Facelift thyroid surgery: a systematic review of indications, surgical and functional outcomes.

OBJECTIVE: To investigate indications, surgical and functional outcomes of robotic or endoscopic facelift thyroid surgery (FTS) and whether FTS reported comparable outcomes of other surgical approaches. DATA SOURCES: PubMed, Cochrane Library, and Scopus. REVIEW METHODS: A literature search was conducted about indications, clinical and surgical outcomes of patients who underwent FTS using PICOTS and PRISMA Statements. Outcomes reviewed included age; gender; indications; pathology; functional evaluations; surgical outcomes and complications. RESULTS: Fifteen papers met our inclusion criteria, accounting for 394 patients. Endoscopic or robotic FTS was carried out for benign and malignant thyroid lesions, with or without central neck dissection. Nodule size and thyroid lobe volume did not exceed 6, 10 cm, respectively. FTS reported comparable outcome with transaxillary or oral approaches about operative time, complication rates or drainage features. The mean operative time ranged from 88 to 220 min, depending on the type of surgery (endoscopic vs robotic hemi- or total thyroidectomy). Conversion to open surgery was rare, occurring in 0-6.3% of cases. The most common complications were earlobe hypoesthesia, hematoma, seroma, transient hypocalcemia and transient recurrent nerve palsy. There was an important disparity between studies about the inclusion/exclusion criteria, surgical and functional outcomes. CONCLUSION: FTS is a safe and effective approach for thyroid benign and malignant lesions. FTS reports similar complications to conventional thyroidectomy and excellent cosmetic satisfaction.

The Face Mask at the Intersection of Preventive Science, Domestic Politics, and International Diplomacy: A Historical Perspective.

Background: The face mask has been used to protect against airborne diseases throughout history. We conducted a historical review of the literature on the origin of the face mask, the scientific evidence of its benefits, and its implications for domestic and international politics. Material and Methods: We performed a comprehensive search for peer- and nonpeer- reviewed literature published between 1905 and 2020. Results: Face mask wearing in hospital settings to prevent disease transmission from health care workers to their patients originates with the first use of the mask in surgery in 1897 by German surgeon Johann von Mikulicz. During the first half of the 20th century, various scientific investigators focused on determining the most effective type of medical mask. The role of the face mask in the general population as a preventive intervention during public health emergencies is supported by historical reports spanning from the European Bubonic Plague in 1619, to the Great Manchurian Plague of 1910-1911, the influenza pandemic of 1918, and the current coronavirus disease in 2019 (COVID-19) pandemic. Although the face mask has helped against airborne disease transmission, its benefits during pandemics have been filtered through the prism of political leanings and geopolitical interests. Conclusions: Our review suggests that while face mask alone cannot stop pandemics, in conjunction with other nonpharmacologic interventions it can be useful in mitigating them. When cooperation rather than division becomes the norm in the global response to pandemics, the face mask can then unite rather than divide us.

Detection and potential consequences of intraoperative adverse events: A pilot study in the veterans health administration.

Surgical quality improvement efforts have focused on tracking and reducing postoperative mortality and morbidity. However, the prevalence of intraoperative adverse events (IAEs) and their association with postoperative surgical outcomes has been poorly studied. In this study, we detected IAEs using both retrospective chart review and prospective provider reporting. We then examined the association of IAEs with postoperative outcomes. The overall IAE detection rate per case was 0.7 and 0.07 (P < 0.0001) based on chart review and provider reporting, respectively. Types of IAEs varied between detection methods. Provider-reported IAEs were more serious, i.e., had a stronger association with 30-day postoperative complications than chart-identified IAEs (risk-adjusted odds ratios were 1.52 vs 1.02, respectively, both p < 0.0001). Our findings suggest that IAEs can be detected using either retrospective chart review or prospective provider reporting. However, provider reporting appears more likely to detect serious (albeit infrequent) IAEs compared to chart review.

Is resection of an esophageal epiphrenic diverticulum always necessary in the setting of achalasia?

