Impact of COVID-19 Restrictions on Demographics and Outcomes of Patients Undergoing Medically Necessary Non-Emergent Surgeries During the Pandemic.

BACKGROUND: The COVID-19 pandemic has resulted in large-scale healthcare restrictions to control viral spread, reducing operating room censuses to include only medically necessary surgeries. The impact of restrictions on which patients undergo surgical procedures and their perioperative outcomes is less understood. METHODS: Adult patients who underwent medically necessary surgical procedures at our institution during a restricted operative period due to the COVID-19 pandemic (March 23-April 24, 2020) were compared to patients undergoing procedures during a similar time period in the pre-COVID-19 era (March 25-April 26, 2019). Cardinal matching and differences in means were utilized to analyze perioperative outcomes. RESULTS: 857 patients had surgery in 2019 (pre-COVID-19) and 212 patients had surgery in 2020 (COVID-19). The COVID-19 era cohort had a higher proportion of patients who were male (61.3% vs. 44.5%, P < 0.0001), were White (83.5% vs. 68.7%, P < 0.001), had private insurance (62.7% vs. 54.3%, p 0.05), were ASA classification 4 (10.9% vs. 3%, P < 0.0001), and underwent oncologic procedures (69.3% vs. 42.7%, P < 0.0001). Following 1:1 cardinal matching, COVID-19 era patients (N = 157) had a decreased likelihood of discharge to a nursing facility (risk difference-8.3, P < 0.0001) and shorter median length of stay (risk difference-0.6, p 0.04) compared to pre-COVID-19 era patients. There was no difference between the two patient cohorts in overall morbidity and 30-day readmission. CONCLUSIONS: COVID-19 restrictions on surgical operations were associated with a change in the racial and insurance demographics in patients undergoing medically necessary surgical procedures but were not associated with worse postoperative morbidity. Further study is necessary to better identify the causes for patient demographic differences.

Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk.

BACKGROUND: In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation. METHODS: We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS). RESULTS: In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001). CONCLUSIONS: In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.

Implementation of a systematic culturing program to monitor the efficacy of endoscope reprocessing: outcomes and costs.

BACKGROUND AND AIMS: In 2015, the U.S. Food and Drug Administration and Centers for Disease Control and Prevention (CDC) issued guidance for duodenoscope culturing and reprocessing in response to outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) duodenoscope-related infections. Based on this guidance, we implemented best practices for reprocessing and developed a systematic process for culturing endoscopes with elevator levers. The aim of this study is to report the outcomes and direct costs of this program. METHODS: First, clinical microbiology data from 2011 to 2014 were reviewed retrospectively to assess for possible elevator lever-equipped endoscope-related CRE infections. Second, a program to systematically culture elevator lever-equipped endoscopes was implemented. Each week, about 25% of the inventory of elevator lever-equipped endoscopes is cultured based on the CDC guidelines. If any cultures return bacterial growth, the endoscope is quarantined pending repeat culturing. The costs of the program, including staff time and supplies, have been calculated. RESULTS: From 2011 to 2014, none of 17 patients with documented CRE infection had undergone ERCP or endoscopic ultrasound in the previous 36 months. From June 2015 to September 2016, 285 cultures were performed. Three (1.1%) had bacterial growth, 2 with skin contaminants and 1 with an oral contaminant. The associated endoscopes were quarantined and reprocessed, and repeat cultures were negative. The total estimated cost of our program for an inventory of 20 elevator lever-equipped endoscopes was $30,429.60 per year ($1521.48 per endoscope). CONCLUSIONS: This 16-month evaluation of a systematic endoscope culturing program identified a low rate of positive cultures after elevator lever endoscope reprocessing. All positive cultures were with non-enteric microorganisms. The program was of modest cost and identified reprocessing procedures that may have led to a low rate of positive cultures.

The Malnourished Patient With Obesity: A Unique Paradox in Bariatric Surgery.

