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BACKGROUND: Gastric cancer is the 5th most common malignancy worldwide. Surgical treatment for the disease can often be highly morbid, especially in elderly patients. The modified 5-item frailty index (mFI-5), a recently developed tool for assessing patient frailty, has been shown to be an effective predictor of post-operative outcomes in various surgical fields. This study aims to assess the utility of the mFI-5 in predicting adverse postoperative outcomes following gastrectomy for gastric cancer. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent partial or total gastrectomy for gastric cancer between 2011 and 2021. The mFI-5 score was calculated based on the presence of hypertension, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, and partially or fully dependent functional status. Patients were stratified into 3 groups according to mFI-5 score (mFI-5 = 0, mFI-5 = 1, mFI-5 ≥ 2). Univariate analysis and multivariate logistic regression were used to evaluate the association between mFI-5 score and post-operative outcomes. RESULTS: 7438 patients were identified (mFI-5 = 0: 3032, mFI-5 = 1: 2805, mFI-5 ≥ 2: 1601). mFI-5 ≥ 2 was an independent predictor of overall complications (OR 1.43, p < 0.001), serious complications (OR 1.42, p < 0.001), pneumonia (OR 1.43, p = 0.010), MI (OR 2.91, p = 0.005), and readmission within 30 days (OR 1.33, p = 0.008). Patients with higher frailty were more likely to experience unplanned intubation (OR 2.06, p < 0.001; OR 2.47, p < 0.001), failure to wean from the ventilator (OR 1.68, p = 0.003; OR 2.00, p < 0.001), acute renal failure (OR 3.25, p = 0.003; OR 3.27, p = 0.005), 30-day mortality (OR 1.73, p = 0.009; OR 1.94, p = 0.004), and non-home discharge (OR 1.34, p = 0.001; OR 1.74, p < 0.001) relative to non-frail patients. CONCLUSION: Higher frailty, as indicated by an increased mFI-5 score, raises the risk of serious post-operative complications in patients with gastric cancer undergoing gastrectomy. The mFI-5 has the potential to help identify high-risk patients and enhance pre-operative discussions and optimization.
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PURPOSE: Magnetic Sphincter Augmentation (MSA) is an FDA-approved anti-reflux procedure with comparable outcomes to fundoplication. However, most data regarding its use are limited to single or small multicenter studies which may limit the generalizability of its efficacy. The purpose of this study is to evaluate the outcomes of patients undergoing MSA vs fundoplication in a national database. MATERIALS AND METHODS: The 2017-2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Registry was utilized to evaluate patients undergoing MSA or fundoplication. Patients requiring Collis gastroplasty, paraesophageal hernia repair, and emergency cases, were excluded. Patient outcomes included overall complication rates, readmissions, reoperations, and mortality. RESULTS: A total of 7,882 patients underwent MSA (n = 597) or fundoplication (n = 7285). MSA patients were younger (51 vs 57, p < 0.001), and more often male (49.6 vs 34.3%, p < 0.001). While patients undergoing MSA experienced similar rates of reoperation (1.0 vs 2.0%, p = 0.095), they experienced fewer readmissions (2.2 vs 4.7%, p = 0.005), complications (0.6 vs 4.0%, p < 0.001), shorter mean (SD) hospital length of stay(days) (0.4 ± 4.3 vs 1.8 ± 4.6, p < 0.001) and operative time(min) (80.8 ± 36.1 vs 118.7 ± 63.7, p < 0.001). Mortality was similar between groups (0 vs 0.3%, p = 0.175). On multivariable analysis, MSA was independently associated with reduced postoperative complications (OR 0.23, CI 0.08 to 0.61, p = 0.002), readmissions (OR 0.53, CI 0.30 to 0.94, p = 0.02), operative time (RC - 36.56, CI - 41.62 to - 31.49. p < 0.001) and length of stay (RC - 1.22, CI - 1.61 to - 0.84 p < 0.001). CONCLUSION: In this national database study, compared to fundoplication MSA was associated with reduced postoperative complications, fewer readmissions, and shorter operative time and hospital length of stay. While randomized trials are lacking between MSA and fundoplication, both institutional and national database studies continue to support the use of MSA as a safe anti-reflux operation.
