Unseen Burden of Injury: Post-Hospitalization Mortality in Geriatric Trauma Patients.

BACKGROUND/OBJECTIVES: Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. METHODS: Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. RESULTS: Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. CONCLUSION: Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.

Pediatric Surgical Reentry Strategy Following the COVID-19 Pandemic: A Tiered and Balanced Approach.

BACKGROUND: In response to the COVID-19 pandemic, children's hospitals across the country postponed elective surgery beginning in March 2020. As projective curves flattened, administrators and surgeons sought to develop strategies to safely resume non-emergent surgery. This article reviews challenges and solutions specific to a children's hospital related to the resumption of elective pediatric surgeries. We present our tiered reentry approach for pediatric surgery as well as report early data for surgical volume and tracking COVID-19 cases during reentry. METHODS: The experience of shutdown, protocol development, and early reentry of elective pediatric surgery are reported from Levine's Children's Hospital (LCH), a free-leaning children's hospital in Charlotte, North Carolina. Data reported were obtained from de-identified hospital databases. RESULTS: Pediatric surgery experienced a dramatic decrease in case volumes at LCH during the shutdown, variable by specialty. A tiered and balanced reentry strategy was implemented with steady resumption of elective surgery following strict pre-procedural screening and testing. Early outcomes showed a steady thorough fluctuating increase in elective case volumes without evidence of a surgery-associated positive spread through periprocedural tracking. CONCLUSION: Reentry of non-emergent pediatric surgical care requires unique considerations including the impact of COVID-19 on children, each children hospital structure and resources, and preventing undue delay in intervention for age- and disease-specific pediatric conditions. A carefully balanced strategy has been critical for safe reentry following the anticipated surge. Ongoing tracking of resource utilization, operative volumes, and testing results will remain vital as community spread continues to fluctuate across the country.

Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair.

INTRODUCTION: Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair. METHODS: A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software. RESULTS: Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm3, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm2, p < 0.001). In multivariate analysis, HSV increase of 100cm3 (OR 1.17 CI 1.02-1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence. CONCLUSIONS: Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.

Delayed primary closure (DPC) of the skin and subcutaneous tissues following complex, contaminated abdominal wall reconstruction (AWR): a propensity-matched study.

BACKGROUND: Wound complications following abdominal wall reconstruction (AWR) in a contaminated setting are common and significantly increase the risk of hernia recurrence. The purpose of this study was to examine the effect of short-term negative pressure wound therapy (NPWT) followed by operative delayed primary closure (DPC) of the skin and subcutaneous tissue after AWR in a contaminated setting. METHODS: A prospective institutional hernia database was queried for patients who underwent NPWT-assisted DPC after contaminated AWR between 2008 and 2020. Primary outcomes included wound complication rate and reopening of the incision. A non-DPC group was created using propensity-matching. Standard descriptive statistics were used, and a univariate analysis was performed between the DPC and non-DPC groups. RESULTS: In total, 110 patients underwent DPC following AWR. The hernias were on average large (188 ± 133.6 cm2), often recurrent (81.5%), and 60.5% required a components separation. All patients had CDC Class 3 (14.5%) or 4 (85.5%) wounds and biologic mesh placed. Using CeDAR, the wound complication rate was estimated to be 66.3%. Postoperatively, 26.4% patients developed a wound complication, but only 5.5% patients required reopening of the wound. The rate of recurrence was 5.5% with mean follow-up of 22.6 ± 27.1 months. After propensity-matching, there were 73 patients each in the DPC and non-DPC groups. DPC patients had fewer overall wound complications (23.0% vs 43.9%, p = 0.02). While 4.1% of the DPC group required reopening of the incision, 20.5% of patients in the non-DPC required reopening of the incision (p = 0.005) with an average time to healing of 150 days. Hernia recurrence remained low overall (2.7% vs 5.4%, p = 0.17). CONCLUSIONS: DPC can be performed with a high rate of success in complex, contaminated AWR patients by reducing the rate of wound complications and avoiding prolonged healing times. In patients undergoing AWR in a contaminated setting, a NPWT-assisted DPC should be considered.

