Malpractice claims after antireflux surgery and paraesophageal hernia repair: a population-based analysis.

BACKGROUND: The complication rate of modern antireflux surgery or paraesophageal hernia repair is unknown, and previous estimates have been extrapolated from institutional cohorts. METHODS: A population-based retrospective cohort study of patient injury cases involving antireflux surgery and paraesophageal hernia repair from the Finnish National Patient Injury Centre (PIC) register between Jan 2010 and Dec 2020. Additionally, the baseline data of all the patients who underwent antireflux and paraesophageal hernia operations between Jan 2010 and Dec 2018 were collected from the Finnish national care register. RESULTS: During the study period, 5734 operations were performed, and the mean age of the patients was 54.9 ± 14.7 years, with 59.3% (n = 3402) being women. Out of all operations, 341 (5.9%) were revision antireflux or paraesophageal hernia repair procedures. Antireflux surgery was the primary operation for 79.9% (n = 4384) of patients, and paraesophageal hernia repair was the primary operation for 20.1% (n = 1101) of patients. A total of 92.5% (5302) of all the operations were laparoscopic. From 2010 to 2020, 60 patient injury claims were identified, with half (50.0%) of the claims being related to paraesophageal hernia repair. One of the claims was made due to an injury that resulted in a patient's death (1.7%). The mean Comprehensive Complication Index scores were 35.9 (± 20.7) and 47.6 (± 20.8) (p = 0.033) for antireflux surgery and paraesophageal hernia repair, respectively. Eleven (18.3%) of the claims pertained to redo surgery. CONCLUSIONS: The rate of antireflux surgery has diminished and the rate of paraesophageal hernia repair has risen in Finland during the era of minimally invasive surgery. Claims to the PIC remain rare, but claims regarding paraesophageal hernia repairs and redo surgery are overrepresented. Additionally, paraesophageal hernia repair is associated with more serious complications.

Postoperative Complications and Reoperative Surgery in the Treatment of Patients With Zenker Diverticulum.

Importance: The association of the surgical approach, surgical specialty, and other factors with the outcomes of surgical treatment of Zenker diverticulum (ZD) have been debated in the literature. Objectives: To explore the outcomes of 3 different surgical methods used in the management of ZD and determine the associations between patient characteristics, such as preoperative comorbidities and treatment outcomes. Design, Setting, and Participants: This retrospective, population-based cohort study examined patient records of patients who underwent surgical treatment for ZD from the Care Register for Healthcare database in Finland between January 1996 and December 2015. Data review and analysis were completed in 2021. Exposure: Surgical treatment for ZD. Main Outcome and Measures: Complications of surgical procedures used in the management of ZD. Results: In this study, 1044 patients (median [IQR] age, 70.0 [22.0-98.0] years; 416 female individuals [39.8%]) surgically treated for ZD were identified. Most patients (606 [58.0%]) had no preoperative comorbidities. A total of 67 (6.4%) complications were recorded, with a mortality rate of 0.9%. The likelihood of complications was associated with patient age (t [1042] = 2.28; Cohen d, 0.29; 95%, CI 0.04, 0.54), surgical approach (Cramer V = 0.14 [95% CI 0.07-0.21]), and surgical specialty (Cramer V, 0.16; 95% CI, 0.06-0.28). The median (IQR) length of stay in association with the primary surgical intervention was 3.0 (0-85.0) days. Length of stay was associated with patient age (Cramer V, 0.14; 95% CI, 0.06-0.25), especially in patients older than 90 years, surgical approach (F [2, 466.2] = 26.9; ηp2 = 0.08; 95% CI, 0.05-0.11), and surgical specialty (F [4, 22.1] = 11.0; ηp2 = 0.07; 95% CI, 0.04-0.10). Reoperation was associated with the initial surgical approach (Cramer V, 0.18; 95% CI, 0.12-0.23) and surgical specialty (Cramer V, 0.14; 95% CI, 0.09-0.21). Conclusions and Relevance: The results of this cohort study suggest that the outcomes of surgical management depended on the surgical approach, surgical specialty, and patient age. Overall, surgical treatment may be considered safe and may be considered for all patients with symptomatic ZD.

Epidemiology and Management of Zenker Diverticulum in a Low-Threshold Single-payer Health Care System.

