Short-term outcomes of bariatric surgery in patients with inflammatory bowel disease: a national analysis.

BACKGROUND: While considered standard of care for obesity management, bariatric surgery is uncommon in patients with co-morbid inflammatory bowel disease (IBD). OBJECTIVES: The present study aimed to assess the association of IBD with postoperative outcomes and resource use following bariatric surgery. SETTING: Academic, university-affiliated; United States. METHODS: All elective adult hospitalizations for laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were identified in the 2016-2019 Nationwide Readmissions Database. Patients were classified based on diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). Multivariable regression models were developed to evaluate the association of IBD with outcomes of interest. RESULTS: Of an estimated 719,270 eligible patients, 860 and 1214 comprised the UC and CD cohorts, respectively. Compared to non-IBD, UC and CD had a higher Elixhauser comorbidity index (UC: 3.0 ± 1.4; CD: 3.1 ± 1.5; non-IBD: 2.7 ± 1.4, P < .001) and more frequently underwent sleeve gastrectomy (UC: 77.5%; CD: 83.2%; non-IBD: 68.8%, P < .001). All IBD patients survived to discharge. After adjustment, IBD was not associated with significant differences in most clinical outcomes analyzed. UC (adjusted odds ratio: 2.86; 95% confidence interval: 1.14-7.13) and CD (adjusted odds ratio: 4.40; 95% confidence interval: 2.20-8.80) were associated with increased odds of gastric outlet obstruction after RYGB but not sleeve gastrectomy. CD, but not UC, was linked to significantly higher odds of small bowel obstruction following RYGB (adjusted odds ratio: 4.50; 95% confidence interval: 1.76-11.49). There was no difference in index LOS, hospitalization costs, or odds of 30-day readmission based on IBD. CONCLUSIONS: Patients with obesity and IBD faced low rates of adverse outcomes following bariatric surgery. There is an increased risk of gastrointestinal obstruction for patients with IBD undergoing RYGB. Given its safety profile, bariatric surgery can be utilized as a weight loss intervention for the growing proportion of patients with obesity and co-morbid IBD.

Cost Variation in Bariatric Surgery Across the United States.

BACKGROUND: High costs have been cited as a barrier to utilization of bariatric surgery despite the increasing prevalence of obesity in the United States. The present work characterizes the center-level variation and risk factors for increased hospitalization costs following bariatric operations. STUDY DESIGN: The 2016-2019 Nationwide Readmissions Database was queried to identify all adults undergoing elective laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Random effects were estimated using Bayesian methodology and used to rank hospitals by increasing risk-adjusted center-level costs. RESULTS: Of an estimated 687,866 patients at an annual 2435 hospitals, 69.9% underwent SG and 30.1% RYGB, with median costs of $10,900 (interquartile range: 8600-14,000) and $13,600 (10,300-18,000), respectively. Hospitals in the highest tertile of annual SG and RYGB volume were associated with a $1500 (95% CI - 2,100, -800) and $3400 reduction in costs (95% CI -4,200, -2600). Approximately 37.2% (95% CI 35.8-38.6) of variation in hospitalization costs was attributable to the hospital. Hospitals in the top decile of center-level costs were associated with increased odds of developing complications (AOR 1.22, 95% CI 1.05-1.40) but not mortality. CONCLUSION: The present work identified significant interhospital variation in the costs of bariatric operations. Further efforts to standardize costs may enhance the value of bariatric surgical care in the US.

Bariatric surgery improves outcomes of hospitalizations for acute heart failure: a contemporary, nationwide analysis.

