Compliance of the abdominal wall during laparoscopic insufflation.

BACKGROUND: To provide adequate workspace between the viscera and abdominal wall, insufflation with carbon dioxide is a common practice in laparoscopic surgeries. An insufflation pressure of 15 mmHg is considered to be safe in patients, but all insufflation pressures create perioperative and postoperative physiologic effects. As a composition of viscoelastic materials, the abdominal wall should distend in a predictable manner given the pressure of the pneumoperitoneum. The purpose of this study was to elucidate the relationship between degree of abdominal distention and the insufflation pressure, with the goal of determining factors which impact the compliance of the abdominal wall. METHODS: A prospective, IRB-approved study was conducted to video record the abdomens of patients undergoing insufflation prior to a laparoscopic surgery. Photo samples were taken every 5 s, and the strain of the patient's abdomen in the sagittal plane was determined, as well as the insufflator pressure (stress) at bedside. Patients were insufflated to 15 mmHg. The relationship between the stress and strain was determined in each sample, and compliance of the patient's abdominal wall was calculated. Subcutaneous fat thickness and rectus abdominus muscle thickness were obtained from computed tomography scans. Correlations between abdominal wall compliances and subcutaneous fat and muscle content were determined. RESULTS: Twenty-five patients were evaluated. An increased fat thickness in the abdominal wall had a direct exponential relationship with abdominal wall compliance (R 2 = 0.59, p < 0.05). There was no correlation between muscle and fat thickness. CONCLUSION: All insufflation pressures create perioperative and postoperative complications. The compliance of patients' abdominal body walls differs, and subcutaneous fat thickness has a direct exponential relationship with abdominal wall compliance. Thus, insufflation pressures can be better tailored per the patient. Future studies are needed to demonstrate the clinical impact of varying insufflation pressures.

Quality-of-life scores in laparoscopic preperitoneal inguinal hernia repair.

BACKGROUND: Published support exists for using lightweight polypropylene mesh (PPM) to repair inguinal hernias with increased biocompatibility and decreased foreign body reaction and pain. However, quality of life (QOL) has not been assessed. We assess QOL in patients undergoing laparoscopic totally extraperitoneal hernia repair (TEP) with lightweight PPM. METHODS: We performed an IRB-approved study of patients undergoing TEP hernia repair. Demographic information and hernia characteristics were collected perioperatively. Baseline Short Form-36 (SF-36), Carolinas Comfort Scale (CCS), and visual analog scale (VAS) for pain were performed preoperatively, and then after 1, 26, and 52 weeks. RESULTS: Forty-eight patients undergoing TEP with mesh were selected. Average age was 43.2 years (SD = 13.2), and average BMI was 26.1 kg/m(2) (SD = 4.3). Procedures include bilateral hernia, right inguinal hernia, and left inguinal hernia repairs. Mean scores on the CCS(®) and VAS were low during the immediate post-op period and 1 year. SF-36 mean scores for body pain, physical function, and role physical showed decreases at the postoperative survey and then subsequent increases. Pain-associated scores increased during the immediate post-op period. CCS and SF-36 scores demonstrated improvement after 1 year. There was no significant difference in VAS. Bilateral repair patients reported more pain and reduced physical function versus unilateral repairs. Patients with larger mesh reported greater pain scores and reduced physical function scores. CONCLUSIONS: Laparoscopic inguinal hernia repair is associated with initial declines in QOL in the postoperative period. Improvements appear in the long term. General health does not appear to be impacted by laparoscopic TEP. Smaller mesh and unilateral repairs are associated with improved QOL following laparoscopic TEP with PPM. Multiple metrics for QOL are required to reflect patient recovery.

Laparoscopic ventral hernia repair with primary fascial closure versus bridged repair: a risk-adjusted comparative study.

BACKGROUND: Laparoscopy, specifically the bridged mesh technique, is a popular means used for ventral hernia repair. While laparoscopy has decreased the incidence of surgical site infection (SSI), hernia recurrence rates remain unchanged. Some surgeons advocate laparoscopic primary fascial closure (PFC) with placement of intraperitoneal mesh to decrease recurrence rates. We hypothesize that in patients undergoing laparoscopic ventral hernia repair (LVHR), PFC compared to a bridged mesh repair decreases hernia recurrence rates. METHODS: A multicenter, retrospective database of all ventral hernia repairs performed from 2010-2012 was accessed. Patients who underwent LVHR with mesh were reviewed. Patients who had PFC were compared to bridged repair. Primary outcome was hernia recurrence determined by clinical examination or CT scan. Secondary outcomes included SSI and seroma formation. RESULTS: A total of 1594 patients were identified. Following exclusion, a total of 196 patients were left who underwent LVHR with a mean follow-up period of 17.5 months. Ninety-seven patients underwent PFC, while 99 underwent bridged repairs. Initial comparisons between both groups was negative for any significant statistical difference in terms of recurrence, seroma formation, SSI, deep/organ space SSI, reoperation, and readmission. The same initial findings held true during subgroup analysis. Propensity score analysis was then performed for recurrence, seroma, and SSI controlling for age, gender, immune status, ASA class, BMI, smoking status, and acute repair. No statistically significant differences were identified in either group. CONCLUSION: Primary fascial closure during laparoscopic hernia repairs did not result in reduced recurrence, seroma, and SSI as compared to bridge repairs in a retrospective, multi-institutional study. However, additional research is needed to further evaluate benefits to the patient in terms of pain, function, cosmesis, and overall satisfaction. Randomized, blinded, control trials should focus on these parameters in future investigations.

