Feasibility and Outcomes of Same-Day Surgery in Primary and Reoperative Laparoscopic Hiatal Hernia Repair.

OBJECTIVE: To assess the feasibility and outcomes of same-day surgery in primary and reoperative laparoscopic hiatal hernia repairs. METHODS: Same-day surgery was planned in elective procedures with ASA II-IV. An Enhanced Recovery After Surgery (ERAS) protocol was implemented to achieve same-day surgery, and opioid-based anesthesia was replaced by opioid-free anesthesia. Outcomes were assessed by length of stay, transition from same-day surgery to observation or inpatient, and postoperative emergency department visits/readmissions. The predictors of same-day surgery were assessed. Values are presented as median (interquartile range). RESULTS: From 04/13/2017 to 09/29/2022, there were 518 laparoscopic hiatal hernia repairs in 491 patients, 428/518 (82.6%) were primary, and 90/518 (17.4%) were reoperative. In the primary group, 314/428 (73.4%) were planned as same-day surgery and 246/314 (78.3%) were performed as same-day surgery. Same-day surgery with opioid-based anesthesia protocol was performed in 77/314 (24.5%) vs. same-day surgery with opioid-free anesthesia protocol in 169/314 (53.8%), p < 0.001, 41/246 (16.7%) same-day surgery primary procedures had emergency department visit post-discharge, and 26/246 (10.6%) were readmitted. In the reoperative group, 51/90 (56.7%) were planned as same-day surgery, and 27/51 (52.9%) were performed as same-day surgery. Same-day surgery with opioid-based anesthesia protocol was performed in 2/51 (3.9%) vs. same-day surgery with opioid-free anesthesia protocol in 25/51 (49.0%), p < 0.001, 3/27 (11.1%) same-day surgery reoperative procedures had emergency department visit post-discharge, and 3/27 (11.1%) were readmitted. Opioid-free anesthesia protocol was the positive predictor of same-day surgery compared to opioid-based anesthesia protocol (OR 7.44 [95% CI: 2.94, 18.83]), p < 0.001. Negative predictors were ASA III compared to II (OR 0.52 [95% CI: 0.28, 0.94]), p = 0.031, and duration of operation (OR 0.98 [0.97, 0.99]) p < 0.001. CONCLUSION: Laparoscopic hiatal hernia repair can be performed as same-day surgery in the majority of primary and reoperative procedures with good outcomes and low postoperative emergency department visits and readmissions. The odds of same-day surgery are higher with opioid-free anesthesia, lower ASA, and shorter operative time.

Changes in age, stage distribution, and survival of patients with esophageal adenocarcinoma over three decades in the United States.

BACKGROUND: Our aim was to evaluate the changes in age, stage distribution, and overall survival (OS) of patients with esophageal adenocarcinoma (EAC) over time. METHODS: Patients from the Surveillance, Epidemiology, and End Results (SEER) database aged ≥ 20 with invasive EAC, diagnosed from 1973-2003 were reviewed. Survival follow-up ended in 2006. RESULTS: There were 11,620 patients; 6580 (57%) aged ≥ 65. The stage distribution was 22%, 35%, and 43% for localized, regional, and distant metastasis for patients aged <65, and 33%, 33%, and 34% for patients aged ≥ 65. The number of patients ≥ 65 years with localized stage increased over time. Three-year OS for localized, regional, and distant disease increased from 19%, 10%, and 1% in 1973-1976, to 34%, 13%, and 2% in 1987-1991, and to 45%, 25%, and 4% in 2002-2003 (P < 0.001). A sub-analysis of 5475 patients from 1988-2002 showed better survival for patients with esophagectomy for all stages. Three-year OS for 2074 patients with esophagectomy improved every 5 years from 1988-2002 (39%, 43% to 54%, P < 0.001). Stratified by stage, year and esophagectomy status, patients aged <65 had better survival compared to patients aged ≥ 65 (P < 0.001). CONCLUSIONS: There has been a substantial improvement in overall survival among patients with invasive EAC over the last 3 decades. Patients receiving esophagectomy had longer survival. Survival with esophagectomy improved in each time period. Although younger EAC patients were diagnosed at more advanced stages over time, they had better survival.