BACKGROUND: The link between obesity and poor outcomes in heart failure (HF) has been well-established. OBJECTIVES: This retrospective study sought to examine national rates and outcomes of acute HF hospitalizations in obese individuals with a prior history of bariatric surgery. SETTING: Academic, university-affiliated; the United States. METHODS: Adult admissions (≥18 years) including a diagnosis of severe obesity were identified in the 2016-2019 Nationwide Readmissions Database. Patients who previously underwent bariatric operations were categorized into the Bariatric cohort. Multivariable linear and logistic models were used to assess the association of prior bariatric surgery with outcomes of interest. RESULTS: Of an estimated 10,343,828 admissions for a diagnosis of severe obesity, 925,716 (8.9%) comprised the bariatric cohort. After risk adjustment, bariatric surgery was associated with significantly decreased odds of acute HF hospitalization (adjusted odds ratio [AOR]: .40, 95% confidence interval [CI]: .38-.41). Among acute HF hospitalizations, prior bariatric surgery was linked to lower odds of mortality (AOR: .68, 95% CI: .52-.89), prolonged mechanical ventilation (AOR .44, 95% CI: .32-.61), acute renal failure (AOR: .76, 95% CI: .70-.82), and prolonged hospitalization (AOR: .77, 95% CI: .68-.87). Bariatric surgery was linked to a decrement of 1 day (95% CI: .7-1.1) and $1200 in hospitalization costs (95% CI: 400-1900), but no significant difference in odds of 30-day readmission. CONCLUSIONS: Bariatric surgery is associated with reduced admissions for acute HF. Among acute HF hospitalizations, bariatric surgery is linked to significantly improved clinical and financial outcomes. Given its potential benefits in obesity and related diseases, bariatric surgery holds promise for promoting value-based healthcare for HF.

Association between Participation in a Preclinical Surgery Elective and Future Match into Surgical Residency.

BACKGROUND: Since 2013, we have offered a robust "Introduction to Surgery" elective (ITS) for preclinical medical students. The present study investigates whether participants of the ITS elective were more likely to match into surgical residencies than non-ITS participants. METHODS: This is a retrospective case-control study of medical students from two medical schools in Southern California who participated in the ITS elective and those who did not. Descriptive results and univariate analysis using STATA were utilized to analyze the de-identified data who matched between 2016 and 2021 were included. RESULTS: Overall, 87 (8.9%) of the 982 matched students participated in the ITS elective, with an increase in participation from 1.2% in 2016 to 13.9% in 2021 (P < .001). Among ITS participants, 49.4% matched into a surgical specialty compared to only 22.9% for non-ITS students (P < .001). There was no difference between ITS and non-ITS students with regards to procedural specialty match (14.9% vs 12.6%, P = .537). CONCLUSION: ITS participants were more than twice as likely to match into a surgical specialty than non-participants. Future qualitative research will help discern the relative impact of the ITS course versus a student's baseline predisposition to surgery.

Impact of Automated Reminder Calls in a Safety-Net Setting on Surgical Clinic No-Show Rates.

In surgical clinics, missed appointments may lead to delayed diagnosis and postponed surgical intervention. Automated reminder calls (robocalls) have replaced live staff phone calls in many systems as a cost-saving measure. This study aims to evaluate whether robocalls reduced the outpatient appointment no-show rate for surgical patients in a county hospital. Demographic and clinic data from two surgical clinics at a safety net hospital were collected over two time periods: 3-months immediately before robocalls went live and 3-months immediately after robocalls went live. No-show rates were compared between time periods. Multivariate analysis confirmed that robocalls were independently associated with reduced no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .032). In addition, new appointments were independently predictive of higher no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .048). Robocalls appear to be an effective tool for improving appointment attendance overall. Furthermore, robocalls may free limited staff to perform higher value work in the healthcare system.

Music in the Operating Room: Comparing the Opinions of Surgeons, Anesthesiologists, and Nurses.