Revisional paraesophageal hernia repair outcomes compare favorably to initial operations.

BACKGROUND: Recurrent paraesophageal hernia (PEH) repair is performed for symptomatic recurrent hiatal hernia and/or reflux with little understanding as to outcomes related to perioperative and subjective patient variables. The aim of this study was to understand what differences exist between patients undergoing initial paraesophageal hernia (IPEH) repair and those undergoing redo paraesophageal hernia (RPEH) repair. METHODS: A review of PEH repairs between 2009 and 2013 was performed from a single institution. RPEH patients were identified and analyzed for demographic information, perioperative/intraoperative details, and postoperative outcomes. A similar comparison group of IPEH patients was randomly selected from the same sample as a control. A phone questionnaire was administered to the RPEH group. RESULTS: Among 336 total PEH repairs from 2009 to 2013, 34 RPEH patients were identified. A matched cohort of 76 patients was identified. RPEH and IPEH groups had similar DeMeester score, incidence of Barrett's esophagus, incidence of gastritis, and LOS. Readmission rates (15 vs. 24 %, p = 0.283) and recurrence rate (4 vs. 12 %, p = 0.201) were not statistically different between IPEH and RPEH repairs, respectively. Operative times (163 vs. 209 min, p < 0.001), incidence of Collis gastroplasty (1 vs. 24 %, p < 0.001), and EBL > 10 cc (25 vs. 51 %, p < 0.023) differed between IPEH and RPEH repairs, respectively. Recurrent symptoms included chest pain (37 %), solid dysphagia (42 %), nausea (58 %), vomiting (32 %), bloating (63 %), and hoarseness (21 %). 21 % of patients required ongoing antacid therapy. Patient satisfaction via phone questionnaires demonstrated 88 % of patients were completely satisfied. CONCLUSIONS: Recurrent PEH repair is performed with similar outcomes to IPEH repair with the exception of increased operative time and blood loss. Collis gastroplasty is required more frequently in RPEH patients. Persistent symptoms exist following RPEH repair. Despite recurrent symptomatology, patient satisfaction is high. RPEH repair may be safely performed in patients with recurrent paraesophageal hernias with outcomes similar to IPEH repairs.

DITPA, a thyroid hormone analog, reduces infarct size and attenuates the inflammatory response following myocardial ischemia.

BACKGROUND: Thyroid hormone can have positive effects on the cardiovascular system but its therapeutic potential is limited secondary to its adverse effects. DITPA (3,5-diiodothyroproprionic acid) is a synthetic thyroid hormone analog with positive inotropic effects similar to thyroid hormone but with minimal systemic effects. DITPA has previously been shown to reduce pathologic remodeling and improve cardiac output following myocardial infarction; however, few studies have examined the role of DITPA in determining infarct size or the early inflammatory response following myocardial ischemia. We examined the role of DITPA in the acute phase following infarction. MATERIALS AND METHODS: Mice were subjected to surgical induction of myocardial infarction and were then randomized to receive daily injections of DITPA or vehicle control. After 3 d, animals were sacrificed and infarct size was determined by H and E staining. Myocardial macrophage and neutrophil accumulation was determined by immunofluorescent staining. Immunoblotting and enzyme-linked immunosorbent assay (ELISA) were used to examine the levels of intercellular adhesion molecule-1 (ICAM-1), keratinocyte-derived chemokine (KC), monocyte chemoattractant protein (MCP-1), and interleukin 6 (IL-6) in homogenates from the ischemic tissue. RESULTS: Compared with vehicle control, DITPA treated animals had smaller infarcts (52.1%±5.7% versus 37.3%±3.6%, P<0.05) and decreased macrophage (32±4 versus 14±1 cells/HPF, P<0.05, and neutrophil (14±2 versus 7±1 cells/HPF, P<0.05) accumulation. Myocardial ICAM-1, (2.37±0.4 versus 1.1±0.2, P<0.05), KC levels (33.32±12.4 pg/mg, versus 21.24±8.9 pg/mg, P<0.05), and IL-6 levels (112.3±78 pg/mg versus 37.3±25.9 pg/mg, P<0.05) were also reduced in the DITPA treated group, while MCP-1 levels were equivalent between groups. CONCLUSIONS: Treatment with DITPA attenuates the acute inflammatory response and reduces myocardial infarct size. The reduction in myocardial ICAM-1, KC, and IL-6 levels in the DITPA group was associated with a decrease in macrophage and neutrophil accumulation.

Synthesis of trehalose-based compounds and their inhibitory activities against Mycobacterium smegmatis.

The synthesis of a library of trehalose-based compounds has been accomplished, and their activities against Mycobacterium smegmatis have been determined. A preliminary structure-activity relationship (SAR) is reported. Despite not having a potent lead, one of the trehalose derivatives displays strong activity when applied with isoniazid (INH), which is known to have low sterilizing activity. The bacteriocidal nature of our compounds against Mycobacterium may be significant for the development of new therapies against tuberculosis.