IMPORTANCE: The incidence of Zenker diverticulum has been established; previous estimates have been extrapolated from small institutional cohorts. OBJECTIVE: To describe the population-wide incidence of Zenker diverticulum over a 20-year period and characterize management strategies across specialties and treatment settings. DESIGN, SETTING, AND PARTICIPANTS: This retrospective national cohort study was conducted from January 1, 1996, through December 31, 2015, and reviewed patient records from the Care Register for Healthcare in Finland, from which patients with Zenker diverticulum were identified. The data were analyzed in October 2021. EXPOSURES: Zenker diverticulum. MAIN OUTCOME AND MEASURE: The incidence of Zenker diverticulum per 100 000 person-years. RESULTS: A total of 2736 patients (median [IQR] age at diagnosis 72.0 [19-106] years; 1278 women [46.7%]) were identified, making the annual incidence of Zenker diverticulum in Finland 2.9/100 000 person-years. Men had higher incidence (3.7/100 000 person-years) compared with women (2.3/100 000 person-years), with an incidence rate ratio of 1.61 (95% CI, 1.48-1.76; P < .001). Within the study population, 1044 patients (38.2%) underwent surgical treatment and 227 (8.3%) underwent 2 or more surgeries. The choice of initial operative approach depended on the medical specialty (Cramer V = 0.41) and on specific catchment area (Cramer V = 0.41). Overall, endoscopic approaches for initial operations were most popular. CONCLUSIONS AND RELEVANCE: The cohort study results found that the incidence of Zenker diverticulum was 2.9/100 000 person-years. Most patients with Zenker diverticulum did not undergo definitive therapy. Some hospital districts and some medical specialties were more likely to opt for conservative treatment than others. The choice of operative approach depended more on physician-level factors rather than patient profiles.

Learning curve in robotic-assisted lobectomy for non-small cell lung cancer is not steep after experience in video-assisted lobectomy; single-surgeon experience using cumulative sum analysis.

BACKGROUND: Robotic assistance in lung lobectomy has been suggested to enhance the adoption of minimally invasive techniques among surgeons. However, little is known of learning curves in different minimally invasive techniques. We studied learning curves in robotic-assisted versus video- assisted lobectomies for lung cancer. METHODS: A single surgeon performed his first 75 video-assisted thoracic surgery (VATS) lobectomies from April 2007 to November 2012, and his 75 first robotic-assisted thoracic surgery (RATS) lobectomies between August 2011 and May 2018. A retrospective chart review was done. Cumulative sum (CUSUM) analysis was used to identify the learning curve. RESULTS: No operative deaths occurred for VATS patients or RATS patients. Conversion-to-open rate was significantly lower in the RATS group (2.7% vs. 13.3%, p = 0.016). Meanwhile, 90-day mortality (1.3% vs. 5.3%, p = 0.172), postoperative complications (24% vs. 24%, p = 0.999), re- operation rates (4% vs. 5.3%, p = 0.688), operation time (170±56 min vs. 178±66 min, p = 0.663) and length of stay (8.9 ± 7.9 days vs. 8.2 ± 5.8 days, p = 0.844) were similar between the two groups. Based on CUSUM analysis, learning curves were similar for both procedures, although slightly shorter for RATS (proficiency obtained with 53 VATS cases vs. 45 RATS cases, p = 0.198). CONCLUSIONS: Robotic-assisted thoracoscopic lung lobectomy can be implemented safely and efficiently in an expert center with earlier experience in VATS lobectomies. However, there seems to be a learning curve of its own despite the surgeon's previous experience in conventional thoracoscopic surgery.

Health-related quality of life after laparoscopic repair of giant paraesophageal hernia: how does recurrence in CT scan compare to clinical success?

BACKGROUND: Computed tomography (CT) is widely used in the diagnosis of giant paraesophageal hernias (GPEH) but has not been utilised systematically for follow-up. We performed a cross-sectional observational study to assess mid-term outcomes of elective laparoscopic GPEH repair. The primary objective of the study was to evaluate the radiological hernia recurrence rate by CT and to determine its association with current symptoms and quality of life. METHODS: All non-emergent laparoscopic GPEH repairs between 2010 to 2015 were identified from hospital medical records. Each patient was offered non-contrast CT and sent questionnaires for disease-specific symptoms and health-related quality of life. RESULTS: The inclusion criteria were met by 165 patients (74% female, mean age 67 years). Total recurrence rate was 29.3%. Major recurrent hernia (> 5 cm) was revealed by CT in 4 patients (4.3%). Radiological findings did not correlate with symptom-related quality of life. Perioperative mortality occurred in 1 patient (0.6%). Complications were reported in 27 patients (16.4%). CONCLUSIONS: Successful laparoscopic repair of GPEH requires both expertise and experience. It appears to lead to effective symptom relief with high patient satisfaction. However, small radiological recurrences are common but do not affect postoperative symptom-related patient wellbeing.

Thoracotomy and VATS Surgery in Local Non-Small-Cell Lung Cancer: Differences in Long-Term Health-Related Quality Of Life.