BACKGROUND: Music is part of operating room (OR) culture; however, some personnel may perceive music as a distraction. METHODS: A single institution survey of surgeons (SURG), anesthesia (ANES), and nursing (NURS) regarding attitudes on music in the OR. RESULTS: There were 222 responses (67% response rate) agreeing that music in the OR should be allowed (91%), is calming (75%), and helps with focus (63%). Most did not feel music was distracting (63%) or unsafe (80%). SURG were more likely to state that surgeons should decide (46.7%) if music should be played, whereas ANES and NURS (81%) were more likely to feel decisions should be made collaboratively (P < .001). CONCLUSION: Most OR personnel feel positively towards music. Surgeons were more likely to believe the decision to play music should be the surgeon's choice. The majority of OR staff agreed with collaborative decision-making, aligning with creating a safe OR culture.

Should Robotic Surgery Training Become a General Surgery Residency Requirement? A National Survey of Program Directors in Surgery.

OBJECTIVE: Robotic-assisted surgery (RAS) accounts for 15% of general surgery (GS) operations performed and is set to grow in prevalence. Currently, there are no training requirements or standard robotic curricula for GS residents. This study aimed to query GS program directors (PDs) on the necessity, extent, and potential impact of including RAS as a required component of residency training. DESIGN: Analysis of responses to a 14-question web-based survey. SETTING: Survey was distributed to PDs via the Association of Program Directors in Surgery listserv in April and May 2021. PARTICIPANTS: General surgery program directors RESULTS: Among 140 respondents, 110 (78.6%) agreed that operating at the robotic console should be a GS residency requirement, yet 93 (66.4%) indicated that RAS exposure negatively impacts the acquisition of other necessary skills. Still, 116 (82.9%) agreed that RAS training provided a net benefit to GS residents, PDs at academic programs were more supportive than those at independent programs of RAS console training requirements (68.2% versus 46.7%, p = 0.048). The median response to the ideal proportion of abdominopelvic cases performed by graduation was 20% robotic, 40% laparoscopic, and 35% open. The suggested minimum number of robotic cases that should be performed by graduation was indicated to be 30 cases by 26% of respondents, 20 by 23%, 10 by 12%, 5 by 4%, and "no minimum" by 36%. CONCLUSIONS: There is strong interest among PDs to institute RAS training requirements for GS residents. This study provides PD perspectives to help inform national conversations on whether and to what extent RAS requirements should be included in GS residency training.

Factors and Outcomes Associated With Venous Thromboembolism Following Bariatric Surgery.

BACKGROUND: The present national study characterized the incidence and factors associated with VTE following bariatric operations and its association with postoperative outcomes and resource use. METHODS: Adults (≥18 years) undergoing elective sleeve gastrectomy or gastric bypass (laparoscopic and open) were identified in the 2016-2018 Nationwide Readmissions Database. International Classification of Diseases 10th Revision codes for deep venous thrombosis and/or pulmonary embolism were used to ascertain the presence of VTE. Multivariable linear and logistic models were developed to evaluate the independent association of VTE with outcomes of interest. RESULTS: Of an estimated 537,522 patients meeting inclusion criteria, .55% developed VTE during index hospitalization (.14%) or within 90 days of index discharge (.41%). Compared to others, VTE patients were older (51.8 vs 44.9 years, P<.001), more commonly male (20.0% vs 31.5%, P<.001), and had gastric bypass (56.3% vs 31.9%, P<.001) or an open procedure (21.9% vs 2.6%, P<.001). After risk adjustment, several factors including increasing age, male gender, gastric bypass and open approach remained associated with increased odds of VTE. Patients with VTE during index hospitalization had greater odds of mortality (AOR 11.6, 95% CI: 6.12-22.19) and increased index LOS (ß:+14.1 days, 95% CI: 11.7-16.5) and hospitalization costs (ß: +$53,100, 95% CI: 43,100-63,500). Additionally, VTE patients had greater odds of readmission within 90 days (AOR 1.86, 95% CI: 1.40-2.47). CONCLUSIONS: Although VTE is uncommon following bariatric operations, it is significantly associated with increased mortality, readmission, and resource use. Further research is necessary to ascertain optimal management of VTE for bariatric surgery patients.