Opioid-Free Anesthesia and Same-Day Surgery Laparoscopic Hiatal Hernia Repair.

BACKGROUND: Laparoscopic hiatal hernia repair is commonly performed with a 1 to 2 night hospitalization. Our aim was to compare the feasibility and short-term outcomes of same-day surgery (SDS) laparoscopic hiatal hernia repair with an opioid-based anesthesia protocol (OBAP) vs an opioid-free anesthesia protocol (OFAP). STUDY DESIGN: Outcomes and pharmacy costs of repairs with OBAP were compared with OFAP. Values were expressed as median (interquartile range) and costs as means. RESULTS: There were 244 primary laparoscopic repairs. OBAP was used in 191 of 244 (78.3%) vs OFAP in 53 of 244 (21.7%). The length of stay was 1 day (0 to 2) vs 0 days (0 to 1), p = 0.006. There was no difference between the percentage of patients requiring analgesics and dosage between the 2 groups. SDS was planned in 157 and performed in 74 of 122 (60.7%) vs 33 of 35 (94.3%), p < 0.001. The age was 56 years (45 to 63) vs 60 years (56 to 68), p = 0.025. There were more type I hiatal hernia in SDS-OBAP and more type III and IV in SDS-OFAP, p = 0.031. American Society of Anesthesiologists Physical Status was II (II-III) vs III (II-III), p = 0.045. SDS was not performed in 50 of 157 (31.8%), 48 of 122 (39.3%) vs 2 of 35 (5.7%), p < 0.001. Out of 157 planned SDS, nausea/retching were causes of transition in 19 of 122 (15.6%) vs 0 of 35 (0%), p = 0.020. Multivariable logistic regression showed the odds of SDS were 8.21 times (95% CI 3.10 to 21.71; p < 0.001) greater in OFAP compared with OBAP, adjusting for sex, age, body mass index, American Society of Anesthesiologists Physical Status, type of hiatal hernia, type of procedure, and duration of the operation. Patients with opioid medication after SDS discharge were 74 of 74 (100%) vs 22 of 33 (66.7%), p < 0.001. CONCLUSIONS: Opioid-free anesthesia increases the feasibility of SDS hiatal hernia repair with less perioperative nausea and comparable pain control and pharmacy cost.

Day-to-day discrepancy in Bravo pH monitoring is related to the degree of deterioration of the lower esophageal sphincter and severity of reflux disease.

BACKGROUND: The Bravo capsule allows monitoring of esophageal acid exposure over a two-day period. Experience has shown that 24-32% of patients will have abnormal esophageal acid exposure detected on only one of the 2 days monitored. This variation has been explained by the effect of endoscopy and sedation. The aim of this study was to assess the day-to-day discrepancy following transnasal placement of the Bravo capsule without endoscopy or sedation and to determine factors related to this variability. METHODS: Bravo pH monitoring was performed by transnasal placement of the capsule in 310 patients. Patients were divided into groups based on the composite pH score: both days normal, both days abnormal and only one of the 2 days abnormal. Lower esophageal sphincter (LES) characteristics were compared between groups. RESULTS: Of the 310 patients evaluated, 60 (19%) showed a discrepancy between the 2 days. A total of 127 patients had a normal pH score on both days and 123 had an abnormal pH score on both days. Of the 60 patients with a discrepancy, 27 were abnormal the first day and 33 (55%) were abnormal the second day. Patients with abnormal esophageal acid exposure on both days had higher degrees of esophageal acid exposure and were more likely to have a defective LES compared to those with an abnormal score on only one day (35 vs. 83%, p=0.027). CONCLUSION: Patients with a discrepancy between days of Bravo pH monitoring have lower esophageal acid exposure. Variability between the 2 days represents early deterioration of the gastroesophageal barrier and indicates less advanced reflux disease.