Technique and Outcomes in Laparoscopic Repair of Morgagni Hernia in Adults.

Background: Morgagni hernias (MHs) are rare anteromedial congenital diaphragmatic hernias. This study describes the effectiveness of a laparoscopic approach for these defects. Methods: A prospectively collected institutional database at a tertiary referral center was queried for patients (≥18 years) with MHs. Results: Fifteen adults underwent laparoscopic MH repair. Abdominal pain was the most common presentation (71.5%), and 2 patients (13.3%) presented with acute obstruction. Laparoscopic bridged mesh repair was the most common approach (66.7%) and was achieved by suturing a bridged synthetic mesh to the diaphragmatic portion of the defect and fixing it with transfascial sutures and/or tacks to the anterior abdominal wall. Primary suture repair was utilized for smaller defects. No mortalities or recurrences occurred after 20.2 months median follow-up. Conclusions: Laparoscopic synthetic mesh repair of adult MHs offers an effective hernia repair with minimal complications and no detected recurrences in long-term follow-up of this patient sample.

The CELIOtomy Risk Score: An effort to minimize futile surgery with analysis of early postoperative mortality after emergency laparotomy.

BACKGROUND: Emergency surgical services often encounter patients with generalized peritonitis. Difficult perioperative decisions impact morbidity, mortality, cost, and utilization of hospital resources. The ability to preoperatively predict patient nonsurvival despite surgical intervention using clinical physiologic indicators was the aim of this study and would be helpful in counseling patients/families. METHODS: A retrospective cohort from an institutional database was queried for nontrauma patients with peritonitis undergoing emergency laparotomy from 2012 to 2016. Time to mortality after surgery was compared: early (≤72 hours) versus late (>72 hours) and no death. RESULTS: After 534 emergency laparotomies, there were 74 (13.9%) mortalities. Of these, death occurred early (≤72 hours) after surgery in 28 (37.8%) patients and late (>72 hours) in 46 (62.2%). Early death patients had a significantly more deranged physiology, as evidenced by higher Acute Physiology and Chronic Health Evaluation II scores (mean 28.1 ± 8.4 vs 22.9 ± 8.7, P = .01), worse acute kidney injury (preoperative creatinine 3.7 ± 3.2 vs 1.9 ± 1.4, P = .001), and greater level of acidosis (pH 7.19 ± 0.12 vs 7.27 ± 0.13, P = .017). Additionally, preoperative lactate was significantly increased in patients with early mortality (6.8 ± 4.1 vs 5.1 ± 4.0, P = .045). Using logarithmic regression, a nomogram was constructed using age, Glasgow Coma Scale, lactate, creatinine, and pH. This nomogram had an area under the curve of 0.908 on receiver operator curve analysis. A score of 13 equates to greater than 50% risk of early mortality after surgery. CONCLUSION: Early mortality (≤72 hours after emergency laparotomy) is associated with decreased pH, elevated creatinine, and elevated lactate. These factors combined into the nomogram constructed may assist surgical teams with patient and family discussions to prevent futile surgical interventions.

Surgery Resident Time Consumed by the Electronic Health Record.