Bariatric surgery outcomes in geriatric patients: a contemporary, nationwide analysis.

OBJECTIVE: This retrospective study sought to characterize the incidence of mortality in elderly patients following bariatric surgery and assessed the association of geriatric status with postoperative outcomes and resource use. BACKGROUND: Bariatric surgery is a safe and efficacious intervention for obesity and related diseases. The clinical and economic impact of geriatric status on bariatric surgery is largely unexplored. SETTING: Academic, university-affiliated hospital; US. METHODS: Adults (≥45 yr) undergoing elective laparoscopic gastric bypass or sleeve gastrectomy were identified in the 2016-2019 Nationwide Readmissions Database. Patients ≥65 years were categorized into the geriatric cohort. Multivariable linear and logistic models were developed to evaluate the independent association of geriatric status with outcomes of interest. RESULTS: Of an estimated number of 351,292 patients meeting inclusion criteria, 44,183 (12.6%) comprised the geriatric cohort. Of these patients, .3% died during the index hospitalization. Geriatric status was associated with significantly increased odds of in-hospital mortality (adjusted odds ratio [AOR] = 2.39, 95% confidence interval [CI]: 1.33-4.30), respiratory (AOR = 1.34, 95% CI: 1.13-1.59), infectious (AOR = 1.65, 95% CI: 1.25-2.17), and renal complications (AOR = 1.27, 95% CI: 1.12-1.46), and prolonged hospitalization (AOR = 1.35, 95% CI: 1.24-1.48). Elderly patients experienced a .19-day increment in the length of stay (95% CI: .11-.27) and $620 in attributable hospitalization costs (95% CI: 310-930). CONCLUSIONS: While overall rates of postoperative death and complications are low, geriatric patients experience significantly increased mortality, morbidity, and resource use following bariatric operations relative to younger adults. These findings may aid in shared decision-making for obesity management in geriatric patients.

Laparoscopic splenectomy as a definitive management option for high-grade traumatic splenic injury when non operative management is not feasible or failed: a 5-year experience from a level one trauma center with minimally invasive surgery expertise.

Technique, indications and outcomes of laparoscopic splenectomy in stable trauma patients have not been well described yet. All hemodynamically non-compromised abdominal trauma patients who underwent splenectomy from 1/2013 to 12/2017 at our Level 1 trauma center were included. Demographic and clinical data were collected and analysed with per-protocol and an intention-to-treat comparison between open vs laparoscopic groups. 49 splenectomies were performed (16 laparoscopic, 33 open). Among the laparoscopic group, 81% were successfully completed laparoscopically. Laparoscopy was associated with a higher incidence of concomitant surgical procedures (p 0.016), longer operative times, but a significantly faster return of bowel function and oral diet without reoperations. No significant differences were demonstrated in morbidity, mortality, length of stay, or long-term complications, although laparoscopic had lower surgical site infection (0 vs 21%).The isolated splenic injury sub-analysis included 25 splenectomies,76% (19) open and 24% (6) laparoscopic and confirmed reduction in post-operative morbidity (40 vs 57%), blood transfusion (0 vs 48%), ICU admission (20 vs 57%) and overall LOS (7 vs 9 days) in the laparoscopic group. Laparoscopic splenectomy is a safe and effective technique for hemodynamically stable patients with splenic trauma and may represent an advantageous alternative to open splenectomy in terms of post-operative recovery and morbidity.

Management options for obesity after bariatric surgery.