Detection of gastric conduit ischemia or anastomotic breakdown after cervical esophagogastrostomy: the use of computed tomography scan versus early endoscopy.

BACKGROUND: Concern over potential injury to the anastomosis has limited the use of early postoperative endoscopy to diagnose conduit ischemia or anastomotic breakdown. Alternatively, a computed tomography (CT) scan has been suggested as a noninvasive means for identifying these complications. This study aimed to compare CT scan with early endoscopy for diagnosing gastric conduit ischemia or anastomotic breakdown after esophagectomy with cervical esophagogastrostomy. METHODS: Between 2000 and 2007, 554 patients underwent an esophagectomy and gastric pull-up with cervical esophagogastrostomy at the University of Southern California. Records were reviewed to identify patients who had undergone endoscopy and CT scan within 24 h of each other during the first three postoperative weeks for suspicion of an ischemic conduit or anastomotic breakdown. The accuracies of CT scan and endoscopy in diagnosing an ischemic conduit were compared. RESULTS: A total of 76 patients had endoscopy and CT scan for clinical suspicion of conduit ischemia or anastomotic breakdown. Endoscopy was performed without complications in all 76 patients. The postoperative endoscopic findings were normal in 24 of the patients, and none subsequently experienced an ischemic conduit or anastomotic breakdown. Evidence of ischemia was present in 28 patients, 7 of whom had black mucosa throughout the gastric conduit with the anastomosis still intact and required removal of their conduit. The remaining 24 patients had partial or complete anastomotic breakdown. On the CT scan, 23 of the 76 patients showed evidence of conduit ischemia (n = 9) or anastomotic breakdown (n = 14). There was no evidence of ischemia or anastomotic breakdown on CT scan for the 24 patients with normal endoscopy or for 3 of the 7 patients who had their conduit removed for graft necrosis. CONCLUSION: A normal CT scan does not rule out the possibility of an ischemic gastric conduit after esophagectomy. Early endoscopy is a safe and accurate method for assessing conduit ischemia.

A simplified technique for intrathoracic stomach repair: laparoscopic fundoplication with Vicryl mesh and BioGlue crural reinforcement.

BACKGROUND: Laparoscopic repair of an intrathoracic stomach has been associated with a high recurrence rate. The use of biologic or synthetic mesh to reinforce the crural repair has been shown to reduce recurrence. This study aimed to assess a simplified technique for reinforcing the crural repair using absorbable Vicryl mesh secured with BioGlue during laparoscopic repair of an intrathoracic stomach. METHODS: The charts of all patients who underwent laparoscopic repair of an intrathoracic stomach from June 2006 to March 2009 using the described technique were retrospectively reviewed. Intrathoracic stomach was defined as more than 50% of the stomach herniated into the chest. Follow-up assessment was routinely performed 1 year or more after surgery and included endoscopy, video esophagram, Bravo 48-h pH monitoring, and a gastroesophageal reflux disease (GERD)-health-related quality-of-life (HRQL) questionnaire. RESULTS: A total of 35 patients (male:female = 10:25) with a mean age of 70 years (48-89 years) and a mean body mass index (BMI) of 30.4 kg/m(2) (20.4-44.8 kg/m(2)) underwent repair using this technique. The median operating time was 144 min (101-311 min), and the median hospital stay was 2 days (1-21 days). There were three conversions (8.6%) and one intraoperative complication (2.9%). Three patients (8.6%) experienced postoperative complications. No mesh-related complications occurred. Follow-up assessment 1 year or more after surgery was available for 21 of the 25 eligible patients [median follow-up period, 14 months (11-34 months)]. There were two recurrences (9.5%), one of them asymptomatic. The median GERD-HRQL score was 5 (2-28). Nearly all the patients (91.3%) were satisfied with the operation, and 96% would have it again. CONCLUSION: Vicryl mesh secured with BioGlue is a simple and easy method for reinforcing the crural closure during laparoscopic repair of an intrathoracic stomach. The recurrence rate at 1 year is low and comparable with that of other series using biologic mesh secured with sutures or tacks.

