Miloslawa Stem

Outcomes and costs of elective surgery for diverticular disease: a comparison with other diseases requiring colectomy.

OBJECTIVE To compare outcomes and costs of elective surgery for diverticular disease (DD) with those of other diseases commonly requiring colectomy. DESIGN Multivariable analyses using the Nationwide Inpatient Sample to compare outcomes across primary diagnosis while adjusting for age, sex, race, year of admission, and comorbid disease. SETTING A sample of US hospital admissions from 2003-2009. PATIENTS All adult patients (≥18 years) undergoing elective resection of the descending colon or subtotal colectomy who had a primary diagnosis of DD, colon cancer (CC), or inflammatory bowel disease (IBD). MAIN OUTCOME MEASURES In-hospital mortality, postoperative complications, ostomy placement, length of stay, and hospital charges. RESULTS Of the 74,879 patients, 50.52% had DD, 43.48% had CC, and 6.00% had IBD. After adjusting for other variables, patients with DD were significantly more likely than patients with CC to experience in-hospital mortality (adjusted odds ratio, 1.90; 95% CI, 1.37-2.63; P < .001), develop a postoperative infection (1.67; 1.48-1.89; P < .001), and have an ostomy placed (1.87; 1.65-2.11; P < .001). The adjusted total hospital charges for patients with DD were

Thirty-Day Outcomes of Paraesophageal Hernia Repair Using the NSQIP Database: Should Laparoscopy Be the Standard of Care?

6678.78 higher (95% CI,

Assessment of postdischarge complications after bariatric surgery: A National Surgical Quality Improvement Program analysis

5722.12-

Defining recurrence after paraesophageal hernia repair: Correlating symptoms and radiographic findings

7635.43; P < .001) and length of stay was 1 day longer (95% CI, 0.86-1.14; P < .001) compared with patients with CC. Patients with IBD had the highest in-hospital mortality, highest rates of complications and ostomy placement, longest length of stay, and highest hospital charges. CONCLUSIONS Despite undergoing the same procedure, patients with DD have significantly worse and more costly outcomes after elective colectomy compared with patients with CC but better than patients with IBD. These relatively poor outcomes should be recognized when considering routine elective colectomy after successful nonoperative management of acute diverticulitis.

Influence of body mass index on outcomes after major resection for cancer

BACKGROUND Although surgical repair is universally recognized as the gold standard for treatment of paraesophageal hernia (PEH), the optimal surgical approach is still the subject of debate. To determine which surgical technique is safest, we compared the outcomes of laparoscopic (lap), open transabdominal (TA), and open transthoracic (TT) PEH repair using the NSQIP database. STUDY DESIGN From 2005 to 2011, we identified 8,186 patients who underwent a PEH repair (78.4% lap, 19.2% TA, 2.4% TT). Primary outcome measured was 30-day mortality. Secondary outcomes included hospital length of stay, and NSQIP-measured postoperative complications. Multivariable analyses were performed to compare the odds of each outcome across procedure type (lap, TA, and TT) while adjusting for other factors. RESULTS Transabdominal patients had the highest 30-day mortality rate (2.6%), compared with 0.5% in the lap patients (p < 0.001) and 1.5% in TT patients. Mean length of stay was statistically significantly longer for TA and TT patients (7.8 days and 6.5 days, respectively) compared with lap patients (3.3 days). After adjusting for age, American Society of Anesthesiologists score, emergency cases, functional status, and steroid use, TA patients were nearly 3 times as likely as lap patients to experience 30-day mortality (odds ratio [OR], 2.97; 95% CI, 1.69 to 5.20; p < 0.001). Moreover, TA and TT patients had significantly increased odds of overall (OR 2.12; 95% CI 1.79 to 2.51; p < 0.001; OR 2.73; 95% CI 1.88 to 3.96; p < 0.001; respectively) and serious morbidity (OR 1.90; 95% CI 1.53 to 2.37, p < 0.001; OR 2.49; 95% CI 1.54 to 4.00; p < 0.001; respectively). CONCLUSIONS In the absence of published data indicating improved long-term outcomes after open TA or TT approach, our findings support the use of laparoscopy, whenever technically feasible, because it yields improved short-term outcomes.

