Age-related outcomes in laparoscopic hiatal hernia repair: Is there a "too old" for antireflux surgery?

BACKGROUND: Minimally invasive antireflux surgery has been shown to be safe and effective for the treatment of gastroesophageal reflux (GERD) in elderly patients. However, there is a paucity of data on the influence of advanced age on long-term quality of life (QoL) and perioperative outcomes after laparoscopic antireflux surgery (LARS). METHOD: A retrospective study of patients undergoing LARS between February 2012 and June 2018 at a single institution was conducted. Patients were divided into four age categories. Perioperative data and quality of life (QOL) outcomes were collected and analyzed. RESULTS: A total of 492 patients, with mean follow-up of 21 months post surgery, were included in the final analysis. Patients were divided into four age-determined subgroups (< 50:75, 50-65:179, 65-75:144, ≥ 75:94). Advancing age was associated with increasing likelihood of comorbid disease. Older patients were significantly more likely to require Collis gastroplasty (OR 2.09), or concurrent gastropexy (OR 3.20). Older surgical patients also demonstrated increased operative time (ß 6.29, p < .001), length of hospital stay (ß 0.56, p < .001) in addition to increased likelihood of intraoperative complications (OR 2.94, p = .003) and reoperations (OR 2.36, p < .05). However, postoperative QoL outcomes and complication rates were parallel among all age groups. CONCLUSIONS: Among older patients, there is a greater risk of intraoperative complications, reoperation rates as well as longer operative time and LOS after LARS. However, a long-term QoL benefit is demonstrated among elderly patients who have undergone this procedure. Rather than serving as an exclusion criterion for surgical intervention, advanced age among chronic reflux patients should instead represent a comorbidity addressed in the planning stages of LARS.

Atypical Psoriatic Arthritis Presenting as Presumed Septic Monoarticular Arthritis.

The authors present a case of monoarticular psoriatic arthritis affecting the knee of a woman with no previously identified manifestations of psoriasis. At time of symptom onset, joint aspirates were initially sterile with predominantly neutrophilic leukocytosis; however, repeat aspiration and culture was positive for Candida parapsilosis. Despite appropriate antifungal treatment, symptoms continued to worsen and other large joint manifestations including the contralateral elbow raised suspicions for alternative etiology. Ultimately new onset skin excoriations on the palms suggested psoriatic arthritis, which was subsequently treated with immunosuppressive therapy.

Predictive Risk Factors Associated With Increased Opioid Use Among Patients Undergoing Elective Spine Surgery.

BACKGROUND: Opioids are commonly used for postoperative pain management in spine surgery. However, few guidelines exist for appropriate prescribing in the acute postoperative phase of care. We identify risk factors for inpatient (IP) opioid use and examine relationships between IP requirements and discharge (DC) opioid prescriptions. METHODS: Retrospective review of elective spine surgeries between January 2014 and May 2018 identified cases of lumbar decompression (LD), LD with fusion (LDF), and cervical decompression with fusion (CDF) at our high-volume spine center. Multiple regression examining potential risk factors for opioid use was performed. Opioid use was normalized into daily morphine milligram equivalents (MME). RESULTS: A total of 2281 patients who underwent 1251 LD, 384 LDF, and 648 CDF procedures were identified (54.1% male, mean age = 57.9 years, mean body mass index = 30.3 kg/m2, median American Society of Anesthesiologists [ASA] score = 2). Mean IP opioid use was 44.4 MME/day and average DC prescriptions totaled 496.5 MME. Multiple regression models identified younger age and increased ASA score as predictive of increased daily IP opioid consumption (ßAGE = -0.36, P < .001, ßASA = 10.1, P < .001; R 2 = 0.308) and increased DC opioid amounts (ßAGE = -4.62, P < .001, ßASA = 72.1, P < .001; R 2 = 0.097). Highest IP and DC opioid use was observed among LDF followed by CDF and LD patients. Significant positive correlations were found between IP opioid usage and DC opioid prescriptions by IP opioid quartiles (r = 0.99 LD, 0.98 LDF, 0.96 CDF). CONCLUSIONS: Younger patients and higher ASA scores correlated with increased IP opioid use and DC opioid prescriptions. DC prescriptions appropriately reflect IP use. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Adequate pain management is an integral component to successful outcomes in spine surgery. Awareness of candidates likely to require higher levels of opioid analgesia will be beneficial in guiding surgeon prescribing practices.

