A fast tract to foregut surgery: Pandemic-driven protocol development.

BACKGROUND: COVID-19 has overwhelmed many health care systems which has affected the landscape of elective surgery. A pandemic driven protocol was developed to perform foregut surgeries as a Same Day Surgery (SDS) discharge for all comers to reduce resource utilization. METHODS: Retrospective review of all patients who underwent elective laparoscopic foregut surgery (hiatal hernia, paraesophageal hernia, heller myotomy, and fundoplication) from 8/1/2020-1/31/2022 by a single surgeon after the implementation of a SDS protocol. Patients were compared to a pre-pandemic cohort, from 8/1/2019-4/30/2020, when overnight admission was standard practice. RESULTS: There were 36 pre-pandemic patients, and 41 pandemic patients successfully discharged the same day of surgery. We failed to detect a statistically significant difference between the two groups regarding 30-day ED visit rate (p-value of 0.4557) and 30-day readmission rate (p-value of 0.6790). CONCLUSION: The creation of a SDS protocol for foregut surgery is a safe way to deliver much needed care to the community while decreasing resource utilization.

Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair.

INTRODUCTION: Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair. METHODS: A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software. RESULTS: Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm3, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm2, p < 0.001). In multivariate analysis, HSV increase of 100cm3 (OR 1.17 CI 1.02-1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence. CONCLUSIONS: Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.