INTRODUCTION: Many patients do not maintain weight loss after gastric bypass. We compared outcomes for patients undergoing diet/exercise intervention with patients undergoing surgical intervention through restorative obesity surgery-endolumenal, band over bypass, and endoscopic gastro gastric fistula closure. METHODS: We hypothesized surgery would result in greater weight loss. A retrospective analysis was performed on a bariatric database. Patients who underwent gastric bypass and failed to lose weight were selected and evaluated after intervention. Records were reevaluated at 3, 6, and 12 months after intervention for primary outcomes, that is, weight loss and comorbidity resolution. RESULTS: A total of 60 patients met the criteria. Forty-three underwent nonsurgical management; 17 underwent operative intervention. Mean body mass index decreased significantly in surgical patients compared with patients with supervised weight loss (P=0.001). Interventional patients trended toward better comorbidity resolution. CONCLUSIONS: Restorative obesity surgery-endolumenal, band over bypass, and endoscopic fistula closure results in greater weight loss and trend toward greater comorbidity resolution compared with diet and exercise.

Management of non-parasitic splenic cysts: does size really matter?

BACKGROUND: Splenic cysts are relatively rare clinical entities and are often diagnosed incidentally upon imaging conducted for a variety of clinical complaints. They can be categorized as primary or secondary based on the presence or absence of an epithelial lining. Primary cysts are further subdivided into those that are and are not secondary to parasitic infection. The treatment of non-parasitic splenic cysts (NPSC) has historically been dictated by two primary factors: the presence of symptoms attributable to the cyst and cyst size greater or less than 5 cm. While it is appropriate to resect a symptomatic lesion, the premise of recommending operative intervention based on size is not firmly supported by the literature. METHODS: In the current study, we identified 115 patients with splenic cysts and retrospectively reviewed their management that included aspiration, resection, or observation. RESULTS: Our data reveal a negative overall growth rate of asymptomatic cysts, a high recurrence rate after percutaneous drainage, as well as demonstrate the safety of observing asymptomatic lesions over time. CONCLUSION: We conclude that observation of asymptomatic splenic cysts is safe regardless of size and that aspiration should be reserved for those who are not surgical candidates or in cases of diagnostic uncertainty.

Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy.

PURPOSE: The purpose of this study was to demonstrate the feasibility of performing peroral endoscopic myotomy (POEM) in the management of recurrent achalasia after failed myotomy. METHODS: Eight patients presented to our institution between October 2010 and June 2013 with recurrent/persistent symptoms after prior laparoscopic Heller myotomy. Three patients underwent redo laparoscopic Heller myotomy, and five patients consented to redo myotomy with POEM. RESULTS: Demographics were similar between the groups with exception of age (POEM 69.5 vs. laparoscopic Heller myotomy (LHM) 34.5, p = 0.003). Preoperative Eckardt scores, motility, and prior interventions were not significantly different. Three patients who underwent POEM and two who underwent laparoscopic Heller myotomy had prior fundoplication. There was one perforation identified after laparoscopic Heller myotomy and one patient with persistent subcutaneous emphysema after POEM. Both POEM and laparoscopic Heller myotomy demonstrated significant improvement in symptoms and Eckardt scores at average follow-up of approximately 5 months (p < 0.05). CONCLUSION: POEM is a feasible option for patients after failed myotomy even in the presence of prior fundoplication. The procedure can be performed safely using a similar technique as for primary myotomy with the exception of creating the myotomy laterally along the right side of the esophagus and lesser curvature avoiding the previous anterior myotomy.

Single-incision results in similar pain and quality of life scores compared with multi-incision laparoscopic cholecystectomy: A blinded prospective randomized trial of 100 patients.

BACKGROUND: Our objective was to compare hospital charges and both perioperative and mid-term quality of life between single- (SILC) and multi-incision (MILC) laparoscopic cholecystectomy in a randomized controlled trial. METHODS: Patients with acute or chronic biliary disease were invited to participate. Pain scores, quality of life, and perioperative outcomes were measured. Patients were followed for 1 year postoperatively in the clinic with examination to document hernia formation. RESULTS: One hundred subjects were randomized to SILC (n = 49) or MILC (n = 51). Demographics were similar for both groups except more women underwent SILC (86% vs 67%, P = .026). Operative time was greater for SILC (63.5 ± 21.0 vs 43.8 ± 24.2 minute, P < .0001). Five SILC patients required added ports. One substantial complication occurred in SILC. Pain, the use of analgesics, and duration of hospital stay were equal between groups; however, charges were greater in the SILC group ($17,602 ± $6,089 vs $13,342 ± $8,197, P < .0001). Both groups reported similar quality of life and cosmesis. At an average follow-up of SILC (16.4 ± 12.1 months) and MILC (16.2 ± 10.5 months), no novel umbilical hernias were identified. CONCLUSION: SILC results in longer operative time and greater hospital charges with similar pain and quality of life scores compared with a standard laparoscopic approach.