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Gastroplastia , Laparoscopia , Humanos , Masculino , Fundoplicatura/efeitos adversos , Fundoplicatura/métodos , Esfíncter Esofágico Inferior/cirurgia , Melhoria de Qualidade , Laparoscopia/métodos , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Fenômenos Magnéticos , Qualidade de Vida , Estudos RetrospectivosRESUMO
Magnetic sphincter augmentation (MSA) is an anti-reflux procedure with comparable outcomes to fundoplication, yet its use in patients with larger hiatal or paraesophageal hernias has not been widely reported. This review discusses the history of MSA and how its utilization has evolved from initial Food and Drug Administration (FDA) approval in 2012 for patients with small hernias to its contemporary use in patients with paraesophageal hernias and beyond.
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Esofagoplastia , Hérnia Hiatal , Estados Unidos , Humanos , Hérnia Hiatal/cirurgia , Herniorrafia , Fundoplicatura , Fenômenos MagnéticosRESUMO
BACKGROUND: Magnetic sphincter augmentation (MSA) is an effective treatment for gastroesophageal reflux disease (GERD). However, the impact of obesity on MSA outcomes is unknown. The objective of this study was to evaluate the effectiveness of MSA in patients with GERD and obesity. METHODS: A retrospective cohort study was performed of consecutive patients who underwent laparoscopic MSA at three high-volume centers from 2016 to 2019. Patients were grouped into four cohorts according to the World Health Organization body mass index (BMI) classification: BMI < 25 (normal weight), BMI 25-29.9 (overweight), BMI 30-34.9 (obese class I), and BMI > 35 (obese class II-III). Preoperative, operative, and postoperative data were compared between groups. RESULTS: A total of 621 patients underwent laparoscopic MSA during the study period. Follow-up with endoscopy or video esophagram was available for 361 patients (58%) with a median follow-up of 15.4 months. Baseline characteristics of the groups were similar except the BMI > 35 group had more females and a higher preoperative median DeMeester score. There were no significant differences in outcomes between normal weight, overweight, and obese patient groups undergoing MSA. All groups experienced significant reductions in acid suppressive medication use, low GERD-HRQL scores, low DeMeester scores, few intraoperative and postoperative complications, and low rates of hiatal hernia recurrence after MSA. CONCLUSIONS: Magnetic sphincter augmentation is safe and effective in improving GERD symptoms, reducing esophageal acid exposure, and preventing hiatal hernia recurrence, irrespective of patient BMI. MSA should be considered an acceptable treatment option for obese patients with GERD.
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Refluxo Gastroesofágico , Hérnia Hiatal , Laparoscopia , Índice de Massa Corporal , Esfíncter Esofágico Inferior/cirurgia , Feminino , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/cirurgia , Hérnia Hiatal/cirurgia , Humanos , Fenômenos Magnéticos , Obesidade/cirurgia , Sobrepeso/complicações , Sobrepeso/cirurgia , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The ratio of hernia size to fascial defect size, termed the hernia-to-neck ratio (HNR), has been proposed as a novel predictive factor for umbilical hernia complications. HNR ≥ 2.5 has been suggested to warrant surgery due to association with bowel strangulation, incarceration, and necrosis. The aim of this study was to evaluate the association between HNR and emergent ventral hernia repair at our institution. METHODS: A retrospective cohort study was performed of consecutive patients with ventral hernias evaluated at a large safety-net hospital from 2017 to 2019. Patients who required emergent ventral hernia repair were compared to patients who did not require repair at latest follow-up. HNR was calculated using a previously described method: maximal hernia sac size and maximal fascial defect size (termed "hernia neck size") were measured in the sagittal plane on CT scan. Data are described as mean ± standard deviation and median (interquartile range). RESULTS: A total of 166 patients were included: 84 (51%) required emergent hernia repair and 82 (49%) did not undergo repair. Median follow-up was 19 (8-27) months. Patient groups were similar except the emergent repair group had more males (50% vs. 34%, p = 0.03), umbilical hernias (93% vs. 56%, p < 0.01), recurrent hernias (31% vs. 15%, p < 0.01), and lower mean BMI (34.3 ± 9.9 vs. 39.1 ± 6.5, p < 0.01). Hernia sac size did not differ between groups (5.8 [3.8-8.4] cm vs. 6.1 [3.5-11.8] cm, p = 0.45). Hernia neck size was significantly smaller in the emergent repair group (1.5 [2.3-3.5] cm vs. 3.4 [1.8-6.2] cm, p < 0.01). Hernia-to-neck ratio was significantly higher in the emergent repair group (2.4 [1.8-3.1] vs. 1.7 [1.1-2.9], p < 0.01). CONCLUSION: This study demonstrated an association between higher HNR and increased risk of emergent ventral hernia repair. Future studies will evaluate the use of HNR to risk-stratify patients with ventral hernias in a safety-net hospital.