Laparoscopic hiatal hernia repair as same day surgery: Feasibility, short-term outcomes and costs.

INTRODUCTION: Laparoscopic hiatal hernia repair is commonly performed with 1 night hospitalization. The aim was to assess repairs as same-day-surgery (SDS). METHODS: Costs/short-term outcomes of SDS were compared to hospital-stay < 24-h: observation (OBS) and hospital-stay ≥ 24-h: inpatient (INP). Outcomes were assessed by postoperative 30-day ER visits/readmissions. RESULTS: There were 262 procedures, excluding 50 reoperative repairs, 212 procedures were included: There were 66 SDS, 65 OBS and 81 INP. SDS vs. OBS: OBS were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. SDS vs. INP: INP were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. CONCLUSION: Laparoscopic hiatal hernia repair can be performed as SDS in majority of elective repairs with good short-term outcomes and reduced cost.

Bravo catheter-free pH monitoring: normal values, concordance, optimal diagnostic thresholds, and accuracy.

BACKGROUND & AIMS: The Bravo pH capsule is a catheter-free intraesophageal pH monitoring system that avoids the discomfort of an indwelling catheter. The objectives of this study were as follows: (1) to obtain normal values for the first and second 24-hour recording periods using a Bravo capsule placed transnasally 5 cm above the upper border of the lower esophageal sphincter determined by manometry and to assess concordance between the 2 periods, (2) to determine the optimal discriminating threshold for identifying patients with gastroesophageal reflux disease (GERD), and (3) to validate this threshold and to identify the recording period with the greatest accuracy. METHODS: Normal values for a manometrically positioned, transnasally inserted Bravo capsule were determined in 50 asymptomatic subjects. A test population of 50 subjects (25 asymptomatic, 25 with GERD) then was monitored to determine the best discriminating thresholds. The thresholds for the first, second, and combined (48-hour) recording periods then were validated in a separate group of 115 patients. RESULTS: In asymptomatic subjects, the values measured using a manometrically positioned Bravo pH capsule were similar between the first and second 24-hour periods of recording. The highest level of accuracy with Bravo was observed when an abnormal composite pH score was obtained in the first or second 24-hour period of monitoring. CONCLUSIONS: Normal values for esophageal acid exposure were defined for a manometrically positioned, transnasally inserted, Bravo pH capsule. An abnormal composite pH score, obtained in either the first or second 24-hour recording period, was the most accurate method of identifying patients with GERD.

Measurement of gastric pH in ambulatory esophageal pH monitoring.

BACKGROUND: Ambulatory esophageal pH monitoring is the method used most widely to quantify gastroesophageal reflux. The degree of gastroesophageal reflux may potentially be underestimated if the resting gastric pH is high. Normal subjects and symptomatic patients undergoing 24-h pH monitoring were studied to determine whether a relationship exists between resting gastric pH and the degree of esophageal acid exposure. METHODS: Normal volunteers (n = 54) and symptomatic patients without prior gastric surgery and off medication (n = 1,582) were studied. Gastric pH was measured by advancing the pH catheter into the stomach before positioning the electrode in the esophagus. The normal range of gastric pH was defined from the normal subjects, and the patients then were classified as having either normal gastric pH or hypochlorhydria. Esophageal acid exposure was compared between the two groups. RESULTS: The normal range for gastric pH was 0.3-2.9. The median age of the 1,582 patients was 51 years, and their median gastric pH was 1.7. Abnormal esophageal acid exposure was found in 797 patients (50.3%). Hypochlorhydria (resting gastric pH >2.9) was detected in 176 patients (11%). There was an inverse relationship between gastric pH and esophageal acid exposure (r = -0.13). For the patients with positive 24-h pH test results, the major effect of gastric pH was that the hypochlorhydric patients tended to have more reflux in the supine position than those with normal gastric pH. CONCLUSION: There is an inverse, dose-dependent relationship between gastric pH and esophageal acid exposure. Negative 24-h esophageal pH test results for a patient with hypochlorhydria may prompt a search for nonacid reflux as the explanation for the patient's symptoms.