BACKGROUND: Hypoalbuminemia is a known risk factor for poor outcomes following surgery. Obesity can be associated with modest to severe malnutrition. We evaluated the impact of hypoalbuminemia on surgical outcomes in patients with obesity undergoing elective bariatric surgical procedures. MATERIALS AND METHODS: The 2015 metabolic and bariatric surgery accreditation and quality improvement program database was queried. Patients ≥ 18 y with body mass index ≥35 undergoing bariatric surgery were included. Revision procedures were excluded. Patients were classified by albumin level (albumin ≥3.5 g/dL [normal], 3.49-3.0 g/dL [mild], 2.99-2.5 g/dL [moderate], and <2.5 g/dL [severe]). Independent logistic regression models were developed to estimate the adjusted odds of (1) death or serious morbidity (DSM); (2) mild to moderate complications; (3) severe complications; and (4) 30-d readmissions by albumin level. In addition, effect modification by >10% weight loss was examined. RESULTS: A total of 106,577 patients were included in the study. Over 6% of patients had hypoalbuminemia. Fifty-five percent of complications were severe as categorized by the Clavien-Dindo classification. Patients with mild hypoalbuminemia had 20% increased odds of DSM (95% confidence interval: 1.1-1.4). There was increasing likelihood of DSM with severe hypoalbuminemia. Patients with mild hypoalbuminemia had 20% increased odds of 30-d readmission (confidence interval: 1.1-1.3). A >10% weight loss modified the effect of moderate to severe hypoalbuminemia on DSM. CONCLUSIONS: More than 6% of patients with obesity undergoing bariatric surgery are malnourished. Hypoalbuminemia is an important and modifiable risk factor for postoperative adverse outcomes following bariatric surgery. Preoperative weight loss >10% combined with moderate to severe hypoalbuminemia is synergistic for high rates of DSM and should be addressed before proceeding with bariatric surgery.

Resection of gallbladder remnants after subtotal cholecystectomy: presentation and management.

BACKGROUND: Subtotal cholecystectomy (SC) involves removal of a portion of the gallbladder typically due to hazardous inflammation. While this technique reliably prevents common bile duct (CBD) injury, future procedures can be required if the gallbladder remnant becomes symptomatic. The morbidity associated with resection of gallbladder remnants in patients that previously underwent SC is reviewed. METHODS: Records for patients having undergone redo cholecystectomy for symptomatic gallbladder remnants in a tertiary care system from 2013 to 2017 were retrospectively reviewed. RESULTS: Fourteen patients underwent repeat cholecystectomy. Five surgeons dictated the initial procedure as a subtotal cholecystectomy. All patients returned with symptomatic cholelithiasis between zero months and seven years after the index cholecystectomy. Redo cholecystectomy was attempted laparoscopically in two patients but ultimately required an open approach in all. One patient had a recognized CBD injury requiring a hepaticojejunostomy, and a second patient had a minor wound infection. Symptoms resolved in 13/14 patients. CONCLUSIONS: Redocholecystectomy (RC) for gallbladder remnants has been detailed in case reports, but no sizable North American series have been presented. These results illustrate a drawback to the reconstituting technique of SC. RC effectively resolves symptoms but requires adherence to safe principles of cholecystectomy and is one indication for an open approach.

Efficacy of adjuvant chemotherapy for small bowel adenocarcinoma: A propensity score-matched analysis.

BACKGROUND: The role of adjuvant chemotherapy (AC) in the treatment of small bowel adenocarcinoma is poorly defined. Previous analyses have been limited by small sample sizes and have failed to demonstrate a survival advantage. METHODS: Patients with resected small bowel adenocarcinoma (American Joint Committee on Cancer [AJCC] pathologic stage I-III) who were receiving AC (n = 1674) or surgery alone (SA; n = 3072) were identified in the NCDB (1998-2011). Cox regression identified covariates associated with overall survival (OS). AC and SA cohorts were matched (1:1) by propensity scores based on the likelihood of receiving AC or the survival hazard from Cox modeling. OS was compared with Kaplan-Meier estimates. RESULTS: The omission of AC conferred an increased risk of death (hazard ratio, 1.36; 95% confidence interval, 1.24-1.50; P < .001). After propensity score matching, there was a nonsignificant trend toward improved OS with AC in AJCC stage I patients (158.8 vs 110.7 months; P = .226) and AJCC stage II patients (104.0 vs 79.6 months; P = .185), including the subset with a T4 tumor classification (64.0 vs 47.4 months; P = .130) or a positive resection margin (44.4 vs 31.0 months; P = .333). Median OS was superior for patients with AJCC stage III disease who were receiving AC versus SA (42.4 vs 26.1 months; P < .001). CONCLUSIONS: These data support the use of AC for resected stage III small bowel adenocarcinoma. The trend toward improved OS for patients without nodal metastasis, including those who have T4 tumors or have undergone positive-margin resection, may justify the use of AC in select patients with earlier stage disease. Cancer 2016;122:693-701. © 2015 American Cancer Society.