The role of body mass index in determining clinical and quality of life outcomes after laparoscopic anti-reflux surgery.

BACKGROUND: Current literature is conflicted regarding the efficacy of laparoscopic anti-reflux surgery (LARS) among obese patients complaining of pathologic reflux or otherwise symptomatic hiatal hernias. Controlling for other factors, this study examined the influence of preoperative body mass index (BMI) on clinical and subjective quality of life (QOL) outcomes following LARS. METHODS: Patients who underwent LARS between February 2012 and April 2018 were subdivided into four BMI stratified categories according to CDC definitions: normal (18.5 to < 25), overweight (25.0 to < 30), obese Class 1 (30 to < 35), and a combination of obese Class 2 (35 to < 40) and Class 3 (≥ 40). Patient demography, perioperative data, and QOL data were collected. QOL was assessed utilizing four validated survey instruments: the Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL), Laryngopharyngeal Reflux Health-Related Quality of Life (LPR-HRQL), and a modified Quality of Life in Swallowing Disorders (mSWAL-QOL) surveys. RESULTS: In this study, 869 patients were identified (213 NL, 323 OW, 219 OC1, 114 OC23). The majority of patients in each subgroup were female (65% NL, 68% OW, 79% OC1, 74% OC23) with similar rates of underlying hypertension, hyperlipidemia, and diabetes mellitus. Coronary artery disease rates between groups were statistically significant (p = .021). Operative time, length of hospital stay, and rates of 30-day readmission and reoperation were similar between groups. Among postoperative complications, rates of arrhythmia and UTI were more commonly reported in OC1 and OC23 populations. When assessed utilizing the RSI, GERD-HRQL, LPR-HRQL, and mSWAL-QOL instruments, QOL was similar among all groups (mean follow-up 15 months) irrespective of BMI. CONCLUSION: These findings suggest LARS in the overweight, obese, and morbidly obese populations-when compared to normal-weight cohorts in short-term follow-up-may have similar value in addressing pathological reflux manifestations and conveying quality of life benefits without added morbidity or mortality.

Demographic-related variables impact subjective experiences of patient wait times and perceived attention afforded in surgical outpatient clinic encounters.

INTRODUCTION: Patient satisfaction remains a key component in successful delivery of high-quality healthcare. In this study, we attempted to better understand how patient demographics might influence perception of clinic wait times and determine factors that may positively influence perception of a clinic experience. METHODS: A prospective study was conducted assessing patient satisfaction during outpatient surgical clinics in minimally invasive, breast, plastic/reconstructive, and orthopaedic surgery between May and September 2017. Patient demographics, subjective and objective assessments of wait time and physician encounter, and qualitative assessments of physician and patient interaction were collected. RESULTS: 150 patients were enrolled with median age between 45 and 54 years old. Patients perceived mean wait times of 22.5 min and contact with physician as 12.3 min. Objective measures of wait and physician-contact times were 30.8 min and 10.7 min. These trends persisted despite surgical specialty and new versus returning patient class. Widowed patients perceived receiving less attention by doctors (p<.05), retirees believed they spent less time with their physician (p<.05), and associate's degree holders as highest education status had greater differences in perceived-versus-actual contact time with their doctor (p<.05). Clinic patients reported high satisfaction scores (>96%) quantifying physician eye-contact (99.3%), attention (99.8%), clarity of clinical communication (98.7%), interest in answering questions (99.2%), and reasonability (98.2%) highly. Patients described their physicians as excellent (99.4%) and were likely to refer their provider to others (99.9%). CONCLUSION: Our findings suggest qualitative factors of patient encounters including eye contact, attention, communication, interest, and subjective perceptions of time bear more weight in the final assessment of patient satisfaction with care than quantitative factors such as actual wait time and duration of time with provider. This is irrespective of differences in perceived wait and contact times between different groups.

