Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.

BACKGROUND: Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. METHODS: A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data were analyzed using univariate analysis. RESULTS: One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7 years, 29.7 ± 5.7 kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6 months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. CONCLUSION: Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

Outcomes of Bariatric Surgery in Patients on Chronic Opioids: Can Bariatric Surgery Assist with Decreasing Long-term Opioid Utilization?

PURPOSE: The aim of our study was to assess long-term opioid use following bariatric surgery in patients on preoperative narcotics. METHODS: We evaluated patients utilizing preoperative opioids (OP) who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2020. Patients were propensity-matched to those without preoperative opioid use (NOP) by demographics and comorbidities. Our objectives were to compare opioid use at 1 and 3 years after surgery and evaluate perioperative outcomes. RESULTS: A total of 806 patients, matched 1:1 were evaluated, with 82.7% being females. Mean age was 46.5 years in the OP and 45.6 years in the NOP (p = 0.0018), preoperative BMI was 45.8 in the OP and 46.1 in the NOP (p = 0.695). All patients were followed up for 1 year. In the OP, 156 (38.7%) patients were taking opioids 1 year after surgery as opposed to 27 (6.7%) in the NOP (p < 0.0001). Three years after surgery, 74 (37.5%) patients in the OP and 27 (14.4%) in the NOP were taking outpatient opioids (p < 0.0001). There was no statistically significant difference between OP and NOP groups in terms of readmissions (9.4% vs. 5.7% p = 0.06), reinterventions (3.7 vs. 1.7% p = 0.13), reoperations (3.5% vs. 1.5% p = 0.11), or emergency room visits (8.9% vs. 7.2% p = 0.44). There were no mortalities. CONCLUSION: Most patients requiring preoperative opioids can be weaned off after bariatric surgery. Enhanced recovery pathways are key to obtaining these results. Preoperative opioid use is not associated with increased complications compared to opioid-naïve patients.

Solitary fibrous tumour of the sigmoid colon mesentery.

Solitary fibrous tumours (SFTs) are rare tumours arising from mesenchymal tissues. Despite of their more frequent occurrence in the pleura, SFT can present anywhere in the body. Only a few cases have been described arising from the mesentery. Most tumours have a benign nature; however, up to 20% of them can spread, most commonly to liver, lung and bone. Surgical excision including all surrounding tissues remains the treatment of choice; however, there is no consensus regarding the need for adjuvant therapies. We present a 79-year-old man with abdominal pain who was found to have a SFT in the mesentery of the sigmoid colon, treated with en bloc resection. A multidisciplinary team including surgeons, medical and radiation oncologists is recommended in the care of these patients.

Natural History of Low-stage Urethral Strictures.

OBJECTIVE: To determine the natural history and rate of progression of incidental wide-caliber, anterior urethral strictures (USs) in men using a validated stricture staging system. SUBJECTS AND METHODS: Men with incidental findings of anterior US on cystoscopy performed for urologic conditions other than US were retrospectively reviewed from 2001 through 2016. Diagnosis of US on cystoscopy was made according to a validated staging system: stage 0 = no stricture; stage 1 = wide-caliber stricture; stage 2 = requires gentle dilation with a flexible cystoscope; stage 3 = impassable stricture with a visible lumen; and stage 4 = no visible lumen. Using this staging system, this study assessed the change over time of US in patients found to have a stage 1 stricture. The primary outcome was the US grade at time of follow-up. Secondary outcomes include the need for further intervention. RESULTS: Thirty-two patients with 42 separate strictures were evaluated. Median length of follow-up between first cystoscopy and ultimate cystoscopy was 23 months, with a median of 4 cystoscopies per patient. Of the 42 strictures, 15 regressed to a stage 0 (36%), 22 remained as stage 1 (52%), and 5 (12%) progressed to stage 2. None of the patients required additional intervention. CONCLUSION: The majority of low-stage USs does not progress. This supports the notion that strictures are a graded phenomenon, and not all require surgical intervention.

Validation of the lower urinary tract symptom score.

