Helen J. Sohn

Laparoscopic versus open anterior abdominal wall hernia repair: 30-day morbidity and mortality using the ACS-NSQIP database.

Objective:To compare short-term outcomes after laparoscopic and open abdominal wall hernia repair. Methods:Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005–2009), 71,054 patients who underwent an abdominal wall hernia repair were identified (17% laparoscopic, 83% open). Laparoscopic and open techniques were compared. Regression models and nonparametric 1:1 matching algorithms were used to minimize the influence of treatment selection bias. The association between surgical approach and risk-adjusted adverse event rates after abdominal wall hernia repair was determined. Subgroup analysis was performed between inpatient/outpatient surgery, strangulated/reducible, and initial/recurrent hernias as well as between umbilical, incisional and other ventral hernias. Results:Patients undergoing laparoscopic repair were less likely to experience an overall morbidity (6.0% vs. 3.8%; odds ratio [OR], 0.62; 95% confidence interval [CI], 0.56–0.68) or a serious morbidity (2.5% vs. 1.6%; OR, 0.61; 95% CI, 0.52–0.71) compared to open repair. Analysis using multivariate adjustment and patient matching showed similar findings. Mortality rates were the same. Laparoscopically repaired strangulated and recurrent hernias, had a significantly lower overall morbidity (4.7% vs. 8.1%, P < 0.0001 and 4.1% vs. 12.2%, P < 0.0001, respectively). Significantly lower overall morbidity was also noted for the laparoscopic approach when the hernias were categorized into umbilical (1.9% vs. 3.0%, P = 0.009), ventral (3.9% vs. 6.3%, P < 0.0001), and incisional (4.3% vs. 9.1%, P < 0.0001). No differences were noted between laparoscopic and open repairs in patients undergoing outpatient surgery, when the hernias were reducible. Conclusion:Laparoscopic hernia repair is infrequently used and associated with lower 30-day morbidity, particularly when hernias are complicated.

Laparoscopic versus Open Repair of Paraesophageal Hernia: The Second Decade

BACKGROUND A decade ago we reported that laparoscopic repair of paraesophageal hernia (PEH) had an objective recurrence rate of 42% compared with 15% after open repair. Since that report we have modified our laparoscopic technique. The aim of this study was to determine if these modifications have reduced the rate of objective hernia recurrence. STUDY DESIGN We retrospectively identified all patients that had primary repair of a PEH with ≥ 50% of the stomach in the chest from May 1998 to January 2010 with objective follow-up by videoesophagram. The finding of any size of hernia was considered to be recurrence. RESULTS There were 73 laparoscopic and 73 open PEH repairs that met the study criteria. There were no significant differences in gender, body mass index, or prevalence of a comorbid condition between groups. The median follow-up was similar (12 months laparoscopic versus 16 months open; p = 0.11). In the laparoscopic group, 84% of patients had absorbable mesh reinforcement of the crural closure and 40% had a Collis gastroplasty, compared with 32% and 26%, respectively, in the open group. A recurrent hernia was identified in 27 patients (18%), 9 after laparoscopic repair and 18 after open repair (p = 0.09). The median size of a recurrent hernia was 3 cm, and the incidence of recurrence increased yearly in those with serial follow-up with no early peak or late plateau. CONCLUSIONS In our first decade of laparoscopic PEH repair, no mesh crural reinforcement was used, and no patient had a Collis gastroplasty. Evolution in the technique of laparoscopic PEH repair during the subsequent decade has reduced the hernia recurrence rate to that seen with an open approach. Reduced morbidity and shorter hospital stay make laparoscopy the preferred approach, but continued efforts to reduce hernia recurrence are warranted.

Psoas abscess rarely requires surgical intervention.

BACKGROUND Surgeons are increasingly encountering psoas abscesses. METHODS We performed a review of 41 adults diagnosed and treated for psoas abscess at a county hospital. Treatment modalities and outcomes were evaluated to develop a contemporary algorithm. RESULTS Eighteen patients had a primary psoas abscess, and 23 had a secondary psoas abscess. Patient characteristics were similar in both groups. Intravenous drug abuse was the leading cause of primary abscesses. Secondary abscesses developed most commonly after abdominal surgery. Treatment was via open drainage (3%), computed tomography-guided percutaneous drainage (63%), or antibiotics alone (34%). Four recurrences occurred in the percutaneous group. Statistical analysis showed that the median size of psoas abscesses in the percutaneous group was significantly larger than in the antibiotics group (6 vs 2 cm; P < .001). The mortality rate was 3%. CONCLUSIONS Initial management of psoas abscesses should be nonsurgical (90% success). Small abscesses may be treated with antibiotics alone, and surgery can be reserved for occasional complicated recurrences.