Development of a Risk Prediction Model With Improved Clinical Utility in Elective Cervical and Lumbar Spine Surgery.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: We present a universal model of risk prediction for patients undergoing elective cervical and lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Previous studies illustrate predictive risk models as possible tools to identify individuals at increased risk for postoperative complications and high resource utilization following spine surgery. Many are specific to one condition or procedure, cumbersome to calculate, or include subjective variables limiting applicability and utility. METHODS: A retrospective cohort of 177,928 spine surgeries (lumbar (L) Ln = 129,800; cervical (C) Cn = 48,128) was constructed from the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Cases were identified by Current Procedural Terminology (CPT) codes for cervical fusion, lumbar fusion, and lumbar decompression laminectomy. Significant preoperative risk factors for postoperative complications were identified and included in logistic regression. Sum of odds ratios from each factor was used to develop the Universal Spine Surgery (USS) score. Model performance was assessed using receiver-operating characteristic (ROC) curves and tested on 20% of the total sample. RESULTS: Eighteen risk factors were identified, including sixteen found to be significant outcomes predictors. At least one complication was present among 11.1% of patients, the most common of which included bleeding requiring transfusion (4.86%), surgical site infection (1.54%), and urinary tract infection (1.08%). Complication rate increased as a function of the model score and ROC area under the curve analyses demonstrated fair predictive accuracy (lumbar = 0.741; cervical = 0.776). There were no significant deviations between score development and testing datasets. CONCLUSION: We present the Universal Spine Surgery score as a robust, easily administered, and cross-validated instrument to quickly identify spine surgery candidates at increased risk for postoperative complications and high resource utilization without need for algorithmic software. This may serve as a useful adjunct in preoperative patient counseling and perioperative resource allocation. LEVEL OF EVIDENCE: 3.

Update on the Durability and Performance of Collis Gastroplasty For Chronic GERD and Hiatal Hernia Repair At 4-Year Post-Intervention.

BACKGROUND: Collis gastroplasty (CG) remains an important procedure to lengthen the esophagus when indicated in patients undergoing fundoplication for longstanding refractory gastroesophageal reflux disease (GERD) or large hiatal hernias. Concerns over potential sequelae of CG such as dysphagia and worsening heartburn as well as questions regarding the durability of the procedure remain a subject of debate. In this study, 3 and 4-year postoperative data is presented assessing patient quality of life (QOL) measures for those undergoing laparoscopic antireflux surgery (LARS) with and without CG. METHODS: Comparative review of a prospectively maintained GERD patient database was conducted between patients undergoing LARS with CG versus non-CG (NC) at two institutions between October 2004 and February 2019. Patient demographic, perioperative, and QOL data was analyzed at 3 and 4 years postoperatively using four validated instruments: the Reflux Symptom Index (RSI), Laryngopharyngeal Reflux QOL (LPR-QOL), Swallowing QOL (SWAL), and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQOL) surveys. RESULTS: A total of 214 CG and 798 NC patients were included in this study. The CG group was older (66.1 ± 12.9 vs. 59.0 ± 14.1, p < 0.001), had a higher frequency of ASA class 3 patients (39.7% vs. 29.7%), and had greater proportion of comorbid disease compared to NG. The groups were parallel in BMI (Collis 28.4 ± 5.2 kg/m2 vs. non-Collis 28.6 ± 5.3 kg/m2, p = 0.673). Subset analysis revealed persistent benefits through 4 years reflected by survey results in both groups. There were no statistically significant differences in QOL outcomes between CG and NC. A majority of patients in both groups reported discontinuation of antireflux medications and satisfaction with surgical outcomes and symptom control. CONCLUSION: Long-term QOL outcomes after laparoscopic CG are comparable to patients treated with fundoplication alone in cases of long-standing GERD and hiatal hernias. Furthermore, CG patients enjoyed equivalent durability of the procedure without risk of subsequent dysphagia. Collis gastroplasty remains an important tool in the armamentarium of foregut surgeons.

Adrenal Hemorrhage in a Patient Anticoagulated with Apixaban with Antiphospholipid Syndrome.