Long-term Quality of Life and Risk Factors for Recurrence After Laparoscopic Repair of Paraesophageal Hernia

BACKGROUND Little is reported about postdischarge complications after bariatric surgery. We sought to identify the rates of postdischarge complications, associated risk factors, and their influence on early hospital readmission. METHODS Using the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) (2005-2013), we identified patients ≥18 years of age who underwent a bariatric operation with a primary diagnosis of morbid/severe obesity and a body mass index ≥35. The incidence of postdischarge complication was the primary outcome, and hospital readmission was the secondary outcome. The association between postdischarge complications and various patient factors was explored by the use of multivariable logistic regression. RESULTS A total of 113,898 patients were identified with an overall postdischarge complication rate of 3.2% within 30 days of operation. The rates decreased from 2005 to 2006 (4.6%) to 2013 (3.0%) (P < .001). On average, postdischarge complications occurred 10 days postoperatively, with wound infection (49.4%), reoperation (30.7%), urinary tract infection (16.9%), shock/sepsis (12.4%), and organ space surgical-site infection (11.0%) being the most common. Patients undergoing open gastric bypass had the greatest postdischarge complication rate of 8.5%. Of those patients experiencing postdischarge complications, 51.6% were readmitted. The overall readmission rate was 4.9%. The factors associated most strongly with increased odds of postdischarge complications were body mass index ≥ 50, use of steroids, procedure type, predischarge complication, prolonged duration of stay, and prolonged operative time. CONCLUSION Postdischarge complications after bariatric surgery represent a substantial source of patient morbidity and hospital readmissions. The majority of postdischarge complications are infection-related, including surgical-site infections and catheter-associated urinary tract infections. Adopting and implementing standardized pre- and postoperative strategies to decrease perioperative infection may help to decrease the rate of postdischarge complications and associated readmissions and enhance overall quality of care.

Does neoadjuvant therapy for esophageal cancer increase postoperative morbidity or mortality

BACKGROUND Laparoscopic repair of paraesophageal hernia (PEH) has been shown to result in excellent relief of symptoms and improved quality of life (QOL) despite a high radiographically identified recurrence rate. Because there is no uniform definition of PEH recurrence, it is difficult to compare studies reporting on this. This study attempts to introduce consistency to the definition of PEH recurrence based on correlation of symptoms and radiographic findings. METHODS This is an analysis of data derived from an ongoing prospective study. From April 2009 to December 2012, we enrolled 101 patients who underwent elective laparoscopic PEH repair with bioprosthesis buttressed over a primary cruroplasty. A validated gastroesophageal reflux disease-specific QOL tool was administered to patients before, and at 2 and 12 months postoperatively. Upper gastrointestinal barium contrast examination (UGI) was performed at 1 year. RESULTS Of 101 patients, 13 were not available for follow-up, 58 reached the 1-year milestone for interval UGI, and 1 patient required reoperation for symptomatic recurrent PEH. There was no relationship between total QOL score and radiographic recurrent hernia (RRH); however, significant deterioration in many symptoms was seen in RRH > 2 cm. Based on these findings, we defined recurrence as RRH > 2 cm and calculated our recurrence rate as 28% (n = 16). CONCLUSION Our analysis of symptom scores after laparoscopic PEH repair suggests that significant worsening occurs with RRH > 2 cm. Given that there is no consistent description of recurrent PEH, we suggest this as a possible standardized definition. Overall, patients with recurrent PEHs continue to experience excellent QOL and rarely require reoperation.

Incidence and Risk Factors for Respiratory Complications in Patients Undergoing Esophagectomy for Malignancy: A NSQIP Analysis

BACKGROUND Evidence supporting worse outcomes among obese patients is inconsistent. This study examined associations between body mass index (BMI) and outcomes after major resection for cancer. METHODS Data from the 2005-2012 ACS-NSQIP were used to identify cancer patients (≥18 years) undergoing 1 of 6 major resections: lung surgery, esophagectomy, hepatectomy, gastrectomy, colectomy, or pancreatectomy. We used crude and multivariable regression to compare differences in 30-day mortality, serious and overall morbidity, duration of stay, and operative time among 3 BMI cohorts defined by the World Health Organization: normal versus underweight, overweight-obese I, and obese II-III. Propensity-scored secondary assessment and resection type-specific stratified analyses corroborated results. RESULTS A total of 529,955 patients met inclusion criteria; 32.06% had normal BMI, 3.45% were underweight, 32.52% overweight, and 17.76%, 7.51%, and 4.94% obese I-III, respectively. Risk-adjusted outcomes for underweight patients consistently were worse. Overweight-obese I fared similarly to patients with normal BMI but had greater odds of isolated complications. Obese II-III patients experienced only marginally increased odds of morbidity. Analyses among propensity-scored cohorts and stratified by cancer-resection type reported similar trends. Worse outcomes were observed among morbidly obese hepatectomy and pancreatectomy patients. CONCLUSION Evidence-based assessment of outcomes after major resection for cancer suggests that obese patients should be treated with the aim for optimal oncologic standards without being hindered by a misleading perception of prohibitively increased perioperative risk. Underweight and certain types of morbidly obese patients require targeted provision of appropriate care.