OBJECTIVE: Time spent on the Electronic Health Record (EHR) influences surgical residents' clinical availability. Objective data assessing EHR usage among surgical residents are lacking and necessary. DESIGN/PARTICIPANTS: Active EHR usage data for 70 surgical residents were collected from April 2015 through April 2016. Active EHR usage was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 "mouse miles" per minute. Usage data of different specialties, interns (PGY 1), juniors (PGY 2, 3), and seniors (PGY 4, 5) were compared. SETTING: Carolinas Medical Center, Charlotte, NC. RESULTS: Interns spent more time than juniors on total EHR activities per day (134.5 vs 105.5 minutes, p < 0.001) and juniors spent more time per day than seniors (105.5 vs 78.7 minutes, p < 0.001). Among different EHR activities per patient, interns spent greater time than juniors on chart review (8.1 vs 6.2 minutes, p < 0.001), documentation (9.0 vs 6.5 minutes, p < 0.001), and orders (3.6 vs 3.0 minutes, p < 0.001). Juniors spent the same time as seniors on chart review (6.2 vs 6.5 minutes, p = 0.2). Juniors spent more time than seniors on documentation (6.5 vs 5.2 minutes, p < 0.001) and orders (3.0 vs 2.7 minutes, p < 0.05). Comparing EHR activities per patient among different specialties, General Surgery residents spent more time than Orthopedic residents on total EHR time (19.9 vs 15.9 minutes, p < 0.001), chart review (6.8 vs 5.7 minutes, p < 0.001), documentation (6.3 vs 5.6 minutes, p < 0.001), and orders (3.6 vs 2.6 minutes, p < 0.001). General Surgery residents spent less time than OB/GYN residents on total EHR time (19.9 vs 22 minutes, p < 0.01), chart review (6.8 vs. 7.5 minutes, p < 0.05), and documentation (6.3 vs 7.6 minutes, p < 0.001), but more time on orders (3.6 vs 2.9 minutes, p < 0.001). CONCLUSIONS: These are the first reported objective findings on surgical resident use of the EHR and may provide an opportunity for improvement in EHR training and usage.

Comparison of Outcomes After Partial Versus Complete Mesh Excision.

OBJECTIVE: Evaluate outcomes of patients undergoing mesh explantation following partial mesh excision (PME) and complete mesh excision (CME). BACKGROUND: Ventral hernia repair (VHR) with mesh remains one of the most commonly performed procedures worldwide. Management of previously placed mesh during reexploration remains unclear. Studies describing PME as a feasible alternative have been limited. METHODS: The AHSQC registry was queried for VHR patients who underwent mesh excision. Variables used for propensity-matching included age, BMI, race, diabetes, COPD, OR time>2 hours, immunosuppressants, smoking, active infection, ASA class, elective case, wound classification, and history of abdominal wall infection. RESULTS: A total of 1904 VHR patients underwent excision of prior mesh. After propensity matching, complications were significantly higher (35% vs 29%, P = 0.01) after PME, including SSI/SSO, SSOPI, and reoperation. No differences were observed in patients with clean wounds, however in clean-contaminated, PME more frequently resulted in SSOPI (24% vs 9%, P = 0.02). In mesh infection/fistulas, higher rates of SSOPI (46% vs 24%, P = 0.04) and reoperation (21% vs 6%, P = 0.03) were seen after PME. Odds-ratio analysis showed increased likelihood of SSOPI (OR 1.5, 95% CI 1.05-2.14; P = 0.023) and reoperation (OR 2.2, 95% CI 1.13-4.10; P = 0.015) with PME. CONCLUSIONS: With over 350,000 VHR performed annually and increasing mesh use, guidelines for management of mesh during reexploration are needed. This analysis of a multicenter hernia database demonstrates significantly increased postoperative complications in PME patients with clean-contaminated wounds and mesh infections/fistulas, however showed similar outcomes in those with clean wounds.

Use of computed tomography volumetric measurements to predict operative techniques in paraesophageal hernia repair.