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Hérnia Umbilical , Hérnia Ventral , Laparoscopia , Masculino , Humanos , Herniorrafia , Estudos Retrospectivos , Telas Cirúrgicas , Hérnia Ventral/cirurgia , Hérnia Umbilical/cirurgia , Dor no Peito , RecidivaRESUMO
Gastroesophageal reflux disease (GERD) is steadily increasing in incidence and now affects 18% to 28% of the population in the United States. A thorough understanding of the pathophysiology underlying this disease is necessary to improve the current standard of care. Most GERD pathophysiology models focus on the lower esophageal sphincter (LES) as the key element which prevents esophageal reflux. More recent research has highlighted the crural diaphragm (CD) as an additional critical component of the GERD barrier. We now know that the CD actively relaxes when the distal esophagus is distended and contracts when the stomach is distended. Crural myotomy in animal models increases esophageal acid exposure, highlighting the CD's vital role. There are also multiple physiological studies in patients with symptomatic hiatal hernia that demonstrate CD dysfunction is associated with GERD. Finally, computer models integrating physiological data predict that the CD and the LES each contribute roughly 50% to the GERD barrier. This more robust understanding has implications for future procedural management of GERD. Specifically, effective GERD management mandates repair of the CD and reinforcement of the LES. Given the high rate of hiatal hernia recurrences, it seems that novel antireflux procedures should target this essential component of the GERD barrier. Future research should focus on methods to maintain crural integrity, decrease hiatal hernia recurrence, and improve long-term competency of the GERD barrier.
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Esofagite Péptica , Refluxo Gastroesofágico , Hérnia Hiatal , Esfíncter Esofágico Inferior , Junção Esofagogástrica , HumanosRESUMO
INTRODUCTION: Magnetic sphincter augmentation (MSA) is a safe and effective treatment for patients with gastroesophageal reflux disease (GERD). MSA was initially indicated for patients with GERD and concomitant hiatal hernias < 3 cm. However, excellent short- and intermediate-term outcomes following MSA and hiatal hernia repair in patients with hiatal hernias ≥ 3 cm have been reported. The purpose of this study is to assess long-term outcomes for this patient population. METHODS AND PROCEDURES: A retrospective review was performed of patients with GERD and hiatal hernias ≥ 3 cm who underwent MSA and hiatal hernia repair. Patients were treated at two tertiary medical centers between May 2009 and December 2016. Follow up included annual video esophagram, upper endoscopy, or both. Outcomes included pre- and post-operative GERD health-related quality of life (GERD-HRQL) scores, length and regression of Barrett's esophagus, resolution of esophagitis, need for endoscopic dilations or implant removal, and clinically significant hiatal hernia recurrence (> 2 cm) on videoesophagram or endoscopy. RESULTS: Seventy-nine patients (53% female) with a median age of 65.56 (58.42-69.80) years were included. Median follow up was 2.98 (interquartile range 1.90-3.32) years. Median DeMeester scores decreased from 42.45 (29.12-60.73) to 9.10 (3.05-24.30) (p < 0.001). Severity of esophagitis (e.g. LA class C to class B) significantly improved (p < 0.01). Forty percent of patients with Barrett's esophagus experienced regression (p < 0.01). Median GERD-HRQL scores improved from 21 to 2. Five (6.3%) hiatal hernia recurrences occurred, and 1 required re-operation. Age, body mass index, size of the initial hiatal hernia, and sex had no significant effect on whether a patient developed a recurrence. CONCLUSIONS: Magnetic sphincter augmentation in conjunction with large hiatal hernia repairs for patients with GERD achieves excellent long-term radiographic and clinical results, and a low overall need for reoperation, without the need for mesh.