Esophageal pH exposure and epithelial cell differentiation.

It is proposed that epithelial changes induced by gastroesophageal reflux disease are related to the pH environment of the esophageal lumen. We hypothesized that the various types of esophageal epithelium are associated with specific pH environments that induce their formation. The aim of this study was to compare the luminal pH environment to the histology of the distal esophageal epithelium in patients with gastroesophageal reflux disease. A total of 197 symptomatic patients with increased esophageal acid exposure on 24-hour pH monitoring were grouped according to the histology based on biopsies from the distal esophagus: 17 with squamous epithelium, 126 with cardiac epithelium (CE), and 54 with Barrett's epithelium (BE). All were free of Helicobacter pylori infection and monitored off acid suppression therapy. Acid exposure was expressed as the percent of time the luminal pH was at intervals of 0-1, 1-2, 2-3, 3-4, 4-5, 5-6, and 6-7 over a 24-hour period. Patients with BE spent significantly more time at pH intervals 2-3, 3-4, and 4-5 than those with CE. This pattern switched at pH interval 5-6, where patients with cardiac mucosa spent more time than those with BE. Patients with squamous and CE had similar pH exposure at all intervals. Patients with BE have significantly longer exposure time at the pH interval of 2 to 5 compared to those with cardiac and squamous epithelium. This suggests that the exposure of stem cells to a luminal pH between 2 and 5 may trigger the differentiation of CE into intestinalized CE.

Patient-related risk factors associated with symptomatic recurrence requiring reoperation in laparoscopic hiatal hernia repair.

BACKGROUND: Recurrent hiatal hernia remains a challenge. METHODS: For initial repairs at our center: patients with 1 repair were compared to those who required reoperation for symptomatic recurrence. Subsequently, patients who had 1 repair at our center were compared to all patients who required reoperation (including initial repair at another center). RESULTS: There were 401 repairs: 308 primary repairs at our center and 93 reoperations, 287/308 (93%) required 1 repair and 21/308 (7%) required reoperation. Comparing 1 repair versus 21 reoperations, risk factors were abdominoplasty odds ratio = 32.0 (4.1-250.6), P < .001, postoperative lifting/vomiting odds ratio = 11.6 (3.2-42.1), P < .0002, tubal ligation odds ratio = 4.9 (1.1-22.6), P < .04 and height < 160 cm odds ratio = 3.9 (1.1-13.3) P < 0.03. Comparing 287 with 1 repair versus all 93 reoperations, risk factors were post-operative vomiting odds ratio = 22.7 (2.3-218.0), P < .007, abdominoplasty odds ratio = 5.6 (1.0-31.4), P < .0495, post-operative lifting odds ratio = 5.4 (2.2-12.9), P < .0002, age < 52 odds ratio = 3.6 (1.8-7.3), P < .0003, tubal ligation odds ratio = 3.2 (1.2-8.7), P < 0.019 and height < 160 cm odds ratio = 3.0 (1.5-6.1), P < 0.003. CONCLUSIONS: Younger age, shorter stature, heavy lifting or vomiting after surgery, abdominoplasty and tubal ligation are risk factors associated with symptomatic recurrence requiring reoperation.

Laparoscopic Heller myotomy and Dor fundoplication in the same day surgery setting with a trained team and an enhanced recovery protocol.