Implications of Lymph Node Staging on Selection of Adjuvant Therapy for Gastric Cancer in the United States: A Propensity Score-matched Analysis.

OBJECTIVE: To compare the efficacy of adjuvant chemoradiotherapy (CRT) and chemotherapy alone (CA) in gastric adenocarcinoma patients undergoing gastrectomy in the United States (US). BACKGROUND: A majority of US gastric adenocarcinoma patients are inadequately staged (<15 nodes examined). Despite this, and limited data comparing adjuvant CRT with CA in US patients, national guidelines endorse CA in selected patients undergoing D2 lymphadenectomy. METHODS: Resected stage IB-III gastric adenocarcinoma patients receiving adjuvant CRT or CA (n = 3008) were identified in the National Cancer Database (1998-2006). Cox regression identified covariates associated with overall survival (OS). CRT and CA cohorts were matched (3:1) by propensity scores based on the likelihood of receiving CA. OS was compared by Kaplan-Meier estimates. RESULTS: Adjuvant CA was associated with an increased risk of death (HR 1.29, P < 0.001) relative to CRT. Inadequate lymph node staging (LNS) and nodal positivity were strong predictors of risk-adjusted mortality (P < 0.001). After propensity score-matching, CRT demonstrated superior median OS compared with CA (36.1 vs 28.9 m; P < 0.0001), regardless of stage. CRT was superior to CA in inadequately staged patients (33.1 m vs 24.5 m; P < 0.001); this benefit was less pronounced with increasing nodal examination. CRT improved OS in node-positive disease (29.8 vs 22.2 m; P < 0.001), regardless of LNS adequacy. In node-negative disease, OS did not differ significantly between CRT and CA cohorts; however, node-negative patients undergoing inadequate LNS benefited from CRT. CONCLUSIONS: CRT is associated with improved stage-stratified OS compared with CA. Lymph node status and adequacy of surgical staging should influence adjuvant therapy selection in the United States.

Multimodality Therapy Improves Survival in Resected Early Stage Gastric Cancer in the United States.

BACKGROUND: National guidelines endorse adjuvant chemotherapy ± radiotherapy (C ± RT) for early-stage gastric cancer (ESGC). Compliance with these guidelines and the specific impact of adjuvant C ± RT on overall survival (OS) in ESGC have not been extensively explored. METHODS: The National Cancer Data Base was queried for stage IB-II gastric adenocarcinoma patients undergoing gastrectomy (1998-2011). Multivariable modeling identified factors associated with adjuvant C ± RT receipt and compared risk-adjusted OS by treatment type (i.e., adjuvant therapy versus surgery alone). RESULTS: Of 23,461 ESGC patients (1998-2011), 79.4 % and 20.6 % received surgery alone and adjuvant C ± RT (chemoradiotherapy 17.7 %; chemotherapy alone 2.9 %), respectively. Predictors of adjuvant C ± RT receipt included age <67 years, pathologic nodal positivity, and adequate lymph node staging (LNS; ≥15 nodes examined; all p < 0.001). Survival analyses included 15,748 patients (1998-2006); median, 1-, and 5-year survival were 63.5 months, 86.0 %, and 27.0 % respectively. Omission of adjuvant C ± RT conferred an increased hazard of risk-adjusted mortality in the overall cohort, and stage IB and II subgroups (all p ≤ 0.001). The benefit of adjuvant C ± RT was most pronounced in stage II and node-positive patients-regardless of LNS adequacy (all p < 0.001)-and inadequately staged IB patients (p = 0.003). While associated with a trend toward improved OS in node-negative patients overall (p = 0.051), adjuvant C ± RT did not improve OS if surgical LNS was adequate in this subgroup (p = 0.960). CONCLUSIONS: Adoption of adjuvant C ± RT in ESGC remains incomplete nationally. Receipt of adjuvant therapy is associated with improved risk-adjusted survival relative to surgery alone; however, in adequately staged patients without lymph node metastasis, this benefit is less certain.