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Hérnia Hiatal , Laparoscopia , Idoso , Esfíncter Esofágico Inferior/cirurgia , Feminino , Hérnia Hiatal/cirurgia , Herniorrafia , Humanos , Fenômenos Magnéticos , Masculino , Recidiva Local de Neoplasia , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Initial adoption of minimally invasive esophagectomy (MIE) began in the late 1990s but its surgical technique, perioperative management, and outcome continues to evolve. METHODS: The aim of this study was to examine the evolving changes in the technique, outcome, and new strategies in management of postoperative leaks after MIE was performed at a single institution over a two-decade period. A retrospective chart review of 75 MIE operations was performed between November 2011 and September 2018 and this was compared to the initial series of 104 MIE operations performed by the same group between 1998 and 2007. Operative technique, outcomes, and management strategies of leaks were compared. RESULTS: There were 65 males (86.7%) with an average age of 61 years. The laparoscopic/thoracoscopic Ivor Lewis esophagectomy became the preferred MIE approach (49% of cases in the initial vs. 95% in the current series). Compared to the initial case series, there was no significant difference in median length of stay (8 vs. 8 days), major complications (12.5% vs. 14.7%, p = 0.68), incidence of leak (9.6% vs. 10.6%, p = 0.82), anastomotic stricture (26% vs. 32.0%, p = 0.38), or in-hospital mortality (2.9% vs. 2.6%, p = 0.47). Management of esophageal leaks has changed from primarily thoracotomy ± diversion initially (50% of leak cases) to endoscopic stenting ± laparoscopy/thoracoscopy currently (87.5% of leak cases). CONCLUSION: In a single-institutional series of MIE over two decades, there was a shift toward a preference for the laparoscopic/thoracoscopic Ivor Lewis approach with similar outcomes. The management of postoperative leaks drastically changed with predilection toward minimally invasive option with endoscopic drainage and stenting.
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Doenças do Esôfago/cirurgia , Esofagectomia/tendências , Laparoscopia/tendências , Toracoscopia/tendências , Adulto , Idoso , Fístula Anastomótica/etiologia , Esofagectomia/métodos , Feminino , Mortalidade Hospitalar/tendências , Humanos , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Estudos Retrospectivos , Toracoscopia/métodos , Resultado do TratamentoRESUMO
OBJECTIVE: The objectives of this study were (i) to evaluate infants with congenital diaphragmatic hernia (CDH) that do not undergo repair, (ii) to identify nonrepair rate by institution, and (iii) to compare institutional outcomes based on nonrepair rate. BACKGROUND: Approximately 20% of infants with CDH go unrepaired and the threshold to offer surgical repair is variable. METHODS: Data were abstracted from a multicenter, prospectively collected database. Standard clinical variables, including repair (or nonrepair), and outcome were analyzed. Institutions were grouped based on volume and rate of nonrepair. Preoperative mortality predictors were identified using logistic regression, expected mortality for each center was calculated, and observed /expected (O/E) ratios were computed for center groups and compared by Kruskal-Wallis ANOVA. RESULTS: A total of 3965 infants with CDH were identified and 691 infants (17.5%) were not repaired. Nonrepaired patients had lower Apgar scores (P < 0.05) and increased incidence of anomalies (P < 0.0001). Low-volume centers ("Lo", n=44 total, < 10 CDH pts/yr) and high-volume centers ("Hi", n = 21) had median nonrepair rates of 19.8% (range 0%-66.7%) and 16.7% (5.1%-38.5%), respectively. High-volume centers were further dichotomized by rate of nonrepair (HiLo = 5.1-16.7% and HiHi = 17.6-38.5%), leaving 3 groups: HiLo, HiHi, and Lo. Predictors of mortality were lower birth weight, lower Apgar scores, prenatal diagnosis, and presence of congenital anomalies. O/E ratios for mortality in the HiLo, HiHi, and Lo groups were 0.81, 0.94, and 1.21, respectively (P < 0.0001). For every 100 CDH patients, HiLo centers have 2.73 (2.4-3.1, 95% confidence interval) survivors beyond expectation. CONCLUSIONS: There are significant differences between repaired and nonrepaired CDH infants and significant center variation in rate of nonrepair exists. Aggressive surgical management, leading to a low rate of nonrepair, is associated with improved risk-adjusted mortality.
