Recurrent epiphrenic diverticulum after transabdominal diverticulectomy: report of a case and review of the literature.

Epiphrenic esophageal diverticula are uncommon esophageal disorders; reported recurrence after surgical treatment is rare. We describe a case of recurrence in a patient previously treated with a transhiatal diverticulectomy myotomy and fundoplication. Anatomic factors that may have contributed to this recurrence are discussed.

Differences in length of stay between coronary bypass and valve procedures.

OBJECTIVE: Emphasis on cost reduction, national standardization of medical care, and quality improvement initiatives have led to reduced postoperative hospital stays after cardiac surgery. The present study was designed to verify the observation that valve patients have longer lengths of stay than bypass patients and to identify possible reasons. METHODS: The inpatient records of 26 consecutive patients who underwent valve procedures at our institution were reviewed and compared with the records of 25 consecutive coronary bypass patients. Patients whose postoperative stays were longer than 2 weeks were considered outliers and were excluded from further review. RESULTS: A total of 51 records were reviewed. There were no in-hospital deaths. Five patients in the valve group and two in the bypass group were excluded because of lengths of stay exceeding 14 days. The mean length of stay for the valve procedure group was 7.7 +/- 2.1 days, vs. 5.7 +/- 1.5 days for the coronary bypass group (p = 0.001). There were no reoperative procedures in either group, and the number of emergency procedures was higher in the bypass group. Both groups were similar with respect to age and sex. The frequencies of associated pulmonary disease and malnutrition were similar. Bypass patients had a higher incidence of vascular disease and/or renal disease. Sixty percent of valve procedures were complex operations. Valve patients had a higher incidence of cardiopulmonary bypass times exceeding 3 hours and more postoperative bleeding complications. Although not statistically significant, valve procedure patients were more likely to require prolonged mechanical ventilatory and circulatory support postoperatively. The frequencies of thrombotic complications, neurological complications, and nosocomial infections were similar for both groups. Postoperatively, more valve patients had atrial fibrillation, and all of them received anticoagulation. Multivariate analysis revealed only two factors to be significant with regard to length of stay: valvular surgery and the duration of postoperative ventilatory support. CONCLUSIONS: Cardiac valve procedures are associated with prolonged lengths of stay compared with isolated coronary bypass procedures. Despite recent trends toward earlier operation, valve patients tended to present with advanced disease. More than half of the valve patients required complex surgical procedures. This is reflected in longer bypass times, increased bleeding complications, and more postoperative support. The proportion of valvular surgery patients should be considered when analyzing lengths of stay for cardiac surgery cohorts.