Findings of Esophagography for 25 Patients After Peroral Endoscopic Myotomy for Achalasia.

OBJECTIVE: The purpose of this study is to better characterize the findings of esophagography after peroral endoscopic myotomy for achalasia. MATERIALS AND METHODS: We evaluated 25 patients who underwent peroral endoscopic myotomy for achalasia. The findings noted on pre- and postprocedural esophagrams were reviewed retrospectively and were correlated with clinical outcomes. RESULTS: None of the patients had esophageal perforation noted on esophagrams obtained after myotomy, and all but two patients had a hospital stay that lasted 1 day only. Esophagrams obtained on postoperative day 1 revealed endoscopic clips in 25 patients (100%), pneumoperitoneum in 18 (72%), retroperitoneal gas in 10 (40%), gastric pneumatosis in nine (36%), intramural dissections in seven (28%), and pneumomediastinum in four (16%). Repeat esophagrams obtained 3 weeks later for 22 of the patients revealed endoscopic clips in 16 patients (73%) and intramural dissections in five patients (23%), but the remaining findings had resolved. Eighteen patients (72%) had a successful myotomy and seven (28%) had suboptimal results on the basis of clinical outcomes. Observation of a distal esophageal width of 5 mm or less on postprocedural esophagrams was often associated with suboptimal results. CONCLUSION: Peroral endoscopic myotomy is a novel procedure that is less invasive than is laparoscopic Heller myotomy for the treatment of achalasia, with fewer complications and shorter recovery times. Radiologists should be aware of the findings expected on esophagography (including pneumoperitoneum, retroperitoneal gas, gastric pneumatosis, intramural dissections, and pneumomediastinum) and should also know that fluoroscopic studies may be helpful for predicting patient outcomes on the basis of the width of the distal esophagus after myotomy.

Diffuse atrophic papules and plaques, intermittent abdominal pain, paresthesias, and cardiac abnormalities in a 55-year-old woman.

KEY TEACHING POINTS.

Laparoscopic transhiatal esophagectomy improves hospital outcomes and reduces cost: a single-institution analysis of laparoscopic-assisted and open techniques.

BACKGROUND: Several case series have demonstrated that laparoscopic transhiatal esophagectomy (LTHE) is associated with favorable perioperative outcomes compared to historical data for open transhiatal esophagectomy (OTHE). Contemporaneous evaluation of open and laparoscopic THE is rare, limiting meaningful comparison of techniques. METHODS: All patients who underwent OTHE (n = 32) and LTHE (n = 41) during the introduction of the latter procedure at our institution (1/2012-4/2014) were identified, and patient charts were retrospectively reviewed. RESULTS: Indications for operation included 69 patients with esophageal malignancy (adenocarcinoma: 64; squamous cell carcinoma: 4; melanoma: 1) and 4 patients with benign disease. There were no significant differences in clinicopathologic variables between OTHE and LTHE cohorts, except for an increased rate of cardiovascular disease in the LTHE cohort (p = 0.04). There was no significant difference in median operative time or operative complications, yet LTHE was associated with a lower incidence of intraoperative blood transfusion (p < 0.01). There were no 30-day mortalities. LTHE was associated with a reduced time to reach 24-h tube feeding goals (p = 0.02), shorter length of hospital stay (p = 0.01), and 6 % reduced median direct cost (p = 0.04). There were no significant differences in rates of major perioperative morbidities. Patients were followed for a median of 11.0 months during which there were no significant differences between cohorts in disease-free survival or overall survival. CONCLUSION: When compared to OTHE, LTHE improves surgical outcomes and decreases hospital costs; short-term oncologic outcomes are similar. LTHE is preferable to OTHE in patients requiring transhiatal esophagectomy.

Minimally invasive gastrectomy for gastric adenocarcinoma in the United States: Utilization and short-term oncologic outcomes.