BACKGROUND: The length of stay after Heller myotomy is 1-5 days. The aim was to report feasibility of the procedure as same day surgery (SDS). METHODS: Three steps of Enhanced Recovery After Surgery protocol: preoperatively, clear liquid diet for 24 hours, in preoperative area: antiemetics as dermal patch/IV form, 2: Intraoperatively, intubation in semi upright position, IV analgesics and antiemetics. 3: Postoperatively, clear liquid diet and discharge instructions. Patients were followed using a phone questionnaire. Values are median (interquartile range). RESULTS: Fifty-seven patients, 32 M (56%)/25F (44%), age 48 (35-59). First 45 were inpatient with LOS of 1 day. Last 12 were planned as same day surgery, 1/12 was discharged on POD#2, 11/12 (92%) were performed as same day surgery. The duration of operation: 139.5 min (114-163) inpatient: vs 123 (107-139) same day surgery, P < .01. Questionnaires were obtained in 78% inpatient at 40 months (25.6-67) vs 82% same day surgery at 8 (4-12). All were satisfied with the operation with no difference between the 2 groups. CONCLUSION: Heller myotomy can be planned as same day surgery and performed successfully in majority of patients with a trained team and an Enhanced Recovery After Surgery protocol focused on prevention of nausea, and pain control in perioperative period.

Plasma DNA as a molecular marker for completeness of resection and recurrent disease in patients with esophageal cancer.

OBJECTIVE: To identify a marker for completeness of resection and recurrent disease in patients with esophageal cancer. DESIGN: Case series. SETTING: Department of Surgery of the University of Southern California. PATIENTS: Forty-four healthy subjects and 45 patients with esophageal cancer prior to esophagectomy. Six patients were unresectable and 39 had a complete resection. MAIN OUTCOME MEASURES: Plasma DNA levels were measured using polymerase chain reaction. Twenty resected patients had follow-up plasma DNA levels measured. RESULTS: Preoperatively, plasma DNA levels exceeded the normal level in 38 (84%) of 45 patients. Preoperatively, 12 patients received neoadjuvant therapy and 11 had plasma DNA levels higher than normal. All 6 unresectable patients had DNA levels higher than normal. At initial follow-up, the plasma DNA levels remained higher than normal in 2 (10%) of 20 patients, and systemic disease was subsequently detected in each. Plasma DNA levels dropped lower than or remained normal in 18 (90%) of 20. In 14 of 18 patients, there was no evidence of recurrent disease at a median of 12 months (range, 3-20 months); in 4 patients, the plasma DNA level rose higher than normal on follow-up and all developed subsequent systemic disease on computed tomographic or positron emission tomographic scan. Six of the 20 patients developed systemic disease during the follow-up (2 had persistently elevated plasma DNA levels, and 4 developed elevated plasma DNA levels at subsequent follow-ups). In 4 of these 6 patients, elevated plasma DNA levels were detected prior to imaging evidence of disease. CONCLUSIONS: Plasma DNA levels are significantly elevated in patients with esophageal cancer and following complete resection should return to normal. Persistently elevated plasma DNA levels after resection or levels that rise on follow-up indicate residual or recurrent disease.

Characteristics, length of stay, and hospital bills associated with severe odontogenic infections in Houston, TX.

BACKGROUND: There were 2 main purposes of this retrospective chart review study. The first was to describe the demographic, social, and financial characteristics of patients with severe odontogenic infections. The second was to assess the relationships among several demographic, social, and treatment variables and length of stay (LOS) in the hospital and hospital bill (charges). METHODS: The authors conducted a retrospective chart review for patients admitted to the hospital and taken to the operating room for treatment of severe odontogenic infections at 3 hospitals in Houston, TX (Ben Taub, Memorial Hermann Hospital, and Lyndon B. Johnson) from January 2010 through January 2015. RESULTS: The authors included data from severe odontogenic infections in 298 patients (55% male; mean age, 38.9 years) in this study. In this population, 45% required admission to the intensive care unit, and the mean LOS was 5.5 days. Most patients (66.6%) were uninsured. The average cost of hospitalization for this patient population was $13,058, and the average hospital bill was $48,351. At multivariable analysis, age (P = .011), preadmission antibiotic use (P = .012), diabetes mellitus (P = .004), and higher odontogenic infection severity score (P < .001) were associated with increased LOS. Higher odontogenic infection severity score, diabetes mellitus, and an American Society of Anesthesiologists score of 3 or more were associated with an increased charge of hospitalization. CONCLUSIONS: Severe odontogenic infections were associated with substantial morbidity and cost in this largely unsponsored patient population. The authors identified variables associated with increased LOS and charge of hospitalization. PRACTICAL IMPLICATIONS: Clinicians should consider these findings in their decision-making processes and prioritize early treatment of odontogenic infections potentially to decrease the number of patients admitted to the hospital, LOS, and overall costs of treatment for these infections.