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Previsões , Hérnias Diafragmáticas Congênitas/cirurgia , Herniorrafia/métodos , Sistema de Registros , Feminino , Seguimentos , Hérnias Diafragmáticas Congênitas/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To determine the incremental cost-effectiveness of a clinical practice guideline (CPG) compared with "usual care" for treatment of perforated appendicitis in children. Secondary objective was to compare cost analyses using hospital accounting system data versus data in the Pediatric Health Information System (PHIS). BACKGROUND: Value-based surgical care (outcomes relative to costs) is frequently touted, but outcomes and costs are rarely measured together. METHODS: During an 18-month period, 122 children with perforated appendicitis at a tertiary referral children's hospital were treated using an evidence-based CPG. Clinical outcomes and costs for the CPG cohort were compared with patients in the 30-month period before CPG implementation (n = 191 children). RESULTS: With CPG-directed care, intra-abdominal abscess rate decreased from 0.24 to 0.10 (adjusted risk ratio 0.44, 95% confidence interval [CI] 0.26-0.75). The rate of any adverse event decreased from 0.30 to 0.23 (adjusted risk ratio 0.82, 95% CI 0.58-1.17). Mean total hospital costs per patient (hospital accounting system) decreased from $16,466 to $10,528 (adjusted absolute difference-$5451, 95% CI -$7755 to -$3147), leading to estimated adjusted total savings of $665,022 during the study period. Costs obtained from the PHIS database also showed reduction with CPG-directed care (-$6669, 95% CI -$8949 to -$4389 per patient). In Bayesian cost-effectiveness analyses, likelihood that CPG was the dominant strategy was 91%. CONCLUSIONS: An evidence-based CPG increased the value of surgical care for children with perforated appendicitis by improving outcomes and lowering costs. Hospital cost accounting data and pre-existing cost data within the PHIS database provided similar results.
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Apendicectomia , Apendicite/cirurgia , Guias de Prática Clínica como Assunto , Abscesso Abdominal/etiologia , Abscesso Abdominal/prevenção & controle , Antibacterianos/uso terapêutico , Apendicectomia/efeitos adversos , Apendicite/complicações , Criança , Redução de Custos , Análise Custo-Benefício , Feminino , Custos Hospitalares , Humanos , Perfuração Intestinal/etiologia , Perfuração Intestinal/cirurgia , Masculino , Complicações Pós-OperatóriasRESUMO
BACKGROUND: Institutional protocols for preincisional antibiotic prophylaxis can standardize care and improve outcomes. However, challenges remain in compliance with such protocols for urgent or emergent operations. We hypothesized that compliance with an institutional protocol for antibiotic prophylaxis for appendectomy for appendicitis in pediatric patients results in reduced surgical site infections (SSIs) after simple appendectomy. METHODS: This retrospective study assessed all pediatric patients (≤18 y) who underwent appendectomy for confirmed simple appendicitis at a tertiary children's hospital between 2012 and 2015. Demographic, admission, and outcome data were recorded. Compliance with the protocol was assessed. Univariate analyses were performed to identify factors associated with any SSI and protocol noncompliance. RESULTS: Overall compliance with antibiotic prophylaxis occurred in 590 of 697 patients (85%). Compliance was high with timing (91%), spectrum (95%), and protocol-recommended drug (87%). Admission antibiotics alone were administered in 65 patients (9%), preincisional antibiotics alone in 254 patients (36%), and both in 378 patients (55%). Patients included in the analysis received a median of 2 (range 1-6) doses of antibiotics preoperatively. Ten patients (1.4%) developed an SSI. Only receipt of any antibiotics within an hour of incision was associated with decreased odds of SSI (odds ratio 0.22, 95% confidence interval 0.06-0.87). No factors were associated with noncompliance. CONCLUSIONS: An institutional appendicitis protocol yields high compliance with prophylactic antibiotic administration and associated low SSI rates, but at a cost of antibiotic over-administration. Further efforts are necessary to sustain compliance while also practicing appropriate antibiotic stewardship.
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Antibacterianos/uso terapêutico , Antibioticoprofilaxia/estatística & dados numéricos , Apendicectomia , Apendicite/cirurgia , Fidelidade a Diretrizes/estatística & dados numéricos , Cuidados Pré-Operatórios/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Antibioticoprofilaxia/normas , Cefepima , Cefalosporinas/uso terapêutico , Criança , Pré-Escolar , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Metronidazol/uso terapêutico , Ácido Penicilânico/análogos & derivados , Ácido Penicilânico/uso terapêutico , Piperacilina/uso terapêutico , Combinação Piperacilina e Tazobactam , Guias de Prática Clínica como Assunto , Cuidados Pré-Operatórios/normas , Cuidados Pré-Operatórios/estatística & dados numéricos , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/epidemiologia , Resultado do TratamentoRESUMO
OBJECTIVE: To assess the impact of socioeconomic status (SES) on pediatric appendicitis outcomes using the validated Agency for Healthcare Research and Quality (AHRQ) SES Index and incorporating block-group data. STUDY DESIGN: We reviewed all patients <18 years old who underwent appendectomy for acute appendicitis from 2009-2013 at our institution. Patient addresses were geocoded and linked to 2010 US Census SES block-group data to determine composite AHRQ SES Index scores based on 7 publically reported SES variables. The primary outcome was appendiceal perforation, and the impact of SES scores, age, race, and insurance status on perforation rates were assessed through regression analyses. RESULTS: Of 1501 patients, 510 (34%) had perforated appendicitis. On bivariate analysis, components of the SES Index associated with an increased perforation rate included lower household income, lower percentage of adults with college education, and higher percentage of adults with <12th grade education (all P < .05). On multivariate analysis, age ≤ 10 years (OR 1.7, 95% CI 1.4-2.2) and public insurance (OR 1.5, 95% CI 1.2-2.0) were associated with increased odds of perforation. CONCLUSIONS: This study used the AHRQ SES scoring system to evaluate SES and its influence on appendiceal perforation. Among our cohort of pediatric patients, the risk of perforation was multifactorial, and younger age and public insurance were stronger predictors of perforation than SES.
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Apendicectomia , Apendicite/cirurgia , Classe Social , Adolescente , Fatores Etários , Apendicite/epidemiologia , Censos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Assistência Médica/estatística & dados numéricos , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Infecção da Ferida Cirúrgica , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Intestinal malrotation can lead to volvulus resulting in necrosis, sepsis, and death. For symptomatic patients, treatment includes the Ladd procedure. However, debate remains regarding the timing and need for intervention for asymptomatic infants. We evaluated our experience with Ladd procedures including a clinical practice of prophylactic surgery for asymptomatic patients. MATERIALS AND METHODS: A retrospective review of pediatric patients undergoing the Ladd procedure was performed. Prophylactic Ladd procedures were identified as those occurring before any malrotation-related symptoms. Results were analyzed with student t test, Mann-Whitney U, and chi-squared tests. RESULTS: From 2011-2014, 42 patients (prophylactic = 19, symptomatic = 23) underwent the Ladd procedure. The median age (IQR, interquartile range) of patients was 9.6 (3.9-18) mo and 18 (2.4-52) mo for prophylactic and symptomatic patients, respectively (P = 0.38). In patients who underwent symptomatic Ladd procedures, nine (39%) had volvulus and one (4.3%) had bowel necrosis at time of surgery. No prophylactic Ladd procedure patients required reoperation, whereas six (26%) symptomatic patients required malrotation-related reoperations (P = 0.02). Median (IQR) days to full enteral feeds were 5.0 d (3.3-6.8) versus 7.4 (5.0-11; P = 0.11), whereas median days to discharge were 8.0 d (6.1-11) versus 11 d (7.5-32) until discharge (P = 0.09) for prophylactic and symptomatic patients, respectively. CONCLUSIONS: Although symptomatic patients represent sicker children, the postoperative complications appear to be higher. For infants with known malrotation, prophylactic operations may be beneficial and should be considered. A larger, prospective study to demonstrate effectiveness and generalizability for prophylactic Ladd procedure is warranted.
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Procedimentos Cirúrgicos do Sistema Digestório/métodos , Obstrução Intestinal/prevenção & controle , Volvo Intestinal/cirurgia , Doenças Assintomáticas , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Obstrução Intestinal/etiologia , Volvo Intestinal/complicações , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Effective communication and patient safety practices are paramount in health care. Surgical residents play an integral role in the perioperative team, yet their perceptions of patient safety remain unclear. We hypothesized that surgical residents perceive the perioperative environment as more unsafe than their faculty and operating room staff despite completing a required safety curriculum. MATERIALS AND METHODS: Surgeons, anesthesiologists, and perioperative nurses in a large academic children's hospital participated in multifaceted, physician-led workshops aimed at enhancing communication and safety culture over a 3-y period. All general surgery residents from the same academic center completed a hospital-based online safety curriculum only. All groups subsequently completed the psychometrically validated safety attitudes questionnaire to evaluate three domains: safety culture, teamwork, and speaking up. Results reflect the percent of respondents who slightly or strongly agreed. Chi-square analysis was performed. RESULTS: Sixty-three of 84 perioperative personnel (75%) and 48 of 52 surgical residents (92%) completed the safety attitudes questionnaire. A higher percentage of perioperative personnel perceived a safer environment than the surgical residents in all three domains, which was significantly higher for safety culture (68% versus 46%, P = 0.03). When stratified into two groups, junior residents (postgraduate years 1-2) and senior residents (postgraduate years 3-5) had lower scores for all three domains, but the differences were not statistically significant. CONCLUSIONS: Surgical residents' perceptions of perioperative safety remain suboptimal. With an enhanced safety curriculum, perioperative staff demonstrated higher perceptions of safety compared with residents who participated in an online-only curriculum. Optimal surgical education on patient safety remains unknown but should require a dedicated, systematic approach.