Proximal esophageal pH monitoring: improved definition of normal values and determination of a composite pH score.

BACKGROUND Patients with respiratory and laryngeal symptoms are commonly referred for evaluation of reflux disease as a potential cause. Dual-probe pH monitoring is often performed, although data on normal acid exposure in the proximal esophagus are limited because of the small number of normal subjects and inconsistent placement of the proximal pH sensor in relation to the upper esophageal sphincter. We measured proximal esophageal acid exposure using dual-probe pH and calculated a composite pH score in a large number of asymptomatic volunteers to better define normal values. STUDY DESIGN Eighty-one normal subjects free of reflux, laryngeal, or respiratory symptoms were recruited. All had video esophagraphy to exclude hiatal hernia. Esophageal pH monitoring was performed using 1 of 3 different dual-probe catheters with sensors spaced 10, 15, or 18 cm apart. The standard components of esophageal acid exposure were measured, excluding meal periods. A composite pH score for the proximal esophagus was calculated using these components. RESULTS The final study population consisted of 59 (49% male) subjects, with a median age of 27 years. All had normal distal esophageal acid exposure and no hiatal hernia. The 95(th) percentile values for the percent time the pH was < 4 for the total, upright, and supine periods were 0.9%, 1.2%, and 0.4%, respectively. The 95(th) percentile for the number of reflux episodes was 24 and for the calculated proximal esophageal composite pH score was 16.4. CONCLUSIONS In a large population of normal subjects, we have defined the normal values and calculated a composite pH score for proximal esophageal acid exposure. The total percent time pH < 4 was similar to previously published normal values, but the number of reflux episodes was greater.

Planned Early Discharge–Elective Surgical Readmission Pathway for Patients With Gallstone Pancreatitis

HYPOTHESIS We assessed outcomes in patients with gallstone pancreatitis (GSP) managed using a readmission pathway of discharge from the index admission with early readmission cholecystectomy and compared these with conventional management. We hypothesized that the pathway would decrease hospital length of stay (LOS). DESIGN Prospective cohort study. SETTING County-based academic center. PATIENTS All patients admitted with GSP between June 1, 2005, and June 30, 2007. The control group consisted of patients from the year before the adoption of the readmission pathway. The pathway group patients were enrolled in the first year from its inception (July 1, 2006). MAIN OUTCOME MEASURES Overall LOS, time from admission until operation, and pathway failures. RESULTS Of 252 patients with GSP, 144 were managed by conventional methods, and 108 were managed using the readmission pathway. The overall mean (SD) LOS was 8.5 (6.0) days in the control group and 5.9 (3.1) days in the pathway group (P < .001). The mean (SD) times to surgery were 6.6 (4.5) days in the control group and 22.7 (10.4) days in the pathway group (P =.01). This did not lead to significantly more treatment failures, with 34 (23.6%) in the control group and 33 (30.6%) in the pathway group (P =.21). There were 6.5%(7 of 108) unplanned readmissions for recurrent pancreatitis in the pathway group. Morbidity was otherwise similar in both groups. CONCLUSION Use of the readmission pathways early discharge protocol decreased overall LOS and in this study population was not associated with any increase in morbidity compared with conventional management.

Loss of Alkalization in Proximal Esophagus: a New Diagnostic Paradigm for Patients with Laryngopharyngeal Reflux

IntroductionCervical esophageal pH monitoring using a pH threshold of <4 in the diagnosis of laryngopharyngeal reflux (LPR) is disappointing. We hypothesized that failure to maintain adequate alkalization instead of acidification of the cervical esophagus may be a better indicator of cervical esophageal exposure to gastric juice. The aim of this study was to define normal values for the percent time the cervical esophagus is exposed to a pH ≥7 and to use the inability to maintain this as an indicator for diagnosis of LPR.Material and MethodsFifty-nine asymptomatic volunteers had a complete foregut evaluation including pH monitoring of the cervical esophagus. Cervical esophageal exposure to a pH <4 was calculated, and the records were reanalyzed using the threshold pH ≥7. The sensitivity of these two pH thresholds was compared in a group of 51 patients with LPR symptoms that were completely relieved after an antireflux operation.ResultsCompared to normal subjects, patients with LPR were less able to maintain an alkaline pH in the cervical esophagus, as expressed by a lower median percent time pH ≥ 7 (10.4 vs. 38.2, p < 0.0001). In normal subjects, the fifth percentile value for percent time pH ≥ 7 in the cervical esophagus was 19.6%. In 84% of the LPR patients (43/51), the percent time pH ≥ 7 were below the threshold of 19.6%. In contrast, 69% (35/51) had an abnormal test when the pH records were analyzed using the percent time pH < 4. Of the 16 patients with a false negative test using pH < 4, 11 (69%) were identified as having an abnormal study when the threshold of pH ≥ 7 was used.ConclusionNormal subjects should have a pH ≥7 in cervical esophagus for at least 19.6% of the monitored period. Failure to maintain this alkaline environment is a more sensitive indicator in the diagnosis of the LPR and identifies two thirds of the patients with a false negative test using pH <4.