Atraumatic adrenal hemorrhage is a rare injury, often due to the disruption of normal hemostasis secondary to sepsis, autoimmune disease, or chronic anticoagulation. We present a case of recurrent adrenal hemorrhage in a patient with antiphospholipid syndrome previously maintained on warfarin for deep vein thrombosis and pulmonary embolism prophylaxis who worsened shortly after transition to apixaban therapy. Initial left-sided adrenal hemorrhage occurred four weeks after beginning apixaban, followed by the development of retinal hemorrhage and later right-sided adrenal hemorrhage. This is, to date, the first reported case of adrenal hemorrhage in a patient receiving chronic anticoagulation with apixaban.

Racial Disparities in Surgical Outcomes After Spine Surgery: An ACS-NSQIP Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Racial disparities in postoperative outcomes are unfortunately common. We present data assessing race as an independent risk factor for postoperative complications after spine surgery for Native American (NA) and African American (AA) patients compared with Caucasians (CA). METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for spine procedures performed in 2015. Data was subdivided by surgery, demography, comorbidity, and 30-day postoperative outcomes, which were then compared by race. Regression was performed holding race as an independent risk factor. RESULTS: A total of 4803 patients (4106 CA, 522 AA, 175 NA) were included in this analysis. AA patients experienced longer length of stay (LOS) and operative times (P < .001) excluding lumbar fusion, which was significantly shorter (P = .035). AA patients demonstrated higher comorbidity burden, specifically for diabetes and hypertension (P < .005), while NA individuals were higher tobacco consumers (P < .001). AA race was an independent risk factor associated with longer LOS across all cervical surgeries (ß = 1.54, P <.001), lumbar fusion (ß = 0.77, P = .009), and decompression laminectomy (ß = 1.23, P < .001), longer operative time in cervical fusion (ß = 12.21, P = .032), lumbar fusion (ß = -24.00, P = .016), and decompression laminectomy (OR = 20.95, P < .001), greater risk for deep vein thrombosis in lumbar fusion (OR = 3.72, P = .017), and increased superficial surgical site infections (OR = 5.22, P = .001) and pulmonary embolism (OR = 5.76, P = .048) in decompression laminectomy. NA race was an independent risk factor for superficial surgical site infections following cervical fusion (OR = 14.58, P = .044) and decompression laminectomy (OR = 4.80, P = .021). CONCLUSION: AA and NA spine surgery patients exhibit disproportionate comorbidity burden and greater 30-day complications compared with CA patients. AA and NA race were found to independently affect rates of complications, LOS, and operation time.

Centers for Medicare & Medicaid Services Hierarchical Condition Category score as a predictor of readmission and reoperation following elective inpatient spine surgery.

OBJECTIVE: A universal, objective predictor of postoperative resource utilization following inpatient spine surgery has not been clearly established. The Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Category (HCC) risk adjustment model, based on a formula using patient demographics and coded diagnoses, is currently used to prospectively estimate financial risk in Medicare Advantage patients; however, the value of this score as a clinical tool is currently unknown. The authors present an analysis evaluating the utility of the CMS HCC score as a universal predictive tool for patients undergoing inpatient spine surgery. METHODS: A total of 1966 consecutive patients (551 with lumbar laminectomy [LL] alone, 592 with lumbar laminectomy and fusion [LF], and 823 with anterior cervical discectomy and fusion [ACDF]) undergoing inpatient spine surgery at a single institution from January 2014 to May 2018 were included in this retrospective outcomes study. Perioperative outcome measures included procedure time, 30-day readmission, reoperation, hospital length of stay (LOS), opioid utilization measured by morphine milligram equivalents (MMEs), and cost of inpatient hospitalization (in US dollars). Published CMS algorithms were incorporated into the electronic health records and used to calculate HCC scores for all patients. Patients were stratified into HCC score quartiles. Linear regression was performed on LOS, procedure time, inpatient opioid consumption, discharge opioid prescriptions, and cost to identify predictors of HCC quartiles when controlling for procedure type. One-way ANOVA and Pearson's chi-square analysis were used to compare perioperative outcomes stratified by HCC score. RESULTS: Across all procedures, the HCC score demonstrated significant association with 30-day readmission (OR 1.45, 95% CI 1.11-1.91, p = 0.007). The average BMI, median American Society of Anesthesiologists score, and 30-day readmission rate were similar across procedures (LL: 30.6 kg/m2, 2, 3.6%; LF: 30.6 kg/m2, 2, 4.6%; ACDF: 30.2 kg/m2, 2, 3.9%; p = 0.265, 0.061, and 0.713, respectively). LOS (p < 0.0001), duration of procedure (p < 0.0001), discharge MME (p = 0.031), total cost (p < 0.001), daily MME (p < 0.001), reoperation (p < 0.001), and 30-day readmission rate (p < 0.001) were significantly different between HCC quartiles. CONCLUSIONS: The HCC score may hold value as an objective, automated predictor of postoperative resource utilization and outcomes, including readmission and reoperation. This may have value as a universal, reproducible tool to target clinical interventions for higher-risk patients.