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Cirurgia Geral/estatística & dados numéricos , Internato e Residência/estatística & dados numéricos , Segurança do Paciente , Atitude do Pessoal de Saúde , HumanosRESUMO
PURPOSE: Following laparoscopic anti-reflux surgery (LARS), recurrence of hiatal hernia is common. Patients with symptomatic recurrence typically undergo revision of the fundoplication or conversion to magnetic sphincter augmentation (MSA) in addition to cruroplasty. However, patients with an intact fundoplication or MSA may only require repeat cruroplasty to repair their recurrent hiatal hernia. The purpose of this study is to compare outcomes following cruroplasty alone compared to full revision (i.e. redo fundoplication or MSA with cruroplasty) for the management of recurrent hiatal hernias. METHODS: A retrospective review of patients undergoing surgical revision of a symptomatic recurrent hiatal hernia between February 2009 and October 2022 was performed. Preoperative characteristics, intraoperative details, and postoperative outcomes were compared between patients undergoing cruroplasty alone versus full revision. RESULTS: A total of 141 patients were included in the analysis. 93 patients underwent full revision, and 48 patients underwent cruroplasty alone. The mean time between initial and revisional surgery was 8 ± 7.7 years. There was no significant difference in operative time or rates of intra-operative or post-operative complication between groups. Patients undergoing cruroplasty alone had a mean Gastroesophageal Reflux Disease Health Related Quality Life (GERD-HRQL) Questionnaire score of 9.6 ± 10.2 compared to a mean score of 8.9 ± 11.2 for full revision patients (p = 0.829). Recurrence rates following revision was 10.4% for cruroplasty alone patients and 11.8% in full revision patients (p > 0.999). CONCLUSION: In patients with intact fundoplication or MSA, cruroplasty alone results in similar post-operative outcomes compared to full revision for recurrent hiatal hernia.
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BACKGROUND: Minimally invasive approaches to esophagectomy have gained popularity worldwide; however, unplanned conversion to an open approach is not uncommon. This study sought to investigate risk factors associated with converting to an open approach and to evaluate outcomes following conversion. METHODS: Patients undergoing minimally invasive esophagectomy (MIE) for cancer were identified using the 2016-2019 Procedure Targeted NSQIP Database. Multivariable, stepwise logistic regression analysis was performed to investigate factors associated with unplanned conversion to open esophagectomy. Propensity-matched comparison of robotic (RAMIE) to traditional MIE was performed. RESULTS: A total of 1347 patients were included; 140 patients (10%) underwent conversion to open. Morbid obesity, diabetes, hypertension, American Society of Anesthesiologists class, and squamous cell carcinoma were associated with a higher likelihood of conversion. A robotic approach was associated with a lower likelihood of conversion to open (OR .57, 95% CI 0.32-.99). On multivariable analysis, squamous cell carcinoma pathology was the only variable independently associated with higher odds of conversion (OR 2.66, 95% CI 1.02-6.98). Propensity-matched comparison of RAMIE vs MIE showed no significant difference in conversion rate (6.5% vs 9.1%, P = .298), morbidity, or mortality. DISCUSSION: A robotic approach to esophagectomy was associated with a lower likelihood of unplanned conversion to open, and patients who were converted to open experienced worse outcomes. Future studies should aim to determine why a robotic esophagectomy approach may lead to fewer open conversions as it may be an underappreciated benefit of this newest operative approach.
