was significant in predicting better outcomes for CEA and AAA procedures, it was not associated with better outcomes for LEAB. Certification for added qualifications in general vascular surgery was a significant predictor of better outcomes for CEA and AAA. Certified vascular surgeons had a 15% lower risk rate of death or complications after CEA (P =.002) and a 24% lower risk rate of a similar outcome after AAA (P =.009). However, for LEAB, certification was not significant. CONCLUSION: Surgeon volume and certification are significantly related to better patient outcomes for patients who undergo CEA and AAA. In addition, surgeons with high volumes demonstrated consistently lower mortality and morbidity rates than did surgeons with low volumes. Hospital volume for a given procedure also is correlated with better outcomes.

Hospital vascular surgery volume and procedure mortality rates in California, 1982-1994.

PURPOSE: Little is known about the long-term growth and outcomes of vascular surgery procedures over time. Trends in the use of three major vascular surgery procedures by a general population-lower extremity arterial bypass (LEAB), carotid endarterectomy (CEA), and abdominal aortic aneurysm repair (AAA)-are described. The extent to which these procedures are being performed in low-, moderate-, and high-volume hospitals is examined. METHODS: California hospital discharge records for LEAB, CEA, AAA, lower extremity angioplasty, coronary angioplasty, and coronary bypass surgery (CABG) were studied in all non-federal hospitals between 1982 and 1994. The data were age- and sex-adjusted to describe procedure growth. In-hospital mortality rates for LEAB, CEA, and AAA are related to overall hospital procedure volume, using logistic regression to control for risk factors and time trends. RESULTS: Growth in the number of vascular procedures performed in California was modest between 1982 and 1994, with no age-adjusted growth. Lower extremity angioplasty grew considerably in the 1980s and has since plateaued. Annual in-hospital death rates declined for all procedures except ruptured AAA. Comparing the two 5-year periods of 1982-1986 and 1990-1994, in-hospital death rates decreased from 4.2% to 3.3% for LEAB, from 9.2% to 6.2% for unruptured AAA, and from 1.6% to 1.0% for CEA (p < 0.0001). The odds of dying for patients treated in high-volume hospitals for LEAB and CEA procedures compared with patients treated in hospitals performing fewer than 20 procedures in a year were 66.7% (p = < 0.0001) and 66.1% (p < 0.0001), respectively. For patients with ruptured and unruptured AAA procedures, the odds of dying in hospitals with at least 50 AAA procedures in a year were 49.1% (p < 0.0001) and 83.8% (p = 0.016), respectively, compared with the odds of dying in low-volume hospitals. CONCLUSIONS: In-hospital mortality rates for CEA, LEAB, and unruptured AAA have been significantly decreasing over time. Mortality is inversely related to hospital volume and directly related to patient age and emergency status. Mortality trends over time for ruptured AAA remains unchanged; however, mortality is less in high-volume hospitals. Coronary angioplasty (PTCA) has not had an impact on rates for LEAB.