BACKGROUND: As a result of routine low-dose computed tomographic screening, lung cancer is more frequently diagnosed at earlier, operable stages of disease. In treating local non-small-cell lung cancer, video-assisted thoracoscopic surgery (VATS), a minimally invasive surgical approach, has replaced thoracotomy as the standard of care. While short-term quality-of-life outcomes favor the use of VATS, the impact of VATS on long-term health-related quality of life (HRQoL) is unknown. PATIENTS AND METHODS: We studied patients who underwent lobectomy for the treatment of non-small-cell lung cancer from January 2006 to January 2013 at a single institution (n = 456). Patients who underwent segmentectomy (n = 27), who received neoadjuvant therapy (n = 13), or who were found to have clinical stage > T2 or > N0 disease (n = 45) were excluded from analysis. At time of HRQoL assessment, 199 patients were eligible for study and were mailed the generic HRQoL instrument 15D. RESULTS: A total of 180 patients (90.5%) replied; 92 respondents underwent VATS while 88 underwent open thoracotomy. The VATS group more often had adenocarcinoma (P = .006), and lymph node stations were sampled to a lesser extent (P = .004); additionally, hospital length of stay was shorter among patients undergoing VATS (P = .001). No other clinical or pathologic differences were observed between the 2 groups. Surprisingly, patients who underwent VATS scored significantly lower on HRQoL on the dimensions of breathing, speaking, usual activities, mental function, and vitality, and they reported a lower total 15D score, which reflects overall quality of life (P < .05). CONCLUSION: In contrast to earlier short-term reports, long-term quality-of-life measures are worse among patients who underwent VATS compared to thoracotomy.

Surgically Treated Unsuspected N2-Positive NSCLC: Role of Extent and Location of Lymph Node Metastasis.

BACKGROUND: The role of surgery in the treatment of non-small-cell lung cancer that has spread to ipsilateral mediastinal or hilar lymph nodes (LNs) is controversial. We examined whether the location of LNs positive for non-small-cell lung cancer in mediastinum or hilum influences the survival of these patients. PATIENTS AND METHODS: We reviewed data from 881 patients and analyzed those with unsuspected N2 disease or hilar (station 10) LNs. The patients were stratified into the following groups: group A, positive hilar Naruke 10; group B, superior mediastinal and aortic nodes (Naruke 1, 2, 3, 4, 5, and 6); group C, inferior mediastinal nodes (Naruke 7, 8, and 9), and multilevel group D (2 or more positive N2 levels). RESULTS: A total of 69 pN2 and 19 pN1 patients were included. Progression-free survival (PFS) was statistically significant better in group B versus group C (P = .044) and group B versus group D (P = .0086). The overall survival (OS) of group A did not differ from that of group C. A statistically significant better OS was found between groups B and D (P = .051). CONCLUSION: Inferior positive mediastinal N2 node patients seem to have an OS and PFS as poor as multilevel N2 disease patients. The OS and PFS of patients with positive hilar disease are similar to those in the inferior mediastinal positive N2 group. Superior positive mediastinal N2 node patients have better OS and PFS than the inferior mediastinal positive N2 group.

Bronchial sleeve resection or pneumonectomy for non-small cell lung cancer: a propensity-matched analysis of long-term results, survival and quality of life.

BACKGROUND: No randomized studies exist comparing pneumonectomy (PN) and sleeve lobectomy (SL). We evaluated surgical results and long-term quality of life in patients operated on for central non-small cell lung cancer (NSCLC) using either SL or PN. METHODS: A total of 641 NSCLC patients underwent surgery 2000-2010. SL was performed in 40 (6.2%) and PN in 67 (10.5%). In 2011, all surviving patients were sent a 15D Quality of Life Questionnaire which 83% replied. Propensity-score-matching analysis was utilized to compare the groups. RESULTS: Thirty-two bronchial (18 right/14 left), seven vasculobronchial (3 right/4 left), one right wedge SL, and 18 right and 22 left PN were performed. Preoperatively, the Charlson Comorbidity Index (CCI) score, forced expiratory volume in 1 s (FEV1) and diffusion capacity did not differ between groups. The perioperative complication rate and pattern were similar, but SL group had less major complications (P<0.027). One perioperative death (2.5%) occurred in SL group and four (6%) in PN. The 90-day mortality rate was 5% (n=2) for SL and 7.5% (n=5) for PN. In the follow-up total cancer recurrence did not differ (P=0.187). Quality of life measured by 15D showed no significant difference in separate dimensions or total score, except tendency to favor SL in moving or breathing. The 5-year survival did not differ between groups (P=0.458), but no deaths were observed in SL group after 5 years. CONCLUSIONS: Due to less major operative complications and better long-term survival, we would advocate using SL when feasible, but in patients tolerating PN it should be considered if SL seems not to be oncologically sufficiently radical.