BACKGROUND: Esophageal epiphrenic diverticulum (ED) is usually secondary to a primary esophageal motility disorder, such as achalasia. Whereas the recommended surgical treatment includes esophageal myotomy and diverticulectomy, the outcome of patients in whom a myotomy without ED resection is performed is not known. The purpose of this study was to compare the outcome of ED patients who underwent ED resection and myotomy and those of ED patients who had a myotomy only. METHODS: Retrospective review of a prospective database. Thirteen ED patients had symptom evaluation, barium swallow, endoscopy, and esophageal high-resolution manometry (HRM). All patients underwent laparoscopic myotomy and Dor fundoplication. In six patients, the ED was resected (excised ED group), whereas in seven it was left in place (nonexcised ED group): in three because it was small and in four for technical reasons. RESULTS: Preoperatively all patients had dysphagia and 85 % had regurgitation. The mean preoperative Eckardt score was 6.5 ± 2.1 in excised ED group and 6.6 ± 3.3 in nonexcised ED group (p = 0.95). HRM showed type II esophageal achalasia in 85 % of patients. One excised ED group patient had a staple line leak (17 %). At a median follow-up of 2 years, the Eckardt score was 0 in excised ED group and 0.1 in nonexcised ED group (p = 0.56). CONCLUSIONS: The results of this study showed that patients in whom a myotomy without ED resection was performed had resolution of their symptoms. These findings suggest that in patients with achalasia and ED the underlying motility disorder rather than the ED may be the cause of symptoms. Studies with a larger number of patients and a longer follow-up will determine the validity of this approach.

A rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Late complications after a laparoscopic inguinal hernia repair are extremely rare and have only recently entered into the literature. One such late complication is mesh infection, of which there have been a handful of cases reported in the literature. Mesh infections occurring many years after inguinal hernia repairs are not only of significance because they are not well documented in the literature, and the pathogenesis and risk factors contributing to their development are not well understood. This report details a rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology.

Controversies in management of achalasia.

BACKGROUND: Esophageal achalasia is a primary motility disorder of unknown etiology. It is characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter to relax appropriately in response to swallowing. The goal of treatment is to improve esophageal emptying and patient's symptoms by decreasing the functional obstruction at the level of the gastroesophageal junction. This can be accomplished by either endoscopic modalities (intra-sphincteric injection of botulinum toxin, pneumatic dilatation, per oral endoscopic myotomy) or by a laparoscopic Heller myotomy. RESULTS: Review of the current literature suggests that a laparoscopic Heller myotomy should be considered today the primary form of treatment for achalasia and recommends a treatment algorithm for this disease.

Idiopathic pulmonary fibrosis and gastroesophageal reflux. Implications for treatment.

BACKGROUND: Even though the pathogenesis of idiopathic pulmonary fibrosis (IPF) is unknown, there is mounting evidence that abnormal reflux (GERD) and aspiration of gastric contents may play a role in the pathogenesis of this disease. AIMS: The aims of this study were to determine in patients with GERD and IPF: (a) the clinical presentation, (b) the esophageal function, and (c) the reflux profile. METHODS: We compared the clinical presentation, the esophageal function (as defined by high-resolution manometry), and the reflux profile (by dual sensor pH monitoring) in 80 patients with GERD (group A) and in 22 patients with GERD and IPF (group B). RESULTS: Heartburn was present in less than 60 % of patients with GERD and IPF. Lower esophageal sphincter pressure and peristalsis were normal in both groups, while the upper esophageal sphincter (UES) was more frequently hypotensive in IPF patients (p = 0.008). In patients with GERD and IPF, the proximal esophageal acid exposure was higher (p = 0.047) and the supine acid clearance was slower as compared with patients with GERD only (p < 0.001). CONCLUSIONS: The results of this study show that in patients with GERD and IPF: (a) reflux is frequently silent, (b) with the exception of a weaker UES, the esophageal function is preserved, and (c) proximal reflux is more common, and in the supine position, it is coupled with a slower acid clearance. Because these factors predisposing IPF patients to the risk of aspiration, antireflux surgery should be considered early after the diagnosis of IPF and GERD is established.

To 'gram or not'? Indications for intraoperative cholangiogram.

