surgical-management-persistent-or-new-symptoms-after-hiatal-hernia

Surgical Management of Persistent or New Symptoms After Hiatal Hernia Repair

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. ...

MedStar Georgetown University Hospital

The field of cancer genetics is rapidly evolving and several genetic mutations have been identified in hereditary cancer syndromes. These mutations can be diagnosed via routine genetic testing allowing prompt intervention. This is especially true for certain variants of colorectal, breast, and thyroid cancers where genetic testing may guide surgical therapy. Ultimately, surgical intervention may drastically diminish disease manifestation or progression in individuals deemed as high-risk based on their genetic makeup. Understanding the concepts of gene-based testing and integrating into current surgical practice is crucial. This review addresses common genetic syndromes, tests, and interventions salient to the current surgeon.

Integrating surgery and genetic testing for the modern surgeon.

Thermal injury is associated with an increased risk of abdominal complications such as ischemia, infarction and pneumatosis intestinalis (PI). PI is characterized by gas in the intestinal wall and, when diagnosed it can signify the presence of a life-threatening condition. We present a case of a patient who survived 75% total body surface area burns complicated by ischemic bowel that initially presented as extensive PI. This patient was emergently taken to the operating room and underwent a subtotal colectomy and small bowel resection for ischemic bowel. Prompt diagnosis and successful management of the underlying condition ultimately contributed to the patient's survival. The presence of peritonitis or abdominal distension, portomesenteric venous gas and lactic acidosis should prompt immediate surgical intervention in the post-burn period.

Survival from a 75% TBSA thermal injury complicated by bowel ischemia presenting with pneumatosis intestinalis.

Malignant pleural effusion (MPE) is a common and complex manifestation of advanced stage cancer. Treatment options have trended towards less invasive approaches such as intrapleural catheter drainage, however this technique is not without morbidity and not suitable for every patient. A troublesome scenario arises when an MPE is secondarily infected in the setting of an indwelling catheter, given both the high frequency of recurrence of such fluid and the presence of a foreign body. Further, quality literature surrounding this specific management issue is sparse and thus practice is heterogeneous. Herein we presented a case report of a 74-year-old gentleman with secondarily infected MPE and subsequent failure of indwelling pleural catheter (IPC) drainage. Given multiple failures of his catheter, we performed an open window thoracostomy (OWT) to provide a durable method of draining the pleural space and concomitantly achieving source control. OWT represents an infrequently described but invaluable alternative measure the surgeon may take when faced with failure of intrapleural catheter drainage and trapped lung.

Open window thoracostomy as an alternative approach to secondarily infected malignant pleural effusion and failure of intrapleural catheter drainage: a case report.

Considering the role of incidental appendectomy during colonic interposition gastroesophageal reconstruction.

Double lumen tube (DLT) intubation is used for lung isolation but is not without disadvantages including increased intubation time, anesthesia expertise, risk of airway trauma, and costs over single lumen tube (SLT) intubation. SLT intubation with CO insufflation can be used as an alternative for lung isolation. We reviewed our experience with this technique during thoracoscopic surgery.

Single lumen endotracheal intubation with carbon dioxide insufflation for lung isolation in thoracic surgery.

 Esophageal thoracic diverticular disease is a rare condition resulting from multiple etiologies. Surgical management is recommended when symptomatic. Traditionally, a thoracotomy was considered the standard approach; however, the use of minimally invasive approaches has been associated with improved outcomes.  We retrospectively reviewed a single surgeon's experience with minimally invasive esophageal diverticulectomy.  Fifteen patients with symptomatic esophageal diverticular disease underwent minimally invasive diverticulectomy between 2005 and 2018. Most patients (86.7%) had epiphrenic diverticula and 53.3% underwent a video-assisted thoracoscopic surgery approach. All patients had a diverticulectomy, while 14 patients (93.3%) also had an esophageal myotomy. Three patients (20%) underwent an extended myotomy, 4 patients (26.7%) underwent a concomitant fundoplication, and 2 patients (13.3%) underwent a concomitant paraesophageal hernia repair. Median length of hospital stay was 2 days (range, 1-16 days). There were no mortalities. Two patients (13.3%) were readmitted with delayed esophageal leaks. Median follow-up was 10.7 months (range, 10 days to 6.3 years). One patient presented with recurrent disease 5 years after his initial operation.  In experienced hands, a minimally invasive diverticulectomy is safe, effective, and associated with excellent patient outcomes. A minimally invasive approach should be performed when possible and should be tailored to the individual patient's disease and preoperative workup.

