Richard L. Feinberg

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

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.

Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery

BACKGROUND: Diverticulitis is a common medical condition that disproportionately affects older adults. The ideal management of recurrent diverticulitis, including the role of prophylactic colectomy, remains uncertain. OBJECTIVE: This study aimed to investigate the outcomes among older patients undergoing elective surgery for diverticulitis and examine subgroups of patients with comorbid congestive heart failure and chronic obstructive pulmonary disease to determine whether outcomes in these patients are worse than in other groups. DESIGN: This article reports a retrospective cohort study of patients undergoing elective surgery for diverticulitis. SETTING: Data were derived from the 100% Medicare Provider Analysis and Review inpatient files from 2004 to 2007. PATIENTS: Included were 22,752 patients, age 65 years and older, with a primary diagnosis of diverticulitis that underwent elective left-colon resection, colostomy, or ileostomy. MAIN OUTCOME MEASURE: The primary outcome measure was in-hospital mortality. The secondary outcome measures were intestinal diversion rates (colostomy and ileostomy) and postoperative complications. RESULTS: Overall mortality, intestinal diversion (colostomy and ileostomy), and postoperative complication rate were 1.2%, 11.3%, and 22.1%. Patients with congestive heart failure had increased odds of in-hospital mortality (OR 3.5, 95% CI 2.59–4.63), colostomy (OR 1.9, 95% CI 1.69–2.27), and all postoperative complications, including hemorrhagic (OR 1.5, 95% CI 1.01–2.11), wound (OR 1.9, 95% CI 1.50–2.39), pulmonary (OR 4.2, 95% CI 3.59–4.85), cardiac (OR 4.6, 95% CI 3.68–5.74), postoperative shock/sepsis (OR 3.2, 95% CI 2.53–4.35), renal (OR 4.1, 95% CI 3.22–5.12), and thromboembolic (OR 1.6, 95% CI 1.00–2.43) complications. Patients with chronic obstructive pulmonary disease had significantly increased odds of wound (OR 1.4, 95% CI 1.19–1.67) and pulmonary (OR 2.2, 95% CI 1.94–2.50) complications. Advancing age, congestive heart failure, and chronic obstructive pulmonary disease were significantly associated with increased morbidity and mortality. LIMITATIONS: Medicare data are limited by the potential for lack of generalizability to patients <65 years and the potential for coding errors. CONCLUSIONS: Elective diverticular surgery in older patients carries substantial morbidity, especially in those patients with comorbid congestive heart failure and chronic obstructive pulmonary disease. The rate of perioperative complications that we document in this patient population may attenuate some of the expected benefit of surgery.

Outcomes of operations for benign foregut disease in elderly patients: A National Surgical Quality Improvement Program database analysis

BACKGROUND The development of minimally invasive operative techniques and improvement in postoperative care has made surgery a viable option to a greater number of elderly patients. Our objective was to evaluate the outcomes of laparoscopic and open foregut operation in relation to the patient age. METHODS Patients who underwent gastric fundoplication, paraesophageal hernia repair, and Heller myotomy were identified via the National Surgical Quality Improvement Program (NSQIP) database (2005-2011). Patient characteristics and outcomes were compared between five age groups (group I: ≤65 years, II: 65-69 years; III: 70-74 years; IV: 75-79 years; and V: ≥80 years). Multivariable logistic regression analysis was used to predict the impact of age and operative approach on the studied outcomes. RESULTS A total of 19,388 patients were identified. Advanced age was associated with increased rate of 30-day mortality, overall morbidity, serious morbidity, and extended length of stay, regardless of the operative approach. After we adjusted for other variables, advanced age was associated with increased odds of 30-day mortality compared with patients <65 years (III: odds ratio 2.70, 95% confidence interval 1.34-5.44, P = .01; IV: 2.80, 1.35-5.81, P = .01; V: 6.12, 3.41-10.99, P < .001). CONCLUSION Surgery for benign foregut disease in elderly patients carries a burden of mortality and morbidity that needs to be acknowledged.

Clinical Presentation and Patient Evaluation in VTOS

This chapter traces the historical development of our current understanding of the pathophysiology of TOS and discusses the specific anatomic relationships at the thoracic outlet pertinent to venous TOS (VTOS). The clinical presentation of patients with VTOS is described, and the diagnostic evaluation is outlined. A unified, multi-modal approach to Paget-von Schroetter syndrome is discussed, which includes catheter-directed lytic therapy, surgical thoracic outlet decompression, endovenous intervention for intrinsic venous disease, and systemic anticoagulation. Several possible clinical scenarios are discussed and treatment algorithms presented.