Laparoscopic antireflux surgery (LARS) is highly effective in the treatment of select patients with chronic cough.

BACKGROUND: We present the largest single-center study to date of surgical and quality-of-life outcomes among patients treated with laparoscopic antireflux surgery for reflux-associated chronic cough. Extraesophageal manifestations of chronic gastroesophageal reflux are increasingly recognized, among which chronic cough may substantially compromise patient quality of life. Although the benefits of antireflux surgery are well documented in patients with typical symptoms of gastroesophageal reflux disease, less is known about the short-term impact of antireflux surgery on associated chronic cough. METHODS: Review of a prospectively maintained database of patients with gastroesophageal reflux disease was conducted, identifying individuals who underwent laparoscopic antireflux surgery between February 2012 and July 2018. Inclusion criteria consisted of identifying manifestations of chronic cough in patients diagnosed with gastroesophageal reflux disease as assessed by preoperative survey in addition to the physiologic diagnosis of pathologic reflux. Patient quality of life was analyzed up to 3 years postoperatively using 4 validated survey instruments: the Reflux Symptom Index, Gastroesophageal Reflux Disease-Health Related Quality of Life, Laryngopharyngeal Reflux Quality of Life, and Swallowing Quality of Life. RESULTS: We identified 232 patients (47 men, 185 women) with symptomatic chronic cough among their manifestations of underlying gastroesophageal reflux disease. Mean age, body mass index, and American Society of Anesthesiologists score were 61.7 years, 28.9 kg/m2, and 2, respectively. We observed no 30-day wound-related complications, 17 patients (7.3%) experienced nonwound-related complications, and 2 patients (0.9%) required reoperation. Patients reported significant improvements in chronic cough and other manifestations of gastroesophageal reflux disease during an average of almost 3 years (Reflux Symptom Index -66%, Gastroesophageal Reflux Disease-Health Related Quality of Life -85%, Laryngopharyngeal Reflux Quality of Life -75%, and Swallowing Quality of Life +29%). Complete resolution of chronic cough was observed in 77% of respondents at follow-up, and 71% of postlaparoscopic antireflux surgery patients stopped antireflux medications. Symptom control was accompanied with a high rate of postoperative satisfaction among 71% patients at latest follow-up. CONCLUSION: Chronic cough associated with gastroesophageal reflux disease after a thorough, objective medical workup can be expected to have an excellent rate of resolution and quality-of-life outcomes after laparoscopic antireflux surgery. A high-volume practice, objective documentation of gastroesophageal reflux disease, and a multidisciplinary approach are key in achieving optimal outcomes.

Minimally Invasive Multidisciplinary Approach to Chronic Giant Inguinoscrotal Hernias.

Background. Giant inguinoscrotal hernias (GIH) are defined as groin hernias extending below the mid-thigh when standing, often significantly encumbering activities of daily living. To date, there are no reports utilizing the combination of progressive pneumoperitoneum (PPP), botulinum toxin A injection (BTI), and enhanced view-totally extraperitoneal (eTEP) technique for GIH repair. In this report, we present 2 such cases of this unique minimally invasive multidisciplinary approach to address GIH. Series Presentation. Two individuals with lifelong complaints of GIH presented for elective hernia repair, each with significant morbidity relating to their pathology and profound loss of abdominal domain. Four weeks prior to surgery, BTI was administered to the lateral abdominal compartment muscles to facilitate regional paralysis, followed by PPP to develop larger intraabdominal domain. Utilizing the eTEP access technique and transversus abdominis release, a wide retromuscular dissection was performed to aid in the increase of intraabdominal domain and to develop a large space for mesh placement. Reconstruction including partial scrotectomy and scrotoplasty using adjacent tissue transfer technique was completed. Both patients tolerated the procedures well without recurrence in the first postoperative year. Conclusion. In this article, we present the first series of GIH patients undergoing combined PPP, BTI, and eTEP access approach to retromuscular dissection. This multidisciplinary approach to patient care has proven both safe and effective.

