Early Cholecystectomy in Patients with Sickle Cell Disease with Uncomplicated Cholelithiasis Is Associated with Better Outcomes.

BACKGROUND: Up to 85% of patients with sickle cell disease (SCD) will develop gallstones by their third decade. Cholecystectomy is the most commonly performed procedure in these patients. Cholecystectomy is recommended for patients with SCD with symptomatic cholelithiasis and leads to lower morbidity. No contemporary large studies have evaluated this recommendation or associated clinical outcomes. This study evaluates clinical outcomes after cholecystectomy in patients with SCD and cholelithiasis with specific advanced clinical presentations. STUDY DESIGN: The Nationwide Inpatient Sample was queried for patients with SCD and gallbladder disease between 2006 and 2015. Patients were divided into groups based on their disease presentation, including uncomplicated cholelithiasis, acute and chronic cholecystitis, and gallstone pancreatitis. Clinical outcomes associated with disease presentation were analyzed. Statistical analysis was performed using the Student's t -test, chi-square test, ANOVA, and logistic regression. RESULTS: There were 6,662 patients with SCD who presented with cholelithiasis. Median age was 20 (interquartile range 16 to 34) years and 54% were female patients. Cholecystectomy was performed in 1,779 patients with SCD with the most common indication being chronic cholecystitis (44%), followed by uncomplicated cholelithiasis (27%), acute cholecystitis (21%), and choledocholithiasis or gallstone pancreatitis (8%). On multivariable regression, advanced clinical presentation was the strongest predictor of perioperative vaso-occlusive crisis, which was the most common complication. Patients undergoing cholecystectomy for uncomplicated cholelithiasis were at lower risk than those with acute cholecystitis (odds ratio [OR] 2.37; 95% CI 1.64 to 3.41), chronic cholecystitis (OR 1.74; 95% CI 1.26 to 2.4), and choledocholithiasis or gallstone pancreatitis (OR 2.24; 95% CI 1.41 to 3.57). CONCLUSIONS: Seventy-three percent of patients with SCD have advanced clinical presentation at the time of their cholecystectomy. After cholecystectomy, perioperative vaso-occlusive events were significantly increased in patients with advanced clinical presentation. These data support screening abdominal ultrasounds and early cholecystectomy for cholelithiasis in patients with SCD.

Utilization and Outcomes of Roux-en-Y Gastric Bypass Surgery Following the Affordable Care Act in the United States.

BACKGROUND: The passage of the Affordable Care Act (ACA) in 2010 marked a pivotal moment in American health care policy, significantly expanding access to health care services. This study aims to explore the relationship between the ACA and the utilization and outcomes of Roux-en-Y Gastric Bypass (RYGB) surgery. METHODS: Using data from the National Inpatient Sample (NIS) Database, this retrospective study compares the pre-ACA period (2007-2009) with the post-ACA period (2017-2019), encompassing patients who had RYGB. Multivariable logistic analysis was done accounting for patient's characteristics, comorbidities, and hospital type. RESULTS: In the combined periods, there were 158 186 RYGB procedures performed, with 30.0% transpiring in pre-ACA and 70.0% in the post-ACA. Post-ACA, the proportion of uninsured patients decreased from 4.8% to 3.6% (P < .05), while Black patients increased from 12.5% to 18.5% (P < .05). Medicaid-insured patients increased from 6.8% to 18.1% (P < .05), and patients in the poorest income quartile increased from 20% to 26% (P < .05). Patients in the post-ACA period were less likely to have longer hospital stays (OR = .16: 95% CI .16-.17, P < .01), in-hospital mortality (OR = .29: 95% CI .18-.46, P < .01), surgical site infection (OR = .25: 95% CI .21-.29, P < .01), postop hemorrhage (OR = .24: 95% CI .21-.28, P < .01), and anastomotic leak (OR = .14: 95% CI .10-.18, P < .01) than those in the pre-ACA period. DISCUSSION: Following the implