Adult pectus excavatum repair: national outcomes of the Nuss and Ravitch procedures.

BACKGROUND: National data is limited on pectus excavatum, the most common chest wall deformity which is often repaired using the Ravitch and Nuss procedures. The purpose of the study was to describe demographics and outcomes of adult patients who underwent surgical repair of pectus excavatum via open and minimally invasive thoracoscopic methods. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2018 was performed, capturing patients 18 years or older with pectus excavatum as the postoperative diagnosis. Patients were placed into two groups of minimally invasive (Nuss) and open (Ravitch) repair procedure code. Baseline characteristics and postoperative outcomes were analyzed. RESULTS: A total of 168 adult patients were captured. Most of these patients were white (84.52%) male (69.64%) and 26 years old on average. Median operative time was longer in the open repair group [250 (IQR, 173-308) versus 122 (IQR, 94-160) minutes, P<0.0001]. Median length of stay was five days (IQR, 4-6) in the open group and three days (IQR, 2-4) in the minimally invasive group (P=0.2873). CONCLUSIONS: Complications after repair of pectus excavatum occur at similar rates between open and minimally invasive repair. Though minimally invasive repair decreases operative time and may decrease length of stay, the decision of type of procedure depends upon clinical scenario and factors unique to the individual patient.

Congenital Diaphragmatic Hernia: Demographics and 30-day Outcomes in Adults.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a pathology most often affecting the pediatric population, although adults can also be affected. Few studies exist of adults undergoing repair of this defect. Using a national database, we sought to determine demographics and outcomes of this population. METHODS: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2015-2018) was performed, capturing patients with postoperative diagnosis of CDH, distinct from ventral hernia. Two groups were created based upon surgical approach of open or minimally invasive (MIS) repair. Baseline demographics and outcomes were compared. RESULTS: 110 patients undergoing surgical correction of CDH were captured in the database. We found rates of return to the operating room (4.55%), postoperative respiratory failure (5.45%), and reintubation (3.64%) with no difference between groups. There was no mortality and no difference between groups in length of operation, discharge to home, or postoperative complications. Patients undergoing open repair had a longer length of stay than patients in the MIS group (6.47 ± 10.76 days vs. 3.68 ± 3.74 days, P = .0471). Mesh was used in MIS more often than the open group (47.30% vs. 5.56%, P < .0001). DISCUSSION: This study describes rates of postoperative complications in patients undergoing repair of CDH, and suggests outcomes those are equivalent between patients receiving open or MIS approaches. Further case series or retrospective studies are needed to further describe this population of patients.

Testicular torsion in adults: Demographics and 30-day outcomes after orchiopexy or orchiectomy.

BACKGROUND: Most often studied in the pediatric population, testicular torsion also affects the adult male population. Little data exists on demographics, patient risk factors, and associated outcomes for the surgical management of testicular torsion. This study sought to describe differences in demographics and outcomes for those patients requiring orchiopexy or orchiectomy. MATERIALS AND METHODS: An analysis of the American College of Surgeons National Surgical Quality Improvement Program database (2015-2018) was performed, capturing patients with a postoperative diagnosis of testicular torsion. Patients were stratified into 2 groups if they received orchiopexy or orchiectomy. Demographics, perioperative variables, surgeon specialty, and outcomes were analyzed. RESULTS: A total of 769 patients undergoing surgical treatment of testicular torsion were captured. Most of these patients were White (46.81%) and young adults (28.33 ±â€Š12.04 years) and 28.8% required orchiectomy. Those undergoing orchiectomy were more likely to be older, have more comorbidities, and have a systemic inflammatory response syndrome. Mean operative time was longer in the orchiectomy group (48 ±â€Š23 vs. 44 ±â€Š20 minutes, p < 0.0124). There were no deaths at 30 days. Length of stay and rate of superficial wound infection were higher in the orchiectomy group and discharge to home was more likely in the orchiopexy group. CONCLUSIONS: Adult testicular torsion should be considered in an acute scrotum differential. Adult patients requiring orchiectomy for testicular torsion are more likely to have confounding medical conditions compared to those undergoing orchiopexy. Clinically, rates of complications between the 2 procedures are small, making the decision to perform orchiopexy or orchiectomy based on the scenario.

Meckel's Diverticulum: A National Surgical Quality Improvement Program Survey in Adults Comparing Diverticulectomy and Small Bowel Resection.

BACKGROUND: Meckel's diverticulum is a congenital abnormality often associated with the pediatric population. When seen in the adult population, management is controversial. This study sought to determine demographic and outcome differences between diverticulectomy and small bowel resection in adults diagnosed with Meckel's diverticulum. METHODS: An analysis of the American College of Surgeons National Surgical Quality Improvement database (2015-2018) was performed, capturing patients with a postoperative diagnosis of Meckel's diverticulum. Inclusion criteria included diverticulectomy or small bowel resection, and exclusion criteria included other major procedures such as colectomy or concomitant diverticulectomy and a small bowel resection. Demographics and outcomes were analyzed between those receiving diverticulectomy or resection. RESULTS: 506 patients undergoing surgical treatment of Meckel's diverticulum were captured. The majority of these patients were white (79.05%), male (68.77%), and averaged 46 years old. The 2 populations were homogenous, with no significant differences in demographics or comorbidities between populations. Mean operative time was shorter in the diverticulectomy group than the resection group (68.92 ± 35.89 vs. 89.33 ± 40.16 minutes, P < .0001). There were no deaths at 30 days. Length of stay, readmission rate, wound infection, and discharge destination were similar among both groups. DISCUSSION: Our analysis of a national database reveals no difference in outcomes between patients receiving a diverticulectomy or resection for Meckel's diverticulum. Operating time may be slightly increased for resection. However, decision to excise the diverticulum vs. the segment of small bowel should be individualized to each patient, their pathology, and clinical picture.

Malrotation Correction in the Adult Population.

BACKGROUND: Malrotation is a congenital anomaly most often affecting the pediatric population. The Ladd procedure is the standard treatment for this pathology. Well-studied in the pediatric population, large studies of the demographics and outcomes of patients who reach adulthood are lacking. METHODS: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2015-2018) was performed, capturing patients with a post-operative diagnosis of malrotation and who underwent surgical correction with or without appendectomy, excluding those who underwent other major procedures such as colectomy. Baseline demographics and outcomes were compared. The primary outcome was mortality. Secondary outcomes such as length of stay and discharge destination were included. RESULTS: Two hundred twenty patients undergoing surgical correction of malrotation were captured, all of which were performed by a general surgeon under general anesthesia. One hundered and nine (49.55%) of these patients also underwent an appendectomy. Most of these patients were female (68.18%). Comorbidities and perioperative variables were clinically similar. Operative time was similar between the two groups (112 ± 86 vs. 98 ± 49 min, p = 0.1385). Thirty-day mortality (1.36%), length of stay (4.79 ± 6.21 days), readmission rate (13.64%), wound infection (2.27%) and discharge destination (95.00% to home) were statistically similar between groups. CONCLUSIONS: The data describes demographics and outcomes in adults undergoing Ladd procedures with and without appendectomy. Immediate outcomes may be equivalent regardless of incidental appendectomy. Further work is necessary to describe the population of adults with malrotation reaching adulthood.

Enterocystoplasty and appendicovesicostomy in adults: a description of demographics and 30-day outcomes of bladder augmentation.

Within the adult population, studies of the granular clinical outcomes of appendicovesicostomy (AV) and augmentation enterocystoplasty (AE) have been limited to case series. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data, this study sought to describe the population undergoing these procedures. An analysis of the ACS NSQIP database (2015 to 2018) was performed, capturing patients with procedure codes of enterocystoplasty with intestinal anastomosis or cutaneous appendicovesicostomy. Patients were stratified into three groups, if they underwent either procedure, or both procedures. Demographics, comorbidities, perioperative variables, surgeon specialty, and outcomes were described. 130 patients undergoing AV or AE were captured. Most of these patients were white (70.77%) and middle aged (46.78±17.33 years). Most patients were an American Society of Anesthesiologists class 3 or greater risk (71.54%). A higher percentage of AE patients were readmitted, returned to the operating room, and had postoperative UTI or sepsis compared to those undergoing AV or AV+AE. The most common complication overall was readmission related to the operation (14.62%). The most common postoperative diagnosis was neurogenic related in over half of cases. The study shows patients undergoing bladder augmentation and appendicovesicostomy are readmitted not infrequently. Risk of infection, sepsis, bleeding, and reoperation are also not insignificant. Further studies should be carried out to aid in decreasing complication rate and readmissions after these procedures.

Are university-based residency training programs lacking in resident education of proper diagnosis and treatment for common skin and breast lesions?

BACKGROUND: Skin and breast cancers are the 2 most common malignancies in US women. Early detection with appropriate therapy is essential in improving survival rates. The aim of this study was to evaluate and compare general surgery (GS) and family medicine (FM) residents in their ability to identify and appropriately treat common skin and breast lesions. METHODS: Thirty-three-question, institutional review board-approved, Web-based surveys (1 breast and 1 skin survey) were each sent to 244 GS and 452 FM training programs (both university-based and community-based programs) uniformly distributed across the United States. Each survey included demographics and 20 multiple-choice questions (10 lesion identification questions and 10 corresponding treatment questions). RESULTS: A total of 374 completed resident surveys were collected (242 FM, 132 GS). Respondents were uniformly distributed geographically (55.9% women, 44.1% men; 54.2% community based, 45.8% university based). GS residents correctly identified 82.7% of lesions compared with 83.3% for FM residents (P = .89) and correctly treated 76.8% of lesions compared with 75.4% for FM residents (P = .81). No significant identification or treatment differences were noted by postgraduate year (PGY), but both GS and FM residents had lower accuracy of correct treatment identification compared with lesion identification, which was significant for GS PGY 2 residents (P = .02), FM PGY 2 residents (P = .03), and FM PGY 2 residents (P = .03). University-based GS residents had a more significant disparity between correct identification and correct treatment (83.6% vs 74.6%, P = .03) compared with community-based GS residents (80.4% vs 74.6%, P = .11). Both university-based and community-based FM residents had significant disparities in this comparison (university-based FM residents with 82.4% vs 69.8%, P = .02, vs community-based FM residents with 86.7% vs 74.5%, P = .04). CONCLUSIONS: Both GS and FM residents incorrectly treated more lesions than they diagnosed. This diagnosis-treatment disparity was more pronounced among university-based residents. Validation of this observation may better identify potential training deficiencies in breast and skin oncology to enhance GS resident education.

Effects of intragastric fructose and dextrose on mesenteric microvascular inflammation and postprandial hyperemia in the rat.

OBJECTIVES: Fructose superfused on the mesenteric venules of rats induces microvascular inflammation via oxidative stress. It is unknown whether intragastric fructose exerts a similar effect and whether fructose impairs postprandial hyperemia (PPH). The goals were to determine whether intragastric fructose administration promotes leukocyte adherence and whether fructose, owing to its oxidative properties, may also impair nitric oxide-dependent PPH in the mesenteric microcirculation of rats. METHODS: Leukocyte adherence to mesenteric venules, arteriolar velocity, and diameter were measured in Sprague-Dawley rats before and 30 minutes after intragastric (1 mL 0.5 M, ~0.3 g/kg) dextrose (n = 5), fructose (n = 6), and fructose after intravenous injection of the antioxidant α-lipoic acid (ALA, n = 6). RESULTS: Only fructose increased leukocyte adherence: control 2.3 ± 0.3 per 100 µm; fructose 9.7 ± 1.4 per 100 µm (P < .001). This effect was independent of changes in venular shear rate: control 269 ± 48 s(-1); fructose 181 ± 27 s(-1) (P > .05, r(2) = 0.083 for shear rate vs leukocyte adherence). Dextrose had no effect on leukocyte adherence: control 1.52 ± 0.13 per 100 µm; dextrose 2.0 ± 0.7 per 100 µm (P > .05). ALA prevented fructose-induced leukocyte adherence: control 1.9 ± 0.2 per 100 µm; fructose + ALA 1.8 ± 0.3 per 100 µm (P > .05). Neither fructose nor dextrose induced PPH: arteriolar velocity: control 3.3 ± 0.49 cm/s, fructose 3.06 ± 0.34 cm/s (P > .05); control 3.3 ± 1.0 cm/s, dextrose 3.15 ± 1.1 cm/s (P > .05); arteriolar diameter: control 19.9 ± 1.10 µm, fructose 19.7 ± 1.0 µm (P > .05); control 21.5 ± 2.6, dextrose 20.0 ± 2.7 µm (P > .05). CONCLUSIONS: Intragastric fructose induced leukocyte adherence via oxidative stress. Neither dextrose nor fructose induced PPH, likely because of the inhibitory effect of anesthesia on splanchnic vasomotor tone.

Minimally invasive surgery in pediatric cancer patients.

BACKGROUND: The specific use of minimally invasive surgery (MIS) in pediatric cancer patients is limited. We evaluated the 5-year experience at a single institution with MIS in children with malignancies. METHODS: A retrospective review was undertaken of all MIS performed between November 1995 and October 2000. RESULTS: A total of 101 pediatric oncology patients underwent 113 MIS procedures-64 laparoscopic (57%) and 49 thoracoscopic (43%)-during this period. Laparoscopy was performed for diagnostic purposes in 27 cases (42%) and was successful in 25 (93%) cases. Laparoscopic tumor resection was performed in seven cases (11%). Thirty additional laparoscopic procedures (47%) were attempted for complications of the malignancy or its treatment. Four of these cases were converted to open laparotomies. Indications for thoracoscopy included the evaluation of a mediastinal mass (n = 7) or biopsy or resection of pulmonary lesions (metastatic, n = 31; infectious, n = 9). Fourteen cases (29%) had to be converted to open thoracotomy procedures, generally because of the inability to localize a lesion. The other 35 procedures were successful. The overall complication rate was 5%. No trocar site recurrences or infections were observed. CONCLUSIONS: We conclude that MIS in pediatric cancer patients is a safe and effective diagnostic modality. The role of MIS for primary tumor resection remains to be defined.

Benefit of surgical resection of invasive pulmonary aspergillosis in pediatric patients undergoing treatment for malignancies and immunodeficiency syndromes.

PURPOSE: The aim of this study was to evaluate the outcome of children undergoing treatment for malignancy and immunodeficiency syndromes in whom invasive pulmonary aspergillosis (IPA) developed. METHODS: The authors reviewed the medical records of all patients treated at their institution from January 1990 to August 1999 for culture-proven pulmonary aspergillus infection. RESULTS: Among the 43 patients studied, the median age at the time of diagnosis of IPA was 13.1 years. The most common primary diagnoses were acute myelogenous leukemia (n = 18) and acute lymphoblastic leukemia (n = 14); 27 patients (63%) had received a bone marrow transplant (BMT). Of the 18 patients who underwent surgical intervention for IPA, 14 (78%) had one operation, whereas the remaining 4 patients had 2. The 4 patients alive at the time this report was written had undergone surgical intervention 2, 10, 23, and 44 months previously respectively. Surgical resection of the involved lung parenchyma was significantly prognostic for survival (P <.001). Other factors that influenced outcome were the extent of pulmonary invasion, steroid use, and the timing of bone marrow transplantation (BMT) in regard to the diagnosis of IPA. CONCLUSIONS: The overall mortality rate of children treated for malignancies and immunodeficiency syndromes in who IPA develops remains high, and antifungal therapy alone may not be curative. Surgical resection may provide a small but possibly the only chance for survival. Therefore, we would advocate for resection of all involved tissue, even if it requires reoperation.