BACKGROUND: The purpose of this study was to evaluate the current practice patterns and results for use of intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC). METHODS: We performed a retrospective review of all patients who underwent LC between January 1, 2005 and December 31, 2009. Data variables included: preoperative laboratory and radiographic studies, indication for and findings of IOC, and perioperative management of choledocholithiasis and retained common bile duct (CBD) stones. RESULTS: There were 1,308 patients who underwent LC by 23 surgeons, of whom 266 also had an IOC (20%) performed. The majority had ultrasonography performed, 242 had an abdominal compute tomography (CT) scan, and 129 patients had a hepatobiliary iminodiacetic acid (HIDA) scan. Indications for an IOC included: diagnosis of choledocholithiasis or gallstone pancreatitis (n = 116), abnormal liver function tests (n = 187), and a dilated CBD ≥ 10 mm (n = 182). Of the 266 IOCs, 36 patients (13.5%) had a CBD stone with the majority (n = 26; 72%) having normal preoperative imaging studies. Only 6 patients (17%) with a CBD calculi on IOC underwent successful clearance of the calculi at the time of LC. Twenty-nine of the remaining 30 patients with a retained calculus on IOC underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) with extraction of the calculi. Of the 1,042 LCs performed without an IOC, 31 patients (3%) were diagnosed with a retained stone managed successfully by ERCP. CONCLUSION: Our data reveals that the selective use of IOC is helpful in diagnosing and clearing CBD calculi, that the use of preoperative CBD size aids in selecting patients for IOC, and that choledocholithiasis identified with IOC or after discharge can be managed successfully with ERCP.

Gastroesophageal reflux disease and morbid obesity: is there a relation?

Gastroesophageal reflux disease (GERD) is highly prevalent in morbidly obese patients, and a high body mass index (BMI) is a risk factor for the development of GERD. However, the mechanism by which the BMI affects esophageal acid exposure is not completely understood. Although many advances have been made in the understanding of the pathophysiology of GERD, many aspects of the pathophysiology of this disease in morbidly obese patients remain unclear. The following review describes the current evidence linking esophageal reflux to obesity, covering the pathophysiology of the disease and the implications for treatment of GERD in the obese patient.

Laparoscopic paraesophageal hernia repair. How I do it.

INTRODUCTION: The approach to paraesophageal hernias has changed radically over the last 15 years, both in terms of indications for the repair and of surgical technique. DISCUSSION: Today we operate mostly on patients who are symptomatic and the laparoscopic repair has replaced in most cases the open approach through either a laparotomy or a thoracotomy. The following describes a step by step approach to the laparoscopic repair of paraesophageal hernia.

Gastroesophageal reflux disease and connective tissue disorders: pathophysiology and implications for treatment.

INTRODUCTION: It has been postulated that in patients with connective tissue disorders (CTD) and gastroesophageal reflux disease (GERD), esophageal function is generally deteriorated, often with complete absence of peristalsis. This belief has led to the common recommendation of avoiding antireflux surgery for fear of creating or worsening dysphagia. METHODS: We hypothesized that in most patients with CTD and GERD: (a) esophageal function is often preserved; (b) peristalsis is more frequently absent when end-stage lung disease (ESLD) is also present; (c) a tailored surgical approach (partial or total fundoplication) based on the findings of esophageal manometry allows control of reflux symptoms without a high incidence of postoperative dysphagia. Forty-eight patients with CTD were evaluated by esophageal manometry and 24-hour pH monitoring (EFT). Twenty patients (group A) had EFT because of foregut symptoms, and 28 patients with ESLD (group B) had EFT as part of the lung transplant evaluation. Two hundred and eighty-six consecutive patients with GERD by pH monitoring served as a control group (group C). A laparoscopic fundoplication was performed in two group A patients (total), eight group B patients (three patients total, five patients partial) and in all group C patients (total). RESULTS: Esophageal peristalsis was preserved in all patients with CTD and GERD. In contrast, peristalsis was absent in about half of patients when ESLD was also present. A tailored surgical approach resulted in control of reflux symptoms in all patients. One patient only developed postoperative dysphagia, which resolved with two Savary dilatations. CONCLUSION: These data show that esophageal motor function is preserved in most patients with CTD, so that they should be offered antireflux surgery early in the course of their disease to prevent esophageal and respiratory complications. In patients with ESLD in whom peristalsis is absent, a partial rather than a total fundoplication should be performed, as it allows control of reflux symptoms while avoiding postoperative dysphagia.

