Transhiatal versus transthoracic esophagectomy for esophageal cancer: a 2005-2011 NSQIP comparison of modern multicenter results.

BACKGROUND: The surgical approach to esophageal cancer continues to be controversial. A transthoracic approach is often advocated for better oncologic staging and improved survival. A transhiatal approach is often preferred due to a perceived decreased operative morbidity and mortality. METHODS: Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-use file, patients were identified who underwent either a transhiatal or transthoracic esophagectomy for cancer at participating hospitals from 2005 to 2011. Demographic, clinical, intra-operative variables, and 30-day morbidity and mortality were collected. RESULTS: Of the 1,428 patients that had esophagectomy, 750 (52.5%) had a transhiatal (TH) resection and 678 (47.5%) had a transthoracic (TT) resection. The transhiatal group was older (66 vs. 63 years, P = 0.003) with a lower ASA class (2.84 vs. 2.91, P = 0.025). Operative time was greater in the TT group (364 vs. 298 min, P < 0.001). There was no significant difference in 30 day overall mortality (TH = 2.9%, TT = 4.7%, P = 0.095) however a trend favored the TH group. Serious morbidity remains clinically significant in both groups (TH = 39.6%, TT = 43.5%, P = 0.146). The TH group had a significantly higher superficial wound infection rate (11.6% vs. 6.2%, P < 0.001) while the TT group required more perioperative blood transfusions (12.5% vs. 8.9%, P = 0.032) and returns to operating room (14.5% vs. 10.9%, P = 0.046). CONCLUSION: Serious morbidity continues to be high for both types of esophagectomy. There needs to be continued efforts to diminish these complications.

Elective laparoscopic versus open colectomy for diverticulosis: an analysis of ACS-NSQIP database.

BACKGROUND: The benefits of laparoscopic (LC) versus open (OC) colectomy for symptomatic colonic diverticulosis as an elective operation remain unclear. METHODS: Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-user file, patients were identified who underwent elective colon resection for symptomatic colonic diverticulosis, between 2005 and 2008. Demographic, clinical, intraoperative variables, and 30-day morbidity and mortality were collected. Logistic regression analysis was performed to determine the association between the surgical approach (LC vs. OC) and risk-adjusted overall mortality, overall morbidity, serious morbidity, and wound complications. RESULTS: A total of 7,629 patients were identified who underwent colon resection for symptomatic diverticulosis. They were subdivided into two groups: OC (3,870 (50.7%)) and LC (3,759 (49.3%)). Patients who underwent OC were significantly older (59.0 vs. 55.7 years, P < 0.0001) with more comorbidities compared with those who underwent LC. After risk-adjusted analysis, it was noted that the patients treated with LC were significantly less likely to experience overall morbidity (11.9% vs. 23.2%), serious morbidity (4.6% vs. 10.9%), and wound complications (9.1% vs. 17.5%), but not mortality (0.3% vs. 0.8%). Operative duration was significantly longer with LC (176.64 vs. 166.70 min, P < 0.0001), but the length of stay was significantly shorter (4.77 vs. 7.68 days, P < 0.0001). Using logistic regression analysis, patients with history of peripheral vascular disease, percutaneous coronary interventions, current steroid use, and hypertension requiring medication were at an increased risk of morbidity and mortality at 30 days. Patients with history of chronic obstructive pulmonary disease and smoking experienced more wound complications at 30 days. CONCLUSIONS: In the elective setting for symptomatic diverticulosis, LC seems to be associated with lower 30-day morbidity and complication rates compared with OC.

Are laparoscopic bariatric procedures safe in superobese (BMI ≥50 kg/m2) patients? An NSQIP data analysis.

BACKGROUND: The safety of laparoscopic bariatric procedures in superobese patients is still debatable. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program's participant-use file, the patients who had undergone laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding for morbid obesity were identified. Several perioperative variables, including 30-day morbidity and mortality, were collected, and the data were compared within each procedure after dividing the patients according to the body mass index: <50 kg/m(2) (morbidly obese group and ≥50 kg/m(2) (superobese group). RESULTS: A total of 29,323 patients who had undergone laparoscopic bariatric procedures from 2005 to 2008 were identified. Overall, compared with the morbidly obese group, the superobese group had more men (3:2), younger patients, a greater incidence of co-morbidities (e.g., hypertension and dyspnea), a significantly increased length of stay, and a greater rate of 30-day mortality (.26% versus .07%, odds ratio [OR] 4.38, P = .0001). In the gastric bypass group, the superobese group had a significantly greater incidence of postoperative complications, including superficial wound infections (2.45%, OR 1.68, P = .0001), reintubation (.61%, OR 1.97, P = .003), pulmonary embolism (.30%, OR 2.13, P = .032), myocardial infarction (.07%, P = .017), deep vein thrombosis (.49%, OR 2.06, P = .006), septic shock (.44%, OR 1.74, P = .04), and 30-day mortality (.28%, OR 2.26, P = .026). In the laparoscopic adjustable gastric banding group, the superobese group had a significantly greater incidence of postoperative complications, including superficial (1.65%, OR 2.18, P = .0013) and deep (.23%, OR 2.56, P = .035) wound infections, sepsis, septic shock and 30-day mortality (.17%, OR 13.4, P = .0219). CONCLUSION: Laparoscopic bariatric procedures in superobese patients have been associated with significantly increased complications, including 30-day mortality, compared with morbidly obese patients. However, overall, the procedures appear to be safe, with low complication and 30-day mortality rates.