BACKGROUND: Despite advances in diagnostic imaging capabilities, little information exists concerning the impact of physical dimensions of a paraesophageal hernia (PEH) on intraoperative decision making. The authors hypothesized that computerized volumetric analysis and multidimensional visualization to measure hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) would correlate to operative findings and required surgical techniques performed. METHODS: Using volumetric analysis software (Aquarius iNtuition, TeraRecon, Inc), HDA and HSV were measured in PEH patients with preoperative computerized tomography (CT) scans, and used to predict the likelihood of intraoperative variables. Multidimensional rotation of images enabled visualization of the entire hiatal defect in a plane mimicking the surgeon's view during repair. The intrathoracic hernia sac was outlined producing volume measurements based on a summation of exact dimensions. RESULTS: A total of 213 PEHR patients had preoperative CT imaging, with 14.1% performed emergently. Primary cruroplasty was performed in 89.2%, salvage gastropexy in 10.3%, and diaphragmatic relaxing incisions in 4.2%. Median HDA was 25.7 cm2 (IQR17.8-35.6 cm2); median HSV was 365.0 cm3 (IQR150.0-611.0 cm3). Incremental 5 cm2 increase in HDA was associated with greater likelihood of presenting emergently (OR 1.27; 95%CI 1.124-1.428, p = 0.0001), incarceration (OR 1.27; 1.074-1.499, p = 0.005), gastric volvulus (OR 1.13; 1.021-1.248, p = 0.02), and requiring either relaxing incision (OR 1.43; 1.203-1.709, p < 0.0001) or salvage gastropexy (OR 1.13; 1.001-1.274, p = 0.04). Similarly, HSV increases of 100 cm3 were associated with 23% greater likelihood of emergent repair (CI 1.121-1.353, p < 0.0001), and were more likely to require a relaxing incision (OR 1.18; 1.043-1.339, p = 0.009) or salvage gastropexy (1.19; 1.083-1.312, p = 0.0003). CONCLUSIONS: Utilization of CT volumetric measurements is a valuable adjunct in preoperative planning, allowing the surgeon to anticipate complexity of repair and operative approach, as incremental increases in HSV by 100 cm3 and HDA by 5 cm2 are more likely to require complex techniques or bailout procedures and/or present emergently.

Mesh fistula after ventral hernia repair: What is the optimal management?

BACKGROUND: A mesh-related intestinal fistula is an uncommon and challenging complication of ventral hernia repair. Optimal management is unclear owing to lack of prospective or long-term data. METHODS: We reviewed our prospective data for mesh-related intestinal fistulas from 2004 to 2017and compared suture repair versus ventral hernia repair with mesh at the time of mesh-related intestinal fistula takedown. RESULTS: Eighty-two mesh-related intestinal fistulas were treated; none of the fistulas had closed spontaneously, and all fistula persisted at the time of our treatment. Mean age was 61 ± 12 years with 33-month follow-up. Comorbidities were similar between groups. Defects were 2.5-times larger in ventral hernia repair with mesh (324 ± 392 cm2 vs 1301 ± 133 cm2; P = .044). Components separation (64% vs 21%; P = .0003) and panniculectomy (35% vs 7%; P = .0074) were more common in ventral hernia repair with mesh. Mortality occurred in 4 patients. Complications were similar. In patients undergoing ventral hernia repair with non-bridged, acellular, porcine dermal matrix, hernia recurrence was less than in patients without mesh (26% vs 66%; P = .0030). Only partial excision of the mesh involved with the fistula resulted in a substantial increase in developing another fistula (29% vs 6%; P < .05). CONCLUSION: Patients undergoing preperitoneal ventral hernia repair with mesh for mesh-related intestinal fistula had a lesser rate of hernia recurrence and similar complications compared to suture repair despite larger hernias. Complete mesh excision decreases the risk of fistula recurrence. We maintain that ventral hernia repair with mesh during mesh-related intestinal fistula takedown represents the best opportunity for a durable herniorrhaphy.

Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP.

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11-1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.

The impact of abnormal BMI on surgical complications after pediatric colorectal surgery.

BACKGROUND/PURPOSE: While childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after elective colorectal procedures. METHODS: Children ages 2-18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts. RESULTS: 858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p=0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p=0.04). Incremental increase in BMI by 1.0kg/m2 was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS. CONCLUSIONS: Increasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications. LEVEL OF EVIDENCE: III.