Laparoscopic repair of paraesophageal hiatal hernias.

The advent of minimally invasive techniques has brought about a shift in the operative approach of patients with paraesophageal hiatal hernia. Today, the laparoscopic repair of a paraesophageal hiatal hernia has almost completely replaced the open approach through either a laparotomy or a left thoracotomy. The laparoscopic repair of paraesophageal hiatal hernias is a technically challenging operation; however, it is technically feasible and safe, and it is associated with a positive relief of symptoms, decreased postoperative pain, and a rapid return to normal activities (1, 2). This paper describes, step by step, our approach to the laparoscopic repair of a paraesophageal hiatal hernia.

Management of high-grade dysplasia.

High-grade dysplasia is the last stage before the development of adenocarcinoma. Despite the fact that the lesion is not yet invasive, it has tremendous potential to become malignant. The approach to the disease has clinicians divided between immediate intervention with surgical resection or continued endoscopic surveillance proof of the unclear natural history. Much knowledge has been acquired recently regarding application of surveillance and outcomes of esophageal resection. Also, many endoscopic techniques for treating high-grade dysplasia have been studied in depth. Results on their safety, efficacy, and complication rates have recently become available. This review analyzes the progress in the understanding and treatment of high-grade dysplasia during the past 24 to 36 months and examines how this new information plays a role in the disease's treatment algorithm.

Clinical, radiological, and manometric profile in 145 patients with untreated achalasia.

BACKGROUND: Esophageal achalasia is characterized by the absence of esophageal peristalsis and by a dysfunctional lower esophageal sphincter (LES). Descriptions of clinical, radiological, and manometric findings in patients with achalasia usually have been based on small numbers of patients. This study was designed to determine in patients with untreated achalasia: (1) clinical presentation; (2) how often a diagnosis of gastroesophageal reflux disease (GERD) was erroneously made based on the presence of heartburn; (3) manometric profile; (4) relationship between chest pain and the manometric finding of vigorous achalasia. METHODS: Between 1990 and 2004, a diagnosis of esophageal achalasia was established in 145 patients. None of them had been previously treated (no previous endoscopic or surgical treatment). We evaluated the demographic and clinical characteristics, as well as the results of the endoscopy, barium swallow, esophageal manometry, and ambulatory pH monitoring. We also compared the clinical and the manometric profile of patients with classic and patients with vigorous achalasia. RESULTS: Most patients with untreated achalasia had dysphagia (94%). Regurgitation was present in 76% and heartburn in 52%. Chest pain (41%) and weight loss (35%) were less common. Acid-suppressing medications had been prescribed to 65 patients (45%) who complained of heartburn on the assumption that GERD was present. The LES was hypertensive in 43% of patients only. There was no significant difference in the prevalence, severity, and duration of chest pain in patients with classic and with vigorous achalasia. CONCLUSIONS: These results show that in patients with untreated achalasia: (1) dysphagia was the most frequent complaint, but regurgitation and heartburn were frequently present; (2) a diagnosis of GERD based on the presence of heartburn was highly unreliable; (3) the LES was hypertensive in less than half of patients; and (4) the prevalence, severity, and duration of chest pain did not correlate with the manometric finding of vigorous achalasia.

The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation.

In the past, a Heller myotomy was considered to be ineffective in patients with achalasia and a markedly dilated or sigmoid-shaped esophagus. Esophagectomy was the standard treatment. The aims of this study were (a) to evaluate the results of laparoscopic Heller myotomy and Dor fundoplication in patients with achalasia and various degrees of esophageal dilatation; and (b) to assess the role of endoscopic dilatation in patients with postoperative dysphagia. One hundred and thirteen patients with esophageal achalasia were separated into four groups based on the maximal diameter of the esophageal lumen and the shape of the esophagus: group A, diameter<4.0 cm, 46 patients; group B, esophageal diameter 4.0-6.0 cm, 32 patients; group C, diameter>6.0 cm and straight axis, 23 patients; and group D, diameter>6.0 cm and sigmoid-shaped esophagus, 12 patients. All had a laparoscopic Heller myotomy and Dor fundoplication. The median length of follow-up was 45 months (range 7 months to 12.5 years). The postoperative recovery was similar among the four groups. Twenty-three patients (20%) had postoperative dilatations for dysphagia, and five patients (4%) required a second myotomy. Excellent or good results were obtained in 89% of group A and 91% of groups B, C, and D. None required an esophagectomy to maintain clinically adequate swallowing. These data show that (a) a laparoscopic Heller myotomy relieved dysphagia in most patients with achalasia, even when the esophagus was dilated; (b) about 20% of patients required additional treatment; (c) in the end, swallowing was good in 90%.

Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia. How I do it.

The advent and the success of minimally invasive surgery have changed the treatment algorithm for esophageal achalasia. Today, a laparoscopic Heller myotomy and partial fundoplication is considered the treatment of choice for this disease. This article describes the technique of laparoscopic Heller myotomy and Dor fundoplication.

Laparoscopic fundoplication in elderly patients with gastroesophageal reflux disease.

HYPOTHESIS: It is unclear if age should be considered a factor in the choice of treatment for gastroesophageal reflux disease (GERD) and if fundoplication in elderly patients is as safe and effective as it is in younger patients. We hypothesized that the outcome of laparoscopic antireflux operations in patients younger than 65 years is similar to that of patients 65 years and older. DESIGN: Retrospective review of findings from a prospectively acquired database. SETTING: University-based tertiary care center. PATIENTS: Three hundred four consecutive patients underwent laparoscopic fundoplication for GERD. Two hundred forty-one patients were younger than 65 years (group A; median age, 46 years), and 63 patients were 65 years or older (group B; median age, 69 years). MAIN OUTCOME MEASURES: Presence, duration, and severity of GERD symptoms; presence of a hiatal hernia or esophageal stricture; duration of operation; incidence of complications; and length of hospital stay. RESULTS: Elderly patients more often had regurgitation and respiratory symptoms in addition to heartburn. Hiatal hernias were more common among elderly patients (77% vs 51%). The duration of the operation was similar for the 2 groups. The incidence of intraoperative and postoperative complications was low and similar in the 2 groups. The median hospital stay was 24 hours for each group. Heartburn resolved in approximately 90% of patients in each group. CONCLUSIONS: Elderly patients more often had hiatal hernias and respiratory symptoms. Laparoscopic antireflux surgery was as safe in elderly patients as it was in younger patients, and clinical outcomes were as good.

Cause and treatment of epiphrenic diverticula.

BACKGROUND: Epiphrenic diverticula of the esophagus are often associated with a concomitant esophageal motor disorder, which is thought to be the cause of the diverticulum and some of the patient's symptoms. At one time diverticula were best removed via a left thoracotomy, but now the operation can be performed laparoscopically in most cases. We hypothesized that: (1) a motor disorder is the underlying cause of the diverticulum; and (2) optimal treatment consists of laparoscopic resection of the diverticulum, a Heller myotomy, and Dor fundoplication. METHODS: We performed a retrospective review of a prospectively collected database from a university hospital tertiary care center. Between June 1994 and December 2002, we evaluated 21 patients with epiphrenic diverticula. An associated motility disorder of the esophagus was found in 81% of patients (achalasia, 9%; diffuse esophageal spasm, 24%; nonspecific esophageal motility disorder, 24%; nutcracker esophagus, 24%). Seven (33%) of these patients, all with esophageal dysmotility, were referred for treatment. The laparoscopic operation entailed resection of the diverticulum (using an endoscopic stapler), a Heller myotomy, and a Dor fundoplication. RESULTS: All operations were completed laparoscopically. The postoperative course of 6 patients was uneventful and they left the hospital after 72 +/- 21 hours. In 1 patient an acute paraesophageal hernia developed, which was repaired on the second postoperative day. Late follow-up (median 57 months) showed that all 7 patients were asymptomatic. CONCLUSIONS: These data support the conclusions that: (1) a primary esophageal motility disorder is the underlying cause of most epiphrenic diverticula; and (2) laparoscopic treatment is successful and should be the method of choice. The diverticular neck can be exposed satisfactorily from the abdomen; a stapler inserted from this angle is better orientated to transect the neck than one inserted through a thoracoscopic approach. Furthermore, the myotomy and fundoplication are much more easily performed from the abdomen than from alternative approaches.