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Effect of Surgical Technique on Recurrence Rates after Laparoscopic Paraesophageal Hernia Repair
Vol. 223, No. 4S1, October 2016
Scientific Forum Abstracts
Table. LPS
LPS + Rofecoxib
LPS + UDCA
LPS + UDCA + Rofecoxib
FITC dextran levels (Fold change from healthy controls SD)
6.5 0.6
2.8 1.5
2.0 0.7
4.0 1.9
Migration (% villus height)
30.9
35.2
38.1
25.7
IL-6 mRNA (Fold change from LPS SD)
1
0.40.2
0.20.2
0.60.3
Variable
CONCLUSIONS: Pharmacologic inhibition of COX-2 blocks UDCA induction of enterocyte migration and inhibits the protective effect of UDCA on the intestinal barrier in experimental peritonitis. This suggests UDCA’s protective effects occur through COX-2. Understanding this mechanism may make UDCA a potential therapeutic agent in patients with sepsis and intestinal barrier breakdown. Differences in Mechanoluminal Stimulation Affect Intestinal Adaptation in a New Murine Ileostomy Model Minna Wieck, MD, Ashley E Hilton, Tracy C Grikscheit, MD, FACS Children’s Hospital, Los Angeles, CA INTRODUCTION: Improving treatment for diseases like short bowel syndrome requires a better understanding of how intestinal adaptation is affected by factors like mechanoluminal stimulation. Defining these adaptive pathways is hindered by the lack of a relevant murine model. We hypothesized that in mice, luminal diversion through an ileostomy would drive adaptive changes similar to those seen in human intestine. METHODS: With Institutional Animal Care and Use Committee approval, a distal ileostomy with a long distal Hartman’s was created in 8- to 12-week old C57/B6 mice (n¼7). Control mice underwent midline laparotomy (n¼4). Postoperatively, mice received a high protein liquid diet and water ad lib. On postoperative day 3, tissue from both the proximal and distal limbs were collected for histologic and RNA analysis. Morphometric measures and RNA expression were compared with Student’s paired t-tests, with a p value < 0.05 considered significant. RESULTS: At 3 days, survival for mice with an ileostomy was 86%, and average weight loss was 8% compared with 5% for control mice. Compared with the proximal limb, the distal limb in mice with an ileostomy demonstrated significantly shorter villi and shallower and narrower crypts. The distal limb also had higher expression of intestinal stem cell markers lgr5, bmi1, and sox9. An increased number of goblet cells per hemivillus and corollary increased expression of goblet cell marker Muc2 was also noted in the distal limb. None of these differences were significant between proximal and distal ileum in control mice. CONCLUSIONS: This new murine ileostomy model mimics adaptive changes seen in human intestine and will enable further delineation of adaptive pathways.
S53
Effect of Surgical Technique on Recurrence Rates after Laparoscopic Paraesophageal Hernia Repair Maximiliano R Sobrero, Chaya Shwaartz, MD, Eric J Wilck, MD, Edward H Chin, MD, FACS, Scott Q Nguyen, MD, FACS, Linda P Zhang, MD, Celia M Divino, MD, FACS Icahn School of Medicine at Mount Sinai, New York, NY INTRODUCTION: Laparoscopic paraesophageal hernia repair (LPEHR) is a challenging procedure associated with high rates of hernia recurrence despite improvements in operative technique. Surgeon preference often dictates the chosen reparative method, with significant variability in surgical steps such as sac excision and use of surgical mesh or gastric fixation. We sought to determine how these and other intraoperative factors affect the rate of hernia recurrence after LPEHR. METHODS: A retrospective review was performed of 237 patients who underwent LPEHR between 2008 and 2015 at The Mount Sinai Hospital. Operative data gathered for each case included the use of surgical mesh, pledgets, fundoplication, gastropexy, extent of sac excision, esophageal bougie, and intraoperative endoscopy. RESULTS: Fifty-seven patients (24%) with radiographic evidence of PEH recurrence were identified. Use of surgical mesh was significantly higher (p ¼ 0.003) in those who had recurrence (37%) compared with those who did not (18%). The use of pledgets, fundoplication, gastropexy, extent of sac excision, esophageal bougie, and intraoperative endoscopy did not differ significantly between patients who experienced hernia recurrence compared with those who did not (Table). Table. Association of Operative Steps with Radiographic Recurrence of Paraesophageal Hernia after Laparoscopic Repair Radiographic Overall recurrence, No recurrence, Operative step n (% of 237) n (%) n (%) p Value Complete sac excision 121 (76) 41 (72) 130 (75) 0.74 Surgical mesh use 53 (22) 21 (37) 32 (18) 0.003 Pledget use 109 (46) 23 (40) 86 (48) 0.33 Fundoplication 212 (89) 51 (89) 161 (89) 1.00 Gastropexy 54 (24) 16 (28) 38 (21) 0.28 Bougie use 92 (39) 18 (32) 74 (41) 0.20 Intraoperative endoscopy 62 (26) 14 (25) 48 (27) 0.75
CONCLUSIONS: Differences in the operative technique used during each case did not affect the frequency of PEH recurrence. However, the use of surgical mesh during PEH repair was associated with increased risk of hernia recurrence. The high rate of radiographic recurrence after LPEHR remains a significant concern; further studies are needed to identify the risk factors responsible for this event.