Outcomes of open abdomen versus primary closure following emergent laparotomy for suspected secondary peritonitis: A propensity-matched analysis.

BACKGROUND: Optimal management following index laparotomy is poorly defined in secondary peritonitis patients. Although "open abdomen" (OA), or temporary abdominal closure with planned relaparotomy, is used to reassess bowel viability or severity of contamination, recent studies demonstrate comparable morbidity and mortality with primary abdominal closure (PC). This study evaluates differences between OA and PC following emergent laparotomy. METHODS: Using the Premier database at a quaternary care center (2012-2016), nontrauma patients with secondary peritonitis requiring emergent laparotomy were identified (N = 534). Propensity matching for PC (n = 331; 62%) or OA (n = 203; 38%) was performed using variables: Mannheim Peritonitis Index, lactate, and vasopressor requirement. One hundred eleven closely matched pairs (PC:OA) were compared. RESULTS: Five hundred thirty-four patients (55.0% female; mean age, 59.6 ± 15.5 years) underwent emergent laparotomy. Of the OA patients, 136 (67.0%) had one relaparotomy, while 67 (33.0%) underwent multiple reoperations. Compared to daytime cases, laparotomies performed overnight (6 pm-6 am) had more temporary closures with OA (42.8% OA vs. 57.2% PC, p = 0.04). When assessing by surgeon type, PC was performed in 78.7% of laparotomies by surgical subspecialties compared to 56.7% (p < 0.0001) of acute care surgeons. After propensity matching, OA patients had increased postoperative complications (71.2% vs. 41.4%, p < 0.0001), mortality (22.5% vs. 11.7%, p = 0.006), and longer median length of stay (13 vs. 9 days, p = 0.0001). CONCLUSION: Open abdomen was performed in 38.0% of patients, with one-third of those requiring multiple reoperations. Complications, mortality rates, and costs associated with OA were significantly increased when compared to PC. Given these findings, future studies are needed to determine appropriate indications for OA. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Trauma Recidivism and Mortality Following Violent Injuries in Young Adults.

BACKGROUND: Trauma recidivism accounts for approximately 44% of emergency department admissions and remains a significant health burden with this patient cohort carrying higher rates of morbidity and mortality. METHODS: A level 1 trauma center registry was queried for patients aged 18-25 y presented between 2009 and 2015. Patients with nonaccidental gunshot wounds, stab wounds, or blunt assault-related injuries were categorized as violent injuries. Primary outcomes included mortality and recidivism, which were defined as patients with two unrelated traumas during the study period. Hospital records and the Social Security Death Index were used to aid in outcomes. RESULTS: A total of 6484 patients presented with 1215 (18.7%) sustaining violent injuries (87.4% male, median age 22.2 y). Mechanism of violent injuries included 64.4% gunshot wound, 21.1% stab, and 14.8% blunt assault. Compared with nonviolent injuries, violent injury patients had increased risk of mortality (9.3% versus 2.1%, P < 0.0001). Out-of-hospital mortality was 2.6% (versus 0.5% nonviolent, P < 0.0005), with an average time to death being 6.4 mo from initial injury. Recidivism was 24.9% with mean time to second violent injury at 31.9 ± 21.0 mo; 14.9% had two trauma readmissions, and 8.0% had ≥3. Ninety percent of subsequent injuries occurred within 5 y, with 19.1% in the first year. CONCLUSIONS: The burden of injury after violent trauma extends past discharge as patients have significantly higher mortality rates following hospital release. Over one-quarter present with a second unrelated trauma or death. Improved medical, psychological, and social collaborative treatment of these high-risk patients is needed to interrupt the cycle of violent injury.

Short-term Outcomes of Esophagectomies in Octogenarians-An Analysis of ACS-NSQIP.