Laparoscopic Repair of Large Hiatal Hernia Without the Need for Esophageal Lengthening With Low Morbidity and Rare Symptomatic Recurrence.

The aim of this study was to assess symptomatic recurrence in patients who underwent a laparoscopic repair of large hiatal hernia without an esophageal lengthening procedure. Patients who underwent a laparoscopic repair of a large hiatal hernia from September 2009 to September 2015 by a single surgeon were identified in the retrospective review. The patients were followed up prospectively by the operating surgeon using a structured questionnaire, administered by telephone, to assess the symptoms. Symptomatic recurrence was defined as the requirement for a reoperative procedure for symptomatic recurrent hiatal hernia. There were 215 laparoscopic repairs. Reoperations (n = 35) and type I hernias of <4 cm (n = 49) were excluded. The study population included 131 patients: 36 had type I hernia, 4 had type II hernia, 37 had type III hernia, and 54 had type IV hernia. There were 102 women and 29 men, aged 63 (56-74) years. For repair, 102 Toupet, 28 Nissen, and 1 Dor fundoplications were performed. The duration of the operation was 138 (119-172) minutes. Adequate esophageal length was obtained by mediastinal esophageal mobilization in all patients, without Collis gastroplasty. A mesh was used in 106 patients. There was 1 conversion and 2 delayed esophageal leaks. The length of stay was 2 (1-3) days. Perioperative complications included atrial fibrillation in 5 patients, gastric distension or ileus in 5 patients, reintubation in 3 patients, heparin-induced thrombocytopenia in 1 patient, and temporary dialysis in 1 patient. There was no 30-day or in-hospital mortality. The questionnaire was completed by 99 out of 131 patients (76%) at 24 (9-38) months; of the 99 patients, 85 (86%) were free of preoperative symptoms; 91 (92%) were satisfied with the operation; and 73 (74%) were off proton pump inhibitors. Reoperation for symptomatic recurrent hiatal hernia occurred in 8 of the 99 patients (8%), 2 in the perioperative period and 6 at 25 (8-31) months. Laparoscopic repair of large hiatal hernia can be performed with low morbidity and results in excellent patient satisfaction. Tension-free, intra-abdominal esophageal length can be achieved laparoscopically without Collis gastroplasty. Reoperation for symptomatic recurrence is rare.

Laparoscopic Reoperative Antireflux Surgery Is More Cost-Effective than Open Approach.