Peroral endoscopic myotomy: A short-term comparison with the standard laparoscopic approach.

BACKGROUND: We report our short-term experience with peroral endoscopic myotomy (POEM) and compare perioperative outcomes with laparoscopic Heller myotomy (LHM) for achalasia. METHODS: Patients from an institutional review board-approved protocol underwent POEM and were followed prospectively. Comparisons were made, in a prospective esophageal database, with patients who underwent LHM over the same period. RESULTS: We studied 18 patients who underwent POEM and compared them to 21 who underwent LHM. Demographics, preoperative Eckardt scores, motility data, and prior intervention history were comparable. Operative time, myotomy length, and complication rates (1 perforation in each group) were equal. Postoperative pain was significantly different by visual analogue score (POEM 3.9 ± 0.6 versus LHM 5.7 ± 0.4, P = .02) and analgesic use (POEM 26.0 ± 13.7 versus LHM 90.0 ± 48.5 mg morphine, P = .02). Return to activities of daily living was significantly faster in the POEM group (2.2 ± 0.6 vs 6.4 ± 1.0 days, P = .03). Postoperative dysphagia and Eckardt scores were equally successful in both groups. CONCLUSION: POEM results in similar relief of dysphagia with less postoperative pain and quicker return to normal activities.

Single-incision surgery has higher cost with equivalent pain and quality-of-life scores compared with multiple-incision laparoscopic cholecystectomy: a prospective randomized blinded comparison.

BACKGROUND: Since the development of single-incision surgery, several retrospective studies have demonstrated its feasibility; however, randomized prospective trials are still lacking. We report a prospective randomized single-blinded trial with a cost analysis of single-incision (SI) to multi-incision (MI) laparoscopic cholecystectomy. STUDY DESIGN: After obtaining IRB approval, patients with chronic cholecystitis, acute cholecystitis, or biliary dyskinesia were offered participation in this multihospital, multisurgeon trial. Consenting patients were computer randomized into either a transumbilical SI or standard MI group; patient data were then entered into a prospective database. RESULTS: We report 79 patients that were prospectively enrolled and analyzed. Total hospital charges were found to be significantly different between SI and MI groups (MI $15,717 ± $14,231 vs SI $17,817 ± $5,358; p < 0.0001). Broken down further, the following subcharges were found to also be significant: operating room charges (MI $4,445 ± $1,078 vs SI $5,358 ± 893; p < 0.0001); medical/surgical supplies (MI $3,312 ± $6,526 vs SI $5,102 ± $1,529; p < 0.0001); and anesthesia costs (MI $579 ± $7,616 vs SI $820 ± $23,957; p < 0.0001). A validated survey (ie, Surgical Outcomes Measurement System) was used to evaluate various patient quality-of-life parameters at set visits after surgery; scores were statistically equivalent for fatigue, physical function, and satisfaction with results. No difference was found between visual analogue scale scores or inpatient and outpatient pain-medication use. CONCLUSIONS: We show SI surgery to have higher costs than MI surgery with equivalent quality-of-life scores, pain analogue scores, and pain-medication use.

Laparoscopic modified Sugarbaker technique results in superior recurrence rate.