Scientific Forum Abstracts
Table. LPS
LPS + Rofecoxib
LPS + UDCA
LPS + UDCA + Rofecoxib
FITC dextran levels (Fold change from healthy controls SD)
6.5 0.6
2.8 1.5
2.0 0.7
4.0 1.9
Migration (% villus height)
30.9
35.2
38.1
25.7
IL-6 mRNA (Fold change from LPS SD)
1
0.40.2
0.20.2
0.60.3
Variable
CONCLUSIONS: Pharmacologic inhibition of COX-2 blocks UDCA induction of enterocyte migration and inhibits the protective effect of UDCA on the intestinal barrier in experimental peritonitis. This suggests UDCA’s protective effects occur through COX-2. Understanding this mechanism may make UDCA a potential therapeutic agent in patients with sepsis and intestinal barrier breakdown. Differences in Mechanoluminal Stimulation Affect Intestinal Adaptation in a New Murine Ileostomy Model Minna Wieck, MD, Ashley E Hilton, Tracy C Grikscheit, MD, FACS Children’s Hospital, Los Angeles, CA INTRODUCTION: Improving treatment for diseases like short bowel syndrome requires a better understanding of how intestinal adaptation is affected by factors like mechanoluminal stimulation. Defining these adaptive pathways is hindered by the lack of a relevant murine model. We hypothesized that in mice, luminal diversion through an ileostomy would drive adaptive changes similar to those seen in human intestine. METHODS: With Institutional Animal Care and Use Committee approval, a distal ileostomy with a long distal Hartman’s was created in 8- to 12-week old C57/B6 mice (n¼7). Control mice underwent midline laparotomy (n¼4). Postoperatively, mice received a high protein liquid diet and water ad lib. On postoperative day 3, tissue from both the proximal and distal limbs were collected for histologic and RNA analysis. Morphometric measures and RNA expression were compared with Student’s paired t-tests, with a p value < 0.05 considered significant. RESULTS: At 3 days, survival for mice with an ileostomy was 86%, and average weight loss was 8% compared with 5% for control mice. Compared with the proximal limb, the distal limb in mice with an ileostomy demonstrated significantly shorter villi and shallower and narrower crypts. The distal limb also had higher expression of intestinal stem cell markers lgr5, bmi1, and sox9. An increased number of goblet cells per hemivillus and corollary increased expression of goblet cell marker Muc2 was also noted in the distal limb. None of these differences were significant between proximal and distal ileum in control mice. CONCLUSIONS: This new murine ileostomy model mimics adaptive changes seen in human intestine and will enable further delineation of adaptive pathways.
S53
Effect of Surgical Technique on Recurrence Rates after Laparoscopic Paraesophageal Hernia Repair Maximiliano R Sobrero, Chaya Shwaartz, MD, Eric J Wilck, MD, Edward H Chin, MD, FACS, Scott Q Nguyen, MD, FACS, Linda P Zhang, MD, Celia M Divino, MD, FACS Icahn School of Medicine at Mount Sinai, New York, NY INTRODUCTION: Laparoscopic paraesophageal hernia repair (LPEHR) is a challenging procedure associated with high rates of hernia recurrence despite improvements in operative technique. Surgeon preference often dictates the chosen reparative method, with significant variability in surgical steps such as sac excision and use of surgical mesh or gastric fixation. We sought to determine how these and other intraoperative factors affect the rate of hernia recurrence after LPEHR. METHODS: A retrospective review was performed of 237 patients who underwent LPEHR between 2008 and 2015 at The Mount Sinai Hospital. Operative data gathered for each case included the use of surgical mesh, pledgets, fundoplication, gastropexy, extent of sac excision, esophageal bougie, and intraoperative endoscopy. RESULTS: Fifty-seven patients (24%) with radiographic evidence of PEH recurrence were identified. Use of surgical mesh was significantly higher (p ¼ 0.003) in those who had recurrence (37%) compared with those who did not (18%). The use of pledgets, fundoplication, gastropexy, extent of sac excision, esophageal bougie, and intraoperative endoscopy did not differ significantly between patients who experienced hernia recurrence compared with those who did not (Table). Table. Association of Operative Steps with Radiographic Recurrence of Paraesophageal Hernia after Laparoscopic Repair Radiographic Overall recurrence, No recurrence, Operative step n (% of 237) n (%) n (%) p Value Complete sac excision 121 (76) 41 (72) 130 (75) 0.74 Surgical mesh use 53 (22) 21 (37) 32 (18) 0.003 Pledget use 109 (46) 23 (40) 86 (48) 0.33 Fundoplication 212 (89) 51 (89) 161 (89) 1.00 Gastropexy 54 (24) 16 (28) 38 (21) 0.28 Bougie use 92 (39) 18 (32) 74 (41) 0.20 Intraoperative endoscopy 62 (26) 14 (25) 48 (27) 0.75
CONCLUSIONS: Differences in the operative technique used during each case did not affect the frequency of PEH recurrence. However, the use of surgical mesh during PEH repair was associated with increased risk of hernia recurrence. The high rate of radiographic recurrence after LPEHR remains a significant concern; further studies are needed to identify the risk factors responsible for this event.