BACKGROUND: We previously reported on the outcomes of laparoscopic and open reoperative antireflux surgery. The aim of this study was to compare the costs of these procedures. STUDY DESIGN: We performed a retrospective review. Financial and procedure coding data were obtained using a cost accounting system. There were 49 procedures in 46 patients (36 female and 10 male). There were 38 laparoscopic (including 4 conversions) and 11 open procedures (7 transabdominal repairs and 4 gastric-preserving Roux-en-Y esophagojejunostomy). Values are median and interquartile range (IQR) and mean costs. RESULTS: Median age was 54 years (IQR 49 to 67 years) for the laparoscopic group vs 56 years (IQR 50 to 65 years) for the open group (p = 0.675). Mean direct costs per case for the laparoscopic group vs open group were $12,655 vs $24,636 (p < 0.002); operating room costs: $3,788 vs $5,547 (p = 0.011); hospital room costs: $1,948 vs $6,438 (p < 0.005); and supply costs: $4,386 vs $5,386 (p = 0.077). Median duration of the operation for the laparoscopic group was 185 minutes (IQR 147 to 254 minutes) vs 308 minutes (IQR 259 to 416 minutes) for the open group (p < 0.002). Median length of stay for the laparoscopic group was 3 days (IQR 2 to 4 days) vs 9 days (IQR 8 to 14 days) for the open group (p < 0.001). There was no 30-day or in-hospital mortality. Excluding the 4 Roux-en-Y procedures, direct costs for the laparoscopic group (n = 38) were $12,655 vs $23,678 for the transabdominal group (n = 7) (p = 0.035); duration of operation: 185 minutes (IQR 147 to 254 minutes) vs 292 minutes (IQR 218 to 309 minutes) (p = 0.003); and length of stay: 3 days (IQR 2 to 4 days) vs 9 days (IQR 7 to 15 days) (p = 0.017). There were 3 recurrences in the laparoscopic group. Two were repaired laparoscopically and 1 required a gastric-preserving Roux-en-Y esophagojejunostomy because the patient had undergone 2 earlier failed repairs. Including the cumulative costs of 3 recurrent hiatal hernia repairs, the driving force to reduce costs remained length of stay, manifested by the costs of the hospital rooms. CONCLUSIONS: Laparoscopic reoperative antireflux surgery is more cost-effective than open repair. The laparoscopic approach, when feasible, should be considered the surgical option for treatment of recurrent hiatal hernia in specialized esophageal centers with highly experienced surgical teams.

Empyema necessitans caused by actinomycosis: A case report.

INTRODUCTION: Pulmonary actinomycosis is an uncommon clinical entity that the practicing thoracic surgeon rarely encounters. Empyema necessitans represents an even less common presentation of this pathology, and the often indolent disease course leads to early misdiagnosis in many cases. Familiarity with the varied presentations and possible operative strategies is essential to obtaining successful outcomes. PRESENTATION OF CASE: A 56-year-old male presented with swelling and pain over the lateral chest wall. Initial imaging studies demonstrated a mass concerning for infection vs. neoplasia. Further studies were obtained to confirm the diagnosis, with rapid progression of the mass. Surgical exploration with aggressive debridement of the chest wall without thoracotomy was performed. Actinomyces was identified on final pathology, confirming the diagnosis of Actinomycosis empyema necessitans. DISCUSSION: Traditional management strategies often involve pulmonary resection in addition to extended duration antimicrobial therapy. This report describes the uncommon clinical presentation and successful management of actinomycosis empyema necessitans with early limited operative intervention. CONCLUSION: In the event of minimal pulmonary involvement and absence of lung abscess, as was seen in this case, a thoracotomy with pulmonary resection can be avoided, and antibiotic duration limited.

Laparoscopic reoperative antireflux surgery: A safe procedure with high patient satisfaction and low morbidity.

BACKGROUND: Laparoscopic reoperative antireflux surgery remains challenging and the advantages compared to an open approach remain unclear. METHODS: Retrospective chart review and follow-up questionnaire via phone. RESULTS: 50 reoperative hiatal hernia repairs were performed in 47 patients. VALUES: median and interquartile range (IQR). There were 10 males, 37 females, 55 (49-66) years. Reoperative procedures: 38 laparoscopic vs. 12 open transabdominal. Length of operation: 185 (147-254) vs. 325 (276-394) minutes (p < 0.0008). Length of stay: 3 (2-4) vs.10 (8-13) days (p < 0.0001). None required Collis gastroplasty. There was no 30-day mortality. Follow-up questionnaire was obtained in 36/45 (80%) at 21 (11-40) months (2 cancer related deaths). In all, 24/36 (67%) were free of preoperative symptoms and 33/36 (92%) were satisfied with the operation. There was no difference between the laparoscopic and open group. CONCLUSIONS: Laparoscopic reoperative antireflux surgery is a safe approach with high patient satisfaction and low morbidity. Tension-free esophageal length can be achieved laparoscopically without Collis gastroplasty. The duration of the operation and length of stay are less in the laparoscopic vs. open group. Symptomatic relief and patient satisfaction are similar in both approaches.