BACKGROUND: In the face of an increasingly aged population, surgical management in the elderly will rise. This study assesses the short-term outcomes of esophagectomies in octogenarians. MATERIAL AND METHODS: The National Surgical Quality Improvement Program database was queried for esophagectomy cases from 2005 to 2014. Patients aged <80 and ≥80 y were compared in univariate and multivariate analysis, controlling for confounding variables. RESULTS: Among 9354 esophagectomies, 4.3% were performed in patients aged ≥80 y. Ivor Lewis was the most common approach, comprising 43% of cases. Octogenarians more frequently had dependent functional status (P < 0.0001) and cardiovascular disease (P < 0.0001), whereas younger patients were more likely obese (P < 0.0001), smokers (P < 0.0001), and have excess preoperative weight loss (P = 0.0043). Compared to younger patients, in multivariate analysis, elderly patients were noted to have increased risk of 30-d mortality (odds ratio [OR] 1.67; confidence interval [CI] 1.03-2.67), discharge to facility (OR 3.08; CI 2.36-4.02), myocardial infarction (OR 2.49; CI 1.29-4.82), and pneumonia (OR 1.47; CI 1.12-1.910). However, regardless of age, dependent functional status demonstrated the strongest association with mortality (OR 3.41; CI 2.14-6.61). Within the elderly, each additional year above 80 y old increased the risk of discharge to a facility by 17% (OR 1.17; CI 1.04-1.30). Cases requiring nongastric intestinal conduit were also more likely to suffer from early mortality (OR 2.87; CI 1.87-4.40). CONCLUSIONS: Age is independently associated with multiple adverse outcomes, including mortality, discharge to facility, and postoperative cardiopulmonary complications. Functional dependence is even more so associated with poor outcomes. Careful selection of very elderly patients is required to minimize additional risk.

Emergent Laparoscopic Ventral Hernia Repairs.

BACKGROUND: Emergent repairs of incarcerated and strangulated ventral hernia repairs (VHR) are associated with higher perioperative morbidity and mortality than those repaired electively. Despite increasing utilization of minimally invasive techniques in elective repairs, the role for laparoscopy in emergent VHR is not well defined, and its feasibility has been demonstrated only in single center studies. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2009-2016) was queried for emergent VHR. Laparoscopic and open techniques were compared using univariate and multivariate analyses. RESULTS: A total of 11,075 patients who underwent emergent ventral and incisional hernia repairs were identified: 85.5% open ventral hernia repair (OVHR), 14.5% laparoscopic ventral hernia repair (LVHR). Patients who underwent emergent OVHRs were older, more comorbid, and more likely to be septic at the time of surgery than those undergoing emergent LVHRs. Emergent OVHR patients were more likely to have minor complications (22.1% versus 11.0%; OR 1.7; 95% CI 1.069-2.834). After controlling for confounding variables, LVHR and OVHR had similar outcomes, with the exception of higher rates of superficial surgical site infection in OVHR (5.0% versus 1.8%; odd's ratio (OR) 2.7; 95% confidence interval (CI) 1.176-6.138). Following multivariate analysis, laparoscopic approach demonstrated similar outcomes in major complications, reoperation, and 30-d mortality compared to open repairs. However, when controlling for other confounding factors, LVHR had reduced length of stay compared to OVHR (6.7 versus 4.0 d; 1.6 d longer, standard error 0.77, P < 0.03). CONCLUSIONS: Emergent LVHR is associated with fewer superficial surgical site infection and shorter length of stay than OVHR but no difference in major complications, reoperation or 30-d mortality is associated with LVHR in the emergency setting.

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial.

PURPOSE: To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis. METHODS: This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared. RESULTS: Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001). CONCLUSION: Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

One More Time: Redo Paraesophageal Hernia Repair Results in Safe, Durable Outcomes Compared with Primary Repairs.