Acute respiratory distress syndrome in nontrauma surgical patients: a 6-year study.

BACKGROUND Acute respiratory distress syndrome (ARDS) has been shown to increase morbidity but not mortality in trauma patients; however, little is known about the effects of ARDS in nontrauma surgical patients. The purpose of this study is to evaluate the risk factors for and outcomes of ARDS in nontrauma surgical patients. STUDY A prospective observational study was performed in the surgical intensive care unit (ICU) of an academic tertiary care center. From 2000 to 2005, all nontrauma surgical admissions to the surgical ICU were evaluated daily for ARDS based on predefined diagnostic criteria. Logistic regression analysis identified independent predictors for ARDS and ICU mortality. RESULTS Of 2,046 patient identified, 125 (6.1%) met criteria for ARDS. The incidence of ARDS declined annually from 12.2% to 2.1% during the study period (p < 0.001). ARDS patients were significantly older (55.4 years vs. 51.8 years, p = 0.014) and more likely to be obese (32% vs. 22%, p = 0.007) than the non-ARDS population. Independent predictors of ARDS included use of pressors (relative risk, RR = 3.30), sepsis (RR = 1.72), and body mass index >or=30 kg/m (RR = 1.57). Independent predictors of ICU mortality included ARDS (RR = 6.88), pressors (RR = 2.85), positive fluid balance (RR = 2.27), Acute Physiology and Chronic Health Evaluation II (RR = 1.04), and age (RR = 1.02). CONCLUSIONS Unlike trauma patients, ARDS was an independent predictor of ICU mortality in nontrauma surgical patients, independent of age and disease severity. Nontrauma surgical patients who developed ARDS were older, sicker, and had a longer ICU stay. Independent predictors of ARDS included use of pressors, sepsis, and obesity.

Establishing an acute care surgery service: lessons learned from the epidemiology of emergent non-trauma patients and increasing utilization of laparoscopy.

BACKGROUND Acute care surgery is a fellowship training model created to address the growing crisis in emergency healthcare due to decreased availability of on-call surgeons and reduction in operative procedures for trauma. Our objective was to identify the demographics and spectrum of diseases in patients presenting with non-trauma surgical emergencies and the use of laparoscopy in emergent surgery in light of implementing an acute care surgery model. METHODS All non-trauma emergency surgical consultations at a large urban academic medical center from January 2005 to December 2008 were retrospectively reviewed. A clinician-completed registry was used to obtain patient information. Diagnoses were categorized into five broad groups for statistical analysis. RESULTS Median age was 41 years (range, 6 weeks to 97 years), 50% were men, and the majority (67%) was Hispanic. The most common disease category was infectious followed by hepatobiliary. Prevalence of disease categories differed significantly among various racial groups. Majority (86%) of consult patients required admission. Thirty-eight percent of the consults resulted in an operative procedure, 40% of which were laparoscopic. The percentage of laparoscopic procedures increased during the 4-year study period. CONCLUSION Patients with non-trauma surgical emergencies are young with a significantly wide range of diseases based on race. Less than half require emergent surgery. Laparoscopy is prevalent in emergency surgery and growing. Resources should be allocated to maximize the ability to treat infectious and hepatobiliary diseases, and to increase utilization of laparoscopy. The acute care surgeon needs to be proficient in laparoscopy.

982 Spontaneous Reflux During Videoesophagram: Its Clinical Significance and Correlation With pH Monitoring

We present the case of a 71-year-old female with a five month history of dysphagia, weight loss and heartburn. Preoperative investigation with barium swallow and upper endoscopy demonstrated a large lower esophageal pulsion divertictulum. A laparoscopic transhiatal resection of the esophageal diverticulum was performed with Heller myotomy and crural repair. Intraoperative endoscopy helps to identify the diverticulum in the mediastinum, to ensure complete resection of the diverticulum, to ensure an adequate esophageal myotomy, and to perform an air leak test. A Heller myotomy is performed to treat the esophageal dysmotility. A fundoplication is not performed due to poor esophageal motility.