Novel combined VATS/laparoscopic approach for giant and complicated paraesophageal hernia repair: description of technique and early results

IMPORTANCE Laparoscopic repair of paraesophageal hernia (PEH) has been shown to result in excellent relief of symptoms and improved quality of life (QOL) despite a relatively high radiographically identified recurrence rate. OBJECTIVE To assess potential risk factors for recurrence and long-term change in QOL after laparoscopic repair of PEH. DESIGN, SETTING, AND PARTICIPANTS This was a prospective study of 111 patients who underwent elective laparoscopic repair of type III PEH with biological mesh buttressed over a primary cruroplasty from April 3, 2009, through July 31, 2014, at the Department of Surgery, Johns Hopkins University of Medicine. We administered a modified version of a validated gastroesophageal reflux disease-specific QOL tool to patients before and at 2, 12, and 36 months after the procedure. Higher QOL scores represent greater severity of symptoms. An upper gastrointestinal tract barium-contrast radiographic examination was performed at 1 year to assess for recurrence. Demographic factors, comorbidities, and preoperative radiographic findings were analyzed as possible indicators for recurrence using logistic regression. MAIN OUTCOMES AND MEASURES Quality of life, measured by the gastroesophageal reflux disease-specific QOL tool, and recurrence, defined as a PEH of greater than 2 cm. RESULTS Median patient age was 61 years, 63.1% of patients were women, and 81.1% of patients were white. Four patients required reoperation, of which only 1 was for symptomatic recurrent PEH. The mean follow-up time for the 36-month QOL assessment was 43.5 months. The overall preoperative and 2-, 12-, and 36-month QOL scores were 28.50, 10.18, 9.74, and 10.58, respectively (P < .001). Recurrences were found in 19 of the 70 patients (27%) who completed the 1-year radiographic examination. Compared with baseline, all individual symptoms improved significantly except for early satiety (mean [SD] score, 3.18 [1.88] at baseline vs 2.07 [1.70] at the 36-month follow-up; P = .07), nausea (1.69 [1.63] vs 0.77 [1.25]; P = .08), pain with swallowing (1.06 [1.50] vs 0.53 [0.90]; P = .73), and bloating/gas (3.28 [1.71] vs 2.23 [1.72]; P = .05) at the 36-month QOL assessment. Although not statistically significant, preoperative hernias containing most of the stomach were more likely to recur after repair when compared with those involving gastric cardia and fundus (odds ratio, 3.74 [95% CI, 0.93-15.14]; P = .06). CONCLUSIONS AND RELEVANCE Overall, laparoscopic repair of PEH with biological mesh results in excellent long-term QOL. The cause of recurrence is likely multifactorial and individualized to each patient. Further evaluation of novel techniques and unidentified patient factors is needed.

Surgery for diverticulitis is associated with high risk of in-hospital mortality and morbidity in older patients with end-stage renal disease

Neoadjuvant therapy has proven to be effective in the reduction of locoregional recurrence and mortality for esophageal cancer. However, induction treatment has been reported to be associated with increased risk of postoperative complications. We therefore compared outcomes after esophagectomy for esophageal cancer for patients who underwent neoadjuvant therapy and patients treated with surgery alone. Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011), we identified 1939 patients who underwent esophagectomy for esophageal cancer. Seven hundred and eight (36.5%) received neoadjuvant therapy, while 1231 (63.5%) received no neoadjuvant therapy within 90 days prior to surgery. Primary outcome was 30-day mortality, and secondary outcomes included overall and serious morbidity, length of stay, and operative time. Patients who underwent neoadjuvant treatment were younger (62.3 vs. 64.7, P < 0.001), were more likely to have experienced recent weight loss (29.4% vs. 15.9%, P < 0.001), and had worse preoperative hematological cell counts (white blood cells <4.5 or >11 × 10(9) /L: 29.3% vs. 15.0%, P < 0.001; hematocrit <36%: 49.7% vs. 30.0%, P < 0.001). On unadjusted analysis, 30-day mortality, overall, and serious morbidity were comparable between the two groups, with the exception of the individual complications of venous thromboembolic events and bleeding transfusion, which were significantly lower in the surgery-only patients (5.71% vs. 8.27%, P = 0.027; 6.89% vs. 10.57%, P = 0.004; respectively). Multivariable and matched analysis confirmed that 30-day mortality, overall, and serious morbidity, as well as prolonged length of stay, were comparable between the two groups of patients. An increasing trend of preoperative neoadjuvant therapy for esophageal cancer was observed through the study years (from 29.0% in 2005-2006 to 44.0% in 2011, P < 0.001). According to our analysis, preoperative neoadjuvant therapy for esophageal cancer does not increase 30-day mortality or the overall risk of postoperative complications after esophagectomy.