Trends and perioperative outcomes of inpatient antireflux surgery in the United States, 1993-2006.

Antireflux surgery is an effective treatment for gastroesophageal reflux disease, but postoperation complications and durability may be problematic. The objective of the study was to determine whether inpatient antireflux surgery continued to decline in the United States due to concerns about its long-term effectiveness and the popularity of gastric bypass surgery and to assess recent changes in its perioperative outcomes. Using the Nationwide Inpatient Sample, we identified adult patients undergoing inpatient antireflux surgery during 1993-2006 and compared the trends of inpatient antireflux surgery with inpatient gastric bypass surgery. Perioperative complications included laceration, splenectomy, transfusion, esophageal dilation, total parenteral nutrition, and infection. Inpatient antireflux surgery increased from 9173 in 1993 to 32 980 in 2000 (+260%) but then decreased to 19 668 in 2006 (-40%). Compared with 2000, patients undergoing inpatient antireflux surgery in 2006 were older (49.9 ± 32.4 vs. 54.6 ± 33.6 years) and had a longer length of stay (3.1 ± 10.0 vs. 3.7 ± 13.4 days), more complications (4.7% vs. 6.1%), and higher mortality (0.26% vs. 0.54%) (all P < 0.05). Compared with inpatient gastric bypass surgery, length of stay was longer and mortality was higher for inpatient antireflux surgery in 2006, but neither was significant controlling for age. In 2006, perioperative outcomes of inpatient antireflux surgery were better in high-volume hospitals (all P < 0.01). Inpatient antireflux surgery continued to decline in the United States from 2000 to 2006, concomitant with a dramatic increase in inpatient gastric bypass surgery. Older patient age and worsening perioperative outcomes for inpatient antireflux surgery suggest increased medical complexity and possibly a larger share of reoperations over time. Designating centers of excellence for antireflux surgery based on local expertise may improve outcomes.

National trends in outcomes for esophageal resection.

BACKGROUND: Case-series reports from tertiary centers report improved outcomes for esophageal resection in recent years. The objective of the current study was to determine trends in short-term outcomes after esophageal resection in a representative sample of United States (US) hospitals. METHODS: Observational study of all adult patients in the Nationwide Inpatient Sample who underwent esophageal resection from 1988 to 2000 (N = 8,657). Temporal trends of in-hospital mortality and prolonged length of stay were determined. Analyses were performed for all hospitals after stratifying by hospital volume. The proportion of patients having surgery at high volume hospitals was used to assess changes in referral patterns. RESULTS: The overall mortality rate was 11.3% and revealed a modest but significant decline from 13.6% to 10.5% during the study period (p = 0.001). Low volume hospitals had markedly higher mortality rates and showed no improvement over time (15.3% vs 14.5%). In contrast, high volume hospitals indicated significant reduction in mortality over time (11.0% vs 7.5%, p = 0.003). Referral patterns changed over time with the proportion of esophageal resections performed at high volume hospitals increasing from 40% (1988 to 1991) to 57% (1997 to 2000). CONCLUSIONS: The operative mortality rate for esophageal resection has declined over the past 13 years, particularly at high volume hospitals. Efforts should be made to understand the processes of care underlying this improvement.

[Current trends in surgical treatment of esophageal cancer].

Esophagectomy with cervical, mediastinal and abdominal lymph-node dissection has contributed to the improved survival of patients with esophageal cancer. However, surgery alone cannot provide more satisfactory survival, and new strategies are needed to progress survival. For patients in the advanced stage, combined therapy, such as chemoradiation followed by surgery, is attempted to improve their survival. Three-field lymph node dissection causes a huge surgical stress and it is not necessary for all patients. The optimal fields for lymph-node dissection should be selected according to the depth of the tumor invasion and the location of the primary lesion. Thoracoscopic and/or laparoscopic methods have been adopted over recent years adopted to reduce surgical stress.

[Development of methods of esophagoplasty in children]. / Evoliutsiia metodov plastiki pishchevoda u detei.

In the Clinic of Pediatric Surgery of the Russian State Medical University 310 operations for esophagoplasty were performed using segments of the small and large intestine. The 50-year progress in the creation of an artificial esophagus is characterized by gradual advancement from prethoracic plasty after Roux-Herzen-Yudin to the refined method of retrosternal coloesophagoplasty. The incidence of the characteristic postoperative complications reduced by 3 to 10 times, necrosis of the transplant was practically not encountered, the mortality reduced to 1.2%, and the functional results improved significantly.

Tratamiento quirúrgico de la esofagitis cáustica severa / Surgical treatment of the severe caustic esophagitis

El autor presenta la experiencia de 46 pacientes con esofagitis caústica severa y estenosis, que fueron tratado quirurgicamente mediante esofagocoloplastia o faringocoloplastia. La etiología correspondio en 26 casos por ácido muriatico, 16 por "Drano", 3 por ácido nítrico y un caso por ácido sulfúrico. En 14 casos se realizó faringocoloplastia y en 32 esofagocoloplastia. El 22 por ciento presento complicaciones respiratorias en el post-operatorio, 3 casos neumotórax y en 4 fístula cervical manejadas médicamente; no se registró mortalidad hospitalaria y la evolución de los pacientes a mediano y largo plazo fue satisfactoria

Atresia of the esophagus. New trends in the management of high-risk neonates.

Once the reconstruction of esophageal atresia in infancy was reported, immediate repair became standard practice. High-risk infants carry an operative mortality of 30% to 80%. Staged surgical procedures were introduced to improve survival. "Delayed" reconstruction of esophageal atresia in selected cases has been reported to improve survival and eliminate staged surgical procedures. Between 1982 and 1986, 21 newborns were diagnosed as having esophageal atresia. Eight infants (32%) underwent "immediate" repair. In 13 infants repair was "delayed" for seven to 252 days. Four neonates with "pure" esophageal atresia underwent primary anastomosis, one was awaiting surgery, and another died in the postnatal period. As more high-risk infants survive the perinatal period, surgical reconstruction must be planned to maximize operative survival. The goal of delayed management of esophageal atresia is to restore intrinsic esophageal continuity.