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Neoplasias Esofágicas , Esofagectomia , Procedimentos Cirúrgicos Robóticos , Humanos , Estudos Retrospectivos , Carcinoma de Células Escamosas/cirurgia , Procedimentos Cirúrgicos Minimamente InvasivosRESUMO
INTRODUCTION: Although mortality rates after esophagectomy have decreased over the last 30 years, anastomotic leaks still commonly persist and portend significant morbidity. Previous studies have analyzed patient and perio-perative risk factors for leaks, yet data describing the association of leaks and an open or minimally invasive approach are lacking. The purpose of this study was to evaluate the impact of operative approach on leak rates and subsequent management of the leaks. METHODS: We queried the Procedure-Targeted National Surgical Quality Improvement Program Database for patients undergoing esophagectomy for cancer in the years from 2016 to 2019. Patient demographics, disease-related information, peri-operative data, and short-term outcomes were reviewed. Multivariable, stepwise logistic regression analysis was performed to investigate factors associated with post-operative anastomotic leaks. RESULTS: Of the 2696 patients who underwent esophagectomy for cancer, anastomotic leaks occurred in 374 (14%). Based on approach, 13% of open, 14% of laparoscopic, and 18% of robotic cases were complicated by leak (P = .123). Multivariable analysis identified the following significant risk factors for leak: diabetes (OR 1.32, P = .047), hypertension (OR 1.32, P = .022), and longer operative time (OR 1.61, P < .001). The percentage of leaks requiring endoscopic or operative intervention was 75% for open, 79% for laparoscopic, and 54% for robotic cases (P = .004). CONCLUSIONS: Anastomotic leaks after esophagectomy for cancer occur frequently regardless of surgical approach. Furthermore, these leaks are managed differently after an open, laparoscopic, or robotic approach. Robotic esophagectomies complicated by anastomotic leak required less invasive management.
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Neoplasias Esofágicas , Procedimentos Cirúrgicos Robóticos , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/epidemiologia , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Neoplasias Esofágicas/etiologia , Neoplasias Esofágicas/cirurgia , Esofagectomia/efeitos adversos , Humanos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Resultado do TratamentoRESUMO
Despite recognizing the occurrence of variances, we noted a low rate of reporting with the established computer variance program. Therefore, we developed and introduced a simple, handwritten variance reporting system. The goal of this study was to compare our pediatric perioperative handwritten variance cards to our established computerized variance reporting system. METHODS: We developed a handwritten variance card program through a stakeholder-driven quality-improvement initiative. We collected variances from handwritten cards in 4 perioperative locations and also from the established computerized variance system. We analyzed the variances and categorized them into 6 safety domains and 5 variance categories. RESULTS: Over 6 consecutive years, 3,434 variances were reported (687 computerized and 2,747 handwritten). For safety domains, the computerized system was more likely to capture adverse events and near-misses (8.7% vs. 1.1%, P < 0.001; 23.5% vs. 8.6%, P < 0.001, respectively) while the handwritten system was more likely to identify the safety process and other non-safety issues (20.1% vs. 38.3%, P < 0.001). Both systems addressed policy/process issues most often, with 37.9% of the handwritten cards and 66.6% of the computerized variance reports. Of the handwritten cards with a patient identifier (n = 1,407), only 5.1% (n = 72) also had a computerized variance filed about the same event. Thus, staff reported >1,300 additional variances that were not identified with the computerized variance system alone. CONCLUSION: The handwritten, stakeholder-driven variance reporting system was essential to identify local and system issues that would not have been identified by the computerized variance reporting system alone.
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BACKGROUND/PURPOSE: The purpose of this study was to describe the outcomes of children with and without congenital heart disease who undergo a Ladd procedure. METHODS: The 2012-2014 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data were queried for patients undergoing a Ladd procedure. Utilizing NSQIP-P definitions, patients were categorized into four cardiac risk groups (none, minor, major, severe) based on severity of cardiac anomalies, previous cardiac procedure(s), and ongoing cardiac dysfunction. Ladd procedures were elective/non-elective. Outcomes included length of stay, adverse events, and mortality. RESULTS: 878 patients underwent Ladd procedures. 633 (72%) patients had no cardiac risk factors and 84 (10%), 109 (12%), and 52 (6%) had minor, major, and severe cardiac risk factors, respectively. Children with congenital heart disease experienced increased morbidity and mortality and longer hospital stays (all p<0.05). Elective Ladd procedures were associated with similar morbidity but shorter length of stay and lower mortality than non-elective procedures. Older age at time of operation was associated with fewer adverse events. CONCLUSIONS: Although overall mortality remains low, children with higher risk cardiac disease experience increased morbidity and mortality when undergoing a Ladd procedure. Older age at the time of the Ladd procedure was associated with improved outcomes in children.