The incidence and causes of failed paraesophageal hernia repairs (PEHR) remain poorly understood. Our study aimed to evaluate long-term clinical outcomes after reoperative fundoplication as compared with initial PEHR. A prospectively maintained institutional hernia-specific database was queried for PEHR between 2008 and 2017. Patients with prior history of PEHR were categorized as "redo" paraesophageal hernia (RPEH). Primary outcomes included postoperative morbidity, mortality, symptom resolution, and hernia recurrence. A total of 402 patients underwent minimally invasive PEHR (Initial PEH = 305, RPEH = 97). Redo PEHR had more prevalent preoperative nausea/vomiting (50.6% vs 34.1%, P < 0.007) and weight loss (24.1% vs 13.5%, P < 0.02). RPEH had had longer mean operative time (256.4 ± 91.2 vs 190.3 ± 59.9 minutes, P < 0.0001) and higher rate of conversion to open (10.3% vs 0.67%, P < 0.0001); however, no difference was noted in postoperative complications, hernia recurrence, or mortality between cohorts. Laparoscopic revision of prior PEHR in symptomatic patients can be safely performed with favorable outcomes compared with initial PEHR. Despite redo procedures seeming to be more technically demanding (as noted by longer operative time and higher conversion rates), outcomes are similar and overall resolution of symptoms is achieved in most patients.

Epiphrenic Diverticulum: 20-Year Single-Institution Experience.

Epiphrenic diverticula are pulsion-type outpouchings of the distal esophagus associated with motility disorders. They can present with chronic symptoms of dysphagia, regurgitation, reflux, and aspiration. A prospectively collected surgical outcomes database was queried for patients who underwent surgical treatment of epiphrenic diverticula at a single institution between August 1997 and August 2018. Patient demographics, presenting symptoms, operative intervention, and perioperative data were retrospectively reviewed. Twenty-seven patients with a symptomatic epiphrenic diverticulum were identified. Abnormal esophageal motility was diagnosed in 16 patients (59.2%), most commonly achalasia (29.6%). All patients had a minimally invasive (26 laparoscopic, one thoracoscopic) diverticulectomy with no conversions to open required. Concurrent myotomy was performed in 88.9 per cent patients and anti-reflux procedure in 85.2 per cent patients. There was minimal morbidity with no esophageal leaks, mortalities, or recurrent diverticula noted after 35.8 months of follow-up. Dysphagia was the most common persistent symptom and occurred in 11.1 per cent; overall resolution of symptoms was achieved with surgery in 89.9 per cent of patients. As minimally invasive techniques have advanced, laparoscopic diverticulectomy seems to be an excellent surgical approach for symptomatic epiphrenic diverticula. Long-term resolution of symptoms was achieved in most patients, with a very low complication rate.

Prevention and Treatment Strategies for Mesh Infection in Abdominal Wall Reconstruction.

BACKGROUND: Mesh infection remains the most feared complication after abdominal wall reconstruction, requiring prolonged hospitalizations and often, mesh removal. Understanding of current prevention and treatment strategies is necessary in the management of a common surgical problem. METHODS: A comprehensive review of the current surgical literature was performed to determine risk factors of mesh infection after abdominal wall reconstruction and best practices in their prevention and surgical management. RESULTS: Patient-related risk factors for mesh infections include smoking, obesity, diabetes mellitus, and COPD. Surgical risk factors such as prolonged operative time and prior enterotomy should also be considered. Prevention strategies emphasize reduction of modifiable risk factors, including obesity and diabetes among other comorbidities. Biologic or biosynthetic mesh is recommended in contaminated fields and use of delayed wound closure or vacuum-assisted closure therapy should be considered in high-risk patients. Conservative treatment with antibiotics, percutaneous or surgical drainage, and negative-pressure vacuum-based therapies have demonstrated limited success in mesh salvage. Mesh infection often requires mesh explantation followed by abdominal wall reconstruction. Staged repairs can be performed; however, definitive hernia repair with biologic mesh has shown promising results. CONCLUSIONS: Management of mesh infections is a complex, yet commonly faced problem. Strategies used in the prevention and surgical treatment of infected mesh should continue to be supported by high-quality evidence from prospective studies.