INTRODUCTION: To develop and validate a lower urinary tract symptom score (LUTSS) as a measure of lower urinary tract symptom (LUTS) severity and a treatment outcome tool in adults. MATERIALS AND METHODS: An expert panel was convened to develop the LUTSS questionnaire. Content validity was achieved by obtaining subject and expert feedback from two prospective drafts. Subjects were divided into three groups: normal, LUTS and overactive bladder (OAB). Questionnaire was administered on two separate occasions within 1-2 weeks. Test-retest reliability, internal consistency, discriminant validity, criterion validity and responsiveness to change were also assessed. RESULTS: The questionnaire contains 14 questions with answers scored on a 5-point Likert scale (0-4). It includes 9 storage, 4 voiding and 1 bother question. One hundred ninety-one patients completed it; 80 males and 111 females, mean age 65 years (range 22-91). Seventy-two had OAB, 91 LUTS without OAB and 28 were normal. Test-retest intraclass correlation was 0.96 and Cronbach's-□ was 0.77, indicating strong test-retest reliability and internal consistency, respectively. ANOVA and post-hoc bootstrap-generated adjustments showed significant differences between the three groups (p < 0.001), demonstrating discriminant validity. Responsiveness to change was exhibited by the significant decrease between preop and postop scores and a concurrent patient global impression of improvement (PGI-I) score indicative of symptomatic improvement. CONCLUSION: The 14-question LUTSS is a validated questionnaire that assesses a full range of LUTS in men and women. The ordinal nature of the data with its highly specific description of symptoms makes it ideally suited as a nuanced and comprehensive symptom score and patient reported outcome (PRO) tool.

Safety considerations for synthetic sling surgery.

Implantation of a synthetic midurethral sling (SMUS) is the most commonly performed anti-incontinence operation in women worldwide. The effectiveness of the SMUS is comparable to that of the historical gold standards--autologous fascial slings and the Burch colposuspension. Much controversy, however, has evolved regarding the safety of this type of sling. Overall, the quality of the studies with respect to assessing risks of SMUS-associated complications is currently poor. The most common risks in patients with SMUS include urethral obstruction requiring surgery (2.3% of patients with SMUS), vaginal, bladder and/or urethral erosion requiring surgery (1.8%) and refractory chronic pain (4.1%); these data likely represent the minimum risks. In addition, the failure rate of SMUS implantation surgery is probably at least 5% in patients with stress urinary incontinence (SUI). Furthermore, at least one-third of patients undergoing sling excision surgery develop recurrent SUI. Considering the additional risks of refractory overactive bladder, fistulas and bowel perforations, among others, the overall risk of a negative outcome after SMUS implantation surgery is ≥15%.

Management of urinary fistulas due to midurethral sling surgery.

PURPOSE: We report our experience with the diagnosis and treatment of women with urinary fistula after mid urethral sling surgery. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with urinary fistula secondary to mid urethral sling surgery. Electronic medical records and billing records were searched. We analyzed sling type, presenting symptoms and interval from initial sling surgery to 1) symptom appearance, 2) fistula diagnosis and 3) fistula repair. Symptomatic outcomes were assessed by PGI-I. Surgical outcomes were based on history and examination. RESULTS: We identified 10 women with a mean age of 58 years (range 37 to 70). Mean interval from mid urethral sling surgery to symptom onset, diagnosis and fistula repair was 2, 16 and 18 months, respectively. Mean followup was 26 months (range 4 to 96). There were 1 ureterovaginal, 1 enterovesical, 6 vesicovaginal and 7 urethrovaginal fistulas. Patients presented with stress urinary incontinence (70%), unaware incontinence (50%), overactive bladder (40%), pelvic pain (30%) and voiding symptoms (20%). Nine women underwent fistula repair and 1 underwent continent urinary diversion. A Martius flap was used in 6 of 9 patients, an omental flap and a bladder wall flap were used in 2 each, urethral reconstruction and ureterocolovesicostomy were performed in 1 each and 7 received an autologous pubovaginal sling. Seven patients (78%) underwent successful fistula repair. A successful symptomatic outcome was achieved in 5 of 7 women with stress urinary incontinence, 3 of 5 with unaware incontinence, 3 of 4 with overactive bladder, 2 of 3 with pelvic pain and 2 of 2 with voiding symptoms. CONCLUSIONS: With careful attention to surgical principles and technique, including removal of as much of the adjacent mesh as possible, a successful outcome can be achieved in most patients with a fistula secondary to mid urethral sling surgery.