Morgagni Hernia Repair: A Review.

Anteromedial subcostosternal defects, also known as a diaphragmatic hernia of Morgagni (MH), allow potentially life-threatening herniation of the abdominal organs into the thorax. Constituting only a small fraction of all types of congenital diaphragmatic hernias, correct diagnosis of MH is often delayed, owing in large part to nonspecific associated respiratory and gastrointestinal complaints. Once identified, the primary management for both symptomatic and incidentally discovered asymptomatic cases of MH are surgical correction because the herniated contents present increasing risk for strangulation. Various thoracic and abdominal surgical approaches have been described without a clear consensus on preference for operative repair technique. In this article, the literature regarding management of MH within the past decade is reviewed, and an illustrative case of laparoscopic repair of a MH with novel reinforcement using a Falciform ligament onlay flap is presented.

Custom Fabrication of a 3-Dimensionally Printed Helmet for Improved Socialization and Subjective Self-Assessment in a Case of Acquired Cranial Defect: A Case Presentation.

Traumatic injury and subsequent residual cosmetic deformity are subject of intense scrutiny for their effects on objective health measures assessing patient morbidity and mortality. Although these remain principal concerns of all members of the treatment team, of less immediate yet lasting importance to the patient are the social costs of such disfigurement. Subjective feelings of unease and embarrassment can hinder social reintegration and encourage deteriorating psychosocial health. The following presents a case of one such individual who sustained traumatic brain injury and associated pneumocephalus and osteomyelitis requiring surgical debridement with bifrontal craniectomy and lobotomy. Postoperative management was cosmetically improved by the application of a custom-fabricated, 3-dimensionally printed helmet used in place of generic over-the-counter hardware, and the associated improvement reported in patient satisfaction is reported. LEVEL OF EVIDENCE: V.

Blunt trauma: An uncommon cause of common bile duct injury.

Blunt force trauma to the extrahepatic biliary ductal system as a cause of avulsion is an uncommon injury associated with wide variability in prognosis. These cases are often difficult to identify, primarily as they are complicated by trauma patients exhibiting more immediate and obviously life-threatening injuries. This case demonstrates a 46 year-old-male involved in a head on motor vehicle collision, sustaining blunt force abdominal trauma resulting in partial transection of the common bile duct. Injury was discovered incidentally on exploratory laparotomy post endovascular repair of abdominal thoracic aortic rupture. Open cholescystectomy with intraoperative cholangiogram was performed, isolating extravasation from the common bile duct. A 16-French T-tube was placed in the common bile duct and two large #24 Jackson-Pratt tubes were placed in the vicinity. The procedure was well-tolerated and the patient was discharged with T-tube in place. Discharge was on postoperative day 28 with removal of tubes on postoperative day 54 and the patient was able to make a full recovery.

E-cigarettes: an up to date review and discussion of the controversy.

Electronic cigarettes (e-cigarettes) present a novel method for nicotine delivery that is reportedly advantageous when compared to traditional cigarette usage. Manufacturers and consumers claim reduced chemical exposure, decreased symptom profiles, and efficacy in smoking reduction and cessation greater than conventional nicotine replacement therapies (NRT). However these products present new challenges and concerns to legislators, clinicians, and public health advocates. Questions of authority in state and federal legislation, establishing product quality control, assessing long-term studies on e-cigarettes and quantifying usefulness in harm reduction represent only a portion of the many unanswered topics being discussed. The purpose of this article is to assess the literature on e-cigarettes and establish perceptions and attitudes on this controversial subject.