BACKGROUND AND OBJECTIVES: When performed at select centers, minimally invasive gastrectomy (MIG) for gastric adenocarcinoma is associated with reduced perioperative morbidity, and similar oncologic outcomes as compared to open gastrectomy (OG). Utilization of, and outcomes associated with, MIG in the United States have not been characterized. METHODS: The National Cancer Database (2010-2011) was queried for AJCC pStage IB-IIIC patients who underwent curative-intent OG (n = 2,303) or MIG (n = 331). Multivariable models identified factors associated with MIG utilization, R0 resection rates, and adequate lymph node staging (LNS). RESULTS: MIG was more frequently utilized for T1/T2 (P < 0.001), N0 (P = 0.022), and stage IB (P = 0.001) tumors. MIG was associated with shorter hospital stay (P < 0.001), equivalent lymph node examination (P = 0.337) and superior rates of R0 resection (P = 0.011) compared with OG. In patients undergoing MIG, R0 resection was associated with performance of near-total/total gastrectomy (OR 3.90, 95%CI 1.10-13.9) and tumors < 5 cm (OR 2.78, 95%CI 1.07-7.26). Adequate LNS was associated with surgery at academic (OR 1.99, 95%CI 1.19-3.32) or high-volume facilities (OR 2.97, 95%CI 1.59-5.54), tumor size ≥ 5 cm (OR 1.85, 95%CI 1.10-3.11), and node positivity (OR 1.75, 95%CI 1.04-2.93). CONCLUSIONS: MIG is selectively utilized in cases with favorable tumor characteristics. In such cases, short-term oncologic outcomes are equivalent to those achieved with OG. Worse oncologic outcomes in specific subgroups underscore opportunities for quality improvement.

The effects of intraoperative hypothermia on surgical site infection: an analysis of 524 trauma laparotomies.

OBJECTIVES: Our primary study objective was to determine whether intraoperative hypothermia predisposes patients to postoperative surgical site infections (SSI) after trauma laparotomy. BACKGROUND: Although intraoperative normothermia is an important quality performance measure for patients undergoing colorectal surgery, the effects of intraoperative hypothermia on SSI remain unstudied in trauma. METHODS: A review of all patients (July 2003-June 2008) who survived 4 days or more after urgent trauma laparotomy at a level I trauma center revealed 524 patients. Patient characteristics, along with preoperative and intraoperative care focusing on SSI risk factors, including the depth and duration of intraoperative hypothermia, were evaluated. The primary outcome measure was the diagnosis of SSI within 30 days of surgery. Cut-point analysis of the entire range of lowest intraoperative temperature measurements established the temperature nadir that best predicted SSI development. Single and multiple variable logistic regression determined SSI predictors. RESULTS: The mean intraoperative temperature nadir of the study population (n = 524) was 35.2°C ± 1.1°C and 30.5% had at least 1 temperature measurement less than 35°C. Patients who developed SSI (36.1%) had a lower mean intraoperative temperature nadir (P = 0.009) and had a greater number of intraoperative temperature measurements <35°C (P < 0.001) than those who did not. Cut-point analysis revealed an intraoperative temperature of 35°C as the nadir temperature most predictive of SSI development. Multivariate analysis determined that a single intraoperative temperature measurement less than 35°C independently increased the site infection risk 221% per degree below 35°C (OR: 2.21; 95% CI: 1.24-3.92, P = 0.007). CONCLUSIONS: Just as intraoperative hypothermia is an SSI risk factor in patients undergoing elective colorectal procedures, intraoperative hypothermia less than 35°C adversely affects SSI rates after trauma laparotomy. Our results suggest that intraoperative normothermia should be strictly maintained in patients undergoing operative trauma procedures.

What is the patient experience of surgical care during the coronavirus disease 2019 (COVID-19) pandemic? A mixed-methods study at a single institution.

BACKGROUND: The coronavirus disease 2019 outbreak has spread worldwide and has resulted in hospital restrictions. The perceived impact of these practices on patients undergoing essential surgeries is less understood. METHODS: Adult (≥18 years) patients who underwent medically necessary surgical procedures spanning multiple surgical specialties from March 23, 2020, to April 24, 2020, during the coronavirus disease 2019 pandemic were identified as eligible for a phone survey. Survey responses were analyzed using a mixed-methods approach involving descriptive statistics and thematic analysis of coded and annotated survey results. RESULTS: Of the 212 patients who underwent medically necessary surgical procedures during the coronavirus disease 2019 pandemic, the majority of these patients were male (61.3%), White (83.5%), married or with a domestic partner (68.9%), and underwent oncologic procedures (69.3%). Of the 46 patients (21.7%) who completed the survey, the majority of these patients indicated that coronavirus disease 2019 pandemic restrictions had no impact on their inpatient hospital stay and were satisfied with their decision to proceed with surgery. Severity of patient condition (44.4%), the risk/benefit discussion with the surgeon (24.4%), and coronavirus disease 2019 education and testing (19.5%) were the most important factors in proceeding with surgery during the pandemic; 34.4% of patients said their inpatient postoperative course was negatively affected by the lack of visitors. CONCLUSION: Medically necessary, time-sensitive surgical procedures, as determined by the surgeon, can be performed during a pandemic with good patient satisfaction provided there is an appropriate discussion between the surgeon and patient about the risks and benefits.

Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006.

OBJECTIVES: Despite progress in diagnosis and treatment, peptic ulcer disease (PUD) remains a common reason for hospitalization and operation. The purpose of this study was to quantify the time trends of hospitalizations and operations for PUD in the United States (US) since 1993. DATA AND METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample is a 20% stratified sample of all hospitalizations in the United States. It was used to study hospitalizations with PUD as the principal diagnosis during 1993 to 2006, including details on ulcer site, complications, procedures, and mortality. Statistical methods included the chi test and multivariate logistic regression. RESULTS: The national estimate of hospitalizations for PUD decreased significantly from 222,601 in 1993 to 156,108 in 2006 (-29.9%), with a larger reduction in duodenal ulcers (95,552 in 1993 vs. 60,029 in 2006, -37.2%) than gastric ulcers (106,987 in 1993 vs. 86,064 in 2006, -19.6%). The inpatient mortality rate of PUD decreased from 3.8% to 2.7% during 1993 to 2006 (P < 0.001). Hemorrhage remained the most common complication (71.6% in 1993; 73.3% in 2006) but perforation had the highest mortality (15.1% in 1993; 10.6% in 2006). In comparison to 1993, patients hospitalized for PUD in 2006 more frequently had endoscopic treatment to control bleeding (12.9% vs. 22.2%, P < 0.001), similar use of surgical oversewing of ulcer (7.6% vs. 7.4%), less use of gastrectomy (4.4% vs. 2.1%, P < 0.001), and less use of vagotomy (5.7% vs. 1.7%, P < 0.001). In multivariate logistic regressions, the determinants of mortality were similar in 1993 and 2006. CONCLUSIONS: Hospitalizations for PUD decreased in the United States from 1993 to 2006, suggesting a decrease in the prevalence and/or severity of ulcer complications over this recent time period. Despite increased patient age and comorbidities, there has been a significant decrease in PUD mortality, a significant increase in the use of therapeutic endoscopy for bleeding ulcer, and a significant decrease in the use of definitive surgery (vagotomy or resection) for ulcer complications.

Hiatal Hernia after Esophagectomy: An Underappreciated Complication?

BACKGROUND: The natural history of hiatal herniation of small and/or large bowel post-esophagectomy (HHBPE) in the current era of improving long-term survival and evolving surgical technique is unknown. The aim of this study was to describe the rate and risk factors of HHBPE at our hospital. METHODS: Patients undergoing esophagectomy between January 2011 and June 2017 were included if both follow-up information and axial imaging were available beyond 3 months post-esophagectomy. Patient characteristics, disease information, and treatment factors were all included in univariate analysis comparing patients with and without HHBPE, and multivariate regression was used to identify significant independent risk factors associated with HHBPE. RESULTS: Of 310 esophagectomy patients analyzed, 258 patients were included in the study, with 79 patients (31%) showing evidence of an HHBPE and an overall median follow-up of 24 months; 44 of 79 patients (56%) had symptoms possibly referable to HHBPE and 17 of 79 patients (22%) underwent surgical repair. On univariate analysis, neoadjuvant therapy (n = 176), higher clinical stage, minimally invasive approach (n = 154), and transhiatal esophagectomy (n = 189) were significant predictors of HHBPE (p < 0.05). On multivariate analysis, neoadjuvant therapy and transhiatal approach remained significant independent predictors (p < 0.05). The rate of HHBPE was 44% in the 131 patients (51%) that had both factors. CONCLUSIONS: HHBPE in the current era of neoadjuvant therapy and minimally invasive esophagectomy is common. HHBPE can cause gastrointestinal symptoms, but operation to repair HHBPE is uncommon on intermediate follow-up. Additional study and long-term follow-up are required to fully assess the impact of HHBPE and to potentially modify surgical practice to prevent or minimize HHBPE.