Evolving Options in Management of Minimally Invasive Diverticular Disease: A Single Surgeon's Experience and Review of the Literature.

Sleeve resection allows for preservation of lung parenchyma and improved long-term outcomes when compared with pneumonectomy. Little is known about minimally invasive sleeve resection, especially indications, feasibility, technical aspects, complications, and outcomes. We reviewed our institutional experience with sleeve resections via a minimally invasive approach.

Outcomes of minimally invasive sleeve resection.

Axillary lymph node involvement (ALNI) in well differentiated papillary thyroid carcinoma (WDPTC) is a rare sequela of disease presentation. We report a case of PTC with extensive cervical lymph node involvement, local extension to the skin of the neck and bilateral ALNI without evidence of distant disease. We posit that ALNI represents local extension of disease rather than distant metastasis. Therefore, in the absence of distant spread, ALNI should result in surgical intervention. This optimizes removal of all bulky disease and increases effectiveness of radioactive iodine (RAI) therapy. Future research centered on genomics should focus on ascertaining the behavior and prognosis of such cases, especially when anatomic spread is discordant with biologic behavior.

Papillary thyroid carcinoma with bilateral axillary lymph node involvement: a case report outlining hypothesis for locoregional spread and therapeutic implications.

PMNGCT is an independent predictor of poor prognosis despite advances in multidisciplinary management. Multidrug chemotherapy followed by aggressive surgical resection remains the mainstay of treatment. Although associated with significant morbidity, an open surgical approach is traditionally used. We describe the first reported case, to our knowledge, of a patient who underwent resection of a PMNGCT via a minimally invasive approach following induction chemotherapy.

Thoracoscopic Resection of a Nonseminomatous Primary Mediastinal Germ Cell Tumor.

Liposomal bupivacaine in minimally invasive thoracic surgery: something is rotten in the state of Denmark.

Prolonged follow-up of colorectal cancer patients after 5 years: to follow or not to follow, that is the question (and how)!

This study aimed to identify the results of the quality assessment and the learning curve of robot-assisted minimally invasive McKeown esophagectomy (RAMIE-MK).

Article	Year
Integrating surgery and genetic testing for the modern surgeon. Annals of translational medicine\| PubMed ID: 29152499	2017
Survival from a 75% TBSA thermal injury complicated by bowel ischemia presenting with pneumatosis intestinalis. Journal of surgical case reports\| PubMed ID: 30181865	2018
Open window thoracostomy as an alternative approach to secondarily infected malignant pleural effusion and failure of intrapleural catheter drainage: a case report. AME case reports\| PubMed ID: 30264008	2018
Considering the role of incidental appendectomy during colonic interposition gastroesophageal reconstruction. The Journal of thoracic and cardiovascular surgery\| PubMed ID: 30501948	2019
Single lumen endotracheal intubation with carbon dioxide insufflation for lung isolation in thoracic surgery. Surgical endoscopy\| PubMed ID: 30511311	2019
Evolving Options in Management of Minimally Invasive Diverticular Disease: A Single Surgeon's Experience and Review of the Literature. Journal of laparoendoscopic & advanced surgical techniques. Part A\| PubMed ID: 30620240	2019
Outcomes of minimally invasive sleeve resection. Journal of thoracic disease\| PubMed ID: 30746210	2018
Papillary thyroid carcinoma with bilateral axillary lymph node involvement: a case report outlining hypothesis for locoregional spread and therapeutic implications. AME case reports\| PubMed ID: 30854508	2019
Thoracoscopic Resection of a Nonseminomatous Primary Mediastinal Germ Cell Tumor. Seminars in thoracic and cardiovascular surgery\| PubMed ID: 30981738	2019
Liposomal bupivacaine in minimally invasive thoracic surgery: something is rotten in the state of Denmark. Journal of thoracic disease\| PubMed ID: 31245105	2019
Prolonged follow-up of colorectal cancer patients after 5 years: to follow or not to follow, that is the question (and how)! Annals of translational medicine\| PubMed ID: 32309311	2020
Assessment of Quality Outcomes and Learning Curve for Robot-Assisted Minimally Invasive McKeown Esophagectomy. Annals of surgical oncology\| PubMed ID: 32720046	2021
Hybrid video-assisted thoracoscopic surgery sleeve lobectomy for non-small cell lung cancer: a case report. Journal of thoracic disease\| PubMed ID: 33282385	2020

Raul Caso

Biography

JoVE Journal Publications

Other Publications