BACKGROUND: Parastomal hernia (PH) is a frequent complication of stoma formation, occurring in 35-50% of patients. Recurrence after repair is common, ranging from 24 to 54% of cases. We hypothesized that repair using a laparoscopic modified Sugarbaker technique (SB) would result in a superior recurrence rate when compared with other repairs. METHODS: An Institutional Review Board-approved retrospective review of patients who underwent PH repair between 2004 and 2011 was performed. We collected demographics, factors related to ostomy formation, risk factors for hernia, intraoperative and postoperative information, as well as the absence or presence of PH on their last physical examination or imaging study. RESULTS: Forty-nine PH repairs were performed: 33 (67%) para-ileostomy and 16 (33%) para-colostomy. Repairs included 14 laparoscopic modified SB, 19 laparoscopic keyhole, 11 ostomy re-sitings, and 5 open primary repairs. There was no statistically significant difference between groups when comparing age, BMI, smoking status, steroid use, ostomy type, location, primary diagnoses, or complication rate. Recurrence rates were 0% for SB, 58% for keyhole, 64% for re-siting, and 20% for open repair. When SB was compared with all groups, the incidence of recurrence was significantly lower (p < 0.001) but follow-up was as well (7.2 vs 32.7 months). When analysis was restricted to the 28 repairs performed between 2009 and 2011, there was no significant difference between the groups in terms of demographics or follow-up period (7.2 months for SB group versus 11.8 months for all others), but again there was a significant difference in recurrence (0 of 14 for the SB group vs 8 of 14, p < 0.01). In addition, there were no differences in postoperative complication rates among all techniques. CONCLUSION: The modified SB technique may offer patients a significant decrease in the risk of recurrence compared with other PH repair techniques with no significant increase in postoperative complications.

Video-assisted thoracic surgery (VATS) for resection of metastatic adenocarcinoma as an acceptable alternative.

BACKGROUND: Adenocarcinomas commonly metastasize to the lungs and can be resected using open thoracotomy or video-assisted thoracic surgery (VATS). This study reviews metastatic resections in primary adenocarcinoma patients, using both thoracotomy and VATS. We aim to compare long-term prognoses to test the efficacy and viability of VATS. METHODS: A retrospective review of primary adenocarcinoma patients who underwent resection of pulmonary metastases from 1990 to 2006 was carried out. Information was obtained by chart review. Endpoints analyzed were disease-free interval (DFI), survival time, and recurrence-free survival (RFS). RESULTS: In a total of 42 (16 male, 26 female; median age 58.5 years) primary adenocarcinoma patients, 21 patients underwent first pulmonary metastatic resection using VATS (7 male, 14 female; median age 57 years) and 21 using thoracotomy (9 male, 12 female; median age 59 years). Primary adenocarcinomas were mainly 27 colorectal (64%) and 11 breast (26%). Two VATS (10%) and three open patients (14%) had local recurrences of the original cancer. Median postoperative follow was 13.3 months [interquartile range (IQR) 4.5-32.8 months] for VATS and 36.9 months (IQR 19.3-48.6 months) after thoracotomy. Median DFI-1 was 22.3 months (IQR 13.5-40.6 months) for VATS patients and 35.6 months (IQR 26.7-61.3 months) for open patients. Second thoracic occurrences were noted in six VATS patients (median DFI-2 9.2 months), and in seven open patients (median DFI-2 21.5 months). Third thoracic occurrences were noted in one VATS patient (DFI-3 18.7 months) and in one thoracotomy patient (DFI-3 21.8 months). Odds ratio of recurrence showed 12.5% less chance of developing recurrence in VATS patients. Five-year RFS was 53% in VATS and 57% in thoracotomy patients. CONCLUSIONS: VATS has become a viable alternative to open thoracotomy for resection of pulmonary metastases. In cases of primary adenocarcinoma, VATS showed no increase in number of thoracic recurrences, and comparable RFS. Short-term follow-up is encouraging; long-term follow-up will be needed to confirm these results.