Nationwide Analysis of 30-Day Readmissions After Esophagectomy: Causes, Costs, and Risk Factors.

BACKGROUND: Postsurgical readmissions are an increasingly scrutinized marker of health care quality. We sought to estimate the rate, risk factors, causes, and costs associated with readmissions after esophagectomy in a large, nationally representative cohort. METHODS: We studied patients from the Nationwide Readmissions Database undergoing esophagectomy from 2010 to 2014. Data were collected on the prevalence and indications for readmission within 30 days as well as the hospital-, procedure-, and patient-level risk factors as determined by multivariable logistic regression. RESULTS: Among 13,282 cases, the rate of 30-day readmission was 19.4%, with the most common indications for readmission being pulmonary (20.6%) and gastrointestinal complications (20%). Median cost of readmission was $9660 (interquartile range, $5392 to $20,447), and pulmonary complications accounted for the greatest total cost burden at 25.8% of all readmission-related costs. Independent risk factors for readmission on multivariable analysis included perioperative blood transfusion (adjusted odds ratio [AOR] 1.33; 95% confidence interval [CI], 1.08 to 1.65; P = .008), discharge to a nursing facility (AOR 1.83; 95% CI, 1.41 to 2.39; P < .001), high illness severity based on All Patients Refined Diagnosis-Related Groups scoring (AOR 1.49; 95% CI, 1.21 to 1.84; P < .001), chronic renal failure (AOR 1.61; 95% CI, 1.13 to 2.29; P = .009), and comorbid drug abuse (AOR 2.19; 95% CI, 1.08 to 4.41; P = .029). CONCLUSIONS: Nearly 1 in 5 patients undergoing esophagectomy are readmitted within 30 days of discharge, at a median cost of $9660 per readmission. Pulmonary complications account for the greatest number of readmissions and the greatest total cost burden. Targeting the causes of readmission, especially pulmonary causes, may help significantly reduce the total morbidity and health care costs associated with esophagectomy.

Correction to: The Association of Body Mass Index with Postoperative Outcomes After Elective Paraesophageal Hernia Repair.

In this paper, the first author's name was incorrectly tagged.

Trends of Heller myotomy hospitalizations for achalasia in the United States, 1993-2005: effect of surgery volume on perioperative outcomes.

OBJECTIVES: Achalasia is a rare chronic disorder of esophageal motor function. Single-center reports suggest that there has been greater use of laparoscopic Heller myotomy for achalasia in the United States since its introduction in 1992. We aimed to study the trends of Heller myotomy and the relationship between surgery volume and perioperative outcomes. DATA AND METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) is a 20% stratified sample of all hospitalizations in the United States. It was used to study the macro-trends of Heller myotomy hospitalizations during 1993-2005. We also used the NIS 2003-2005 micro-data to study the perioperative outcomes of Heller myotomy hospitalizations, using other achalasia and laparoscopic cholecystectomy hospitalizations as control groups. The generalized linear model with repeated observations from the same unit was used to adjust for multiple hospitalizations from the same hospital. RESULTS: The national estimate of Heller myotomy hospitalizations increased from 728 to 2,255 during 1993-2005, while its mean length of stay decreased from 9.9 to 4.3 days. Of the 1,117 Heller myotomy hospitalizations in the NIS 2003-2005, 10 (0.9%) had the diagnosis of esophageal perforation at discharge. Length of stay was negatively correlated with a hospital's number of Heller myotomy per year (correlation coefficient -0.171, P < 0.001). In multivariate log-linear regressions with a control group, a hospital's number of Heller myotomy per year was negatively associated with length of stay (coefficient -0.215 to -0.119, both P < 0.001) and total charges (coefficient -0.252 to -0.073, both P < 0.10). These findings were robust in alternative statistical models, specifications, and subgroup analyses. CONCLUSIONS: On a national level, the introduction of laparoscopic Heller myotomy for achalasia was associated with greater use of surgery and shorter length of stay. A larger volume of Heller myotomy in a hospital was associated with better perioperative outcomes in terms of shorter length of stay and lower total charges.