Comparison of Robotic, Laparoscopic, and Open Unilateral Repair of Non-recurrent Inguinal Hernia.

BACKGROUND: There is a paucity of data comparing open, robotic, and laparoscopic approaches on unilateral, non-recurrent inguinal hernias. Our study presents a large, retrospective triple-arm outcome analysis between robotic, laparoscopic, and open unilateral, non-recurrent inguinal hernia repairs at a single institution. METHODS: 706 patients who underwent elective, non-recurrent inguinal hernia repair performed by 8 general surgeons at a single institution from 2016 to 2019 were reviewed retrospectively. Patient baseline characteristics, operative times, resident involvement, and postoperative outcomes were analyzed for all repair types. A cost analysis of the different procedures was performed. RESULTS: There were 305 laparoscopic repairs, 207 robotic repairs, and 194 open repairs. Open and laparoscopic repairs were performed on patients who were older (p =< .001) and with a higher Charlson Comorbidity Index (p =< .001). Patient BMI was higher in minimally invasive repair than open repair (P = .021). There were no significant differences in complication rates on pairwise analysis. Robotic and open repairs had significantly longer operative times than laparoscopic repairs (P < .001). There was less resident involvement in robotic repair than with the other approaches (P < .001). Resident involvement was associated with shorter OR times (P = .001) and no significant difference in postoperative complications. There was a trend over the study period toward faster operative times and more robotic repair. Robotic repair is the most expensive repair, followed by laparoscopic and open repairs. CONCLUSION: All 3 repair techniques can be performed without significant differences in outcomes. The technique utilized should be based on surgeon preference and patient characteristics.

Outcomes of partial fundoplication for GERD-related allograft decline after lung transplantation.

INTRODUCTION: Gastroesophageal reflux disease contributes to allograft decline secondary to bronchiolitis obliterans after lung transplantation. Antireflux surgery (ARS) slows the decline in lung function related to GERD. ARS operations range from Nissen fundoplications to partial fundoplications, such as the Toupet and Dor. Research in the general population has indicated that partial fundoplication is effective at controlling reflux. We explored lung function and reflux outcomes in a cohort of lung transplant patients who received partial fundoplications. METHODS: Data from an institutional lung transplant registry was reviewed for patients between 2009 and 2020 who underwent fundoplication after transplant. Lung transplant patients underwent routine pulmonary function testing. Patients with FEV1 values within 180 days pre-fundoplication and two years post-fundoplication were included in the analysis. All patients referred for fundoplication underwent esophageal pH testing, manometry, UGI, and EGD. Most patients underwent Toupet fundoplication, but those with severe dysmotility underwent Dor fundoplication. RESULTS: 53 patients were included in the analysis. Median time to fundoplication after transplant was 403 days. 48 patients underwent Toupet fundoplication. Five underwent Dor fundoplication. 40% of patients had abnormal high-resolution manometry. A linear mixed-effects model tested for a change in FEV1 trajectory up to two years post-fundoplication with an auto-regressive correlation structure. Post-fundoplication FEV1 values decreased by 7 mL per month, and suggested a slow in the decline by 2 mL per month, but this was not significant (p = 0.8). In patients for whom postoperative DeMeester scores were available (19), there was a decline in acid exposure from a median of 45.8 to 1.8 after ARS (p = 0.0003). CONCLUSION: Although our results did not reach statistical significance, there was a trend towards a decrease in the rate of decline of allograft function before and after partial fundoplication. In the patients whom results were available, a partial fundoplication appropriately controlled acid exposure.

Treatment of Gastroesophageal Reflux Disease After Lung Transplant Using Radiofrequency Ablation to the Lower Esophageal Sphincter (Stretta Procedure).

BACKGROUND: Gastroesophageal reflux disease (GERD) is associated with chronic lung allograft dysfunction after lung transplant. Treating GERD after lung transplant has been shown to improve lung allograft function. This case series describes the efficacy of the Stretta procedure to control GERD after lung transplant at our institution. METHODS: Eleven patients underwent the Stretta procedure at our institution for GERD after lung transplant during the years 2016-2017. Pre- and post-Stretta reflux parameters were gathered. Pulmonary function was followed up until subsequent fundoplication surgery, death, or end of study observation. RESULTS: Reflux on esophagram was noted in 9 patients before Stretta and 8 patients after Stretta. The median number of acid reflux events was 31.5 vs. 26 after Stretta (P = .95), and median percent time in reflux was 17.7% before vs. 14.5% after Stretta (P = .76). Median DeMeester score before Stretta was 65.5 (range: 33.2-169.8) vs. 42.5 (range: 19.2-109.8) after the procedure (P = .14). Median lower esophageal resting pressure was 20.7 mm Hg (n = 7) compared to 25.9 mm Hg (n = 9) on post-Stretta follow-up (P = .99). Median FEV1% predicted was 84% (41-97%) before compared to 71% (23-108%) at 1 year after the procedure (P = .14). Seven patients required fundoplication surgery for continued reflux. All patients were on triple immunosuppression, most commonly prednisone, tacrolimus, and mycophenolate (n = 9). DISCUSSION: The Stretta procedure did not provide expected results at our institution after lung transplant surgery. Based on our limited series, we do not recommend routine use of the Stretta procedure for management of GERD in lung transplant patients.

Is barium esophagram enough? Comparison of esophageal motility found on barium esophagram to high resolution manometry.

BACKGROUND: The aim of the study is to determine if barium esophagram (BE) alone is sufficient to diagnose esophageal dysmotility when compared to the gold standard, high-resolution manometry (HRM). METHODS: This is a retrospective review of patients that underwent laparoscopic fundoplication by two surgeons at a single institution from 10/1/2015-6/29/2019. Patients with large paraesophageal hernias and patients without both BE and HRM were excluded. RESULTS: Forty-six patients met the inclusion criteria. BE was found to be concordant with HRM for esophageal motility in only 21 patients (46%). Setting HRM as the gold standard, BE had a sensitivity of 14% (95% CI: 5%-35%), specificity of 72% (95% CI: 52%-86%), PPV of 30% (95% CI: 11%-60%), and NPV of 50% (95% CI: 35%-66%). The accuracy was 46%, while a McNemar test showed p = 0.028. CONCLUSION: Traditional BE should not be used in place of HRM for assessing pre-operative motility in patients undergoing anti-reflux surgery.

Cost-efficiency and outcomes in the treatment of perforated peptic ulcer disease: laparoscopic versus open approach.

PURPOSE: Laparoscopic treatment of perforated peptic ulcer disease (perfPUD) has demonstrated comparable operative outcomes with an open approach though the cost-efficiency of this method has not been studied. METHODS: Data were obtained from the Nationwide Inpatient Sample (2007-2010). Patients who underwent operation for perfPUD were divided on the basis of laparoscopic or open approach. The primary outcome measures were hospital duration of stay, mortality, and total charges. RESULTS: A total of 5,361 patients with perfPUD were identified: 5,219 in the open group and 142 in the laparoscopic group. Patients in the laparoscopic group were younger (50.5 vs 60.0, P < .001) and had a lesser incidence at presentation of sepsis (8.5 vs 14.8%, P = .034) and shock (2.1 vs 7.7%, P = .012). On univariate analysis, the laparoscopic group had decreased duration of stay (7.0 vs 8.0 days, P < .001), lesser rates of mortality (3.5 vs 8.1%, P = .048), and were discharged to home more frequently (79.6 vs 68.1%, P = .025). Mean total charges were less in the laparoscopic group ($44,095 vs $52,055, P = .019). Multivariate analyses failed to show a difference between groups for any of the outcome variables. CONCLUSION: The laparoscopic treatment of perfPUD is associated with equivalent costs and outcomes compared with the open technique when we corrected for presentation variables.

Animate advanced laparoscopic courses improve resident operative performance.

BACKGROUND: The use of animate training laboratories have been touted as an important part of a surgical resident's training. This study determines if there was any benefit in resident performance and whether that benefit persisted. METHODS: Twelve senior surgical residents attended a course in advanced laparoscopy with didactic and laboratory components. The residents' skills were tested by having them perform a laparoscopic fundoplication before, immediately after, and 6 months after the course. The procedure was videotaped, and divided into stages that were timed and scored by a single, masked observer. RESULTS: Overall performance score was 35.7 +/- 2.5 for the pretest, improving to 16.5 +/- 1.2 (P <0.05) immediately after the course, and 23.7 +/- 5.1 (P <0.05) at 6 months. Significant improvements were seen with trocar insertion, crural closure, division of short gastric arteries, and fundoplication. CONCLUSIONS: The data presented demonstrate significant and persistent improvement in laparoscopic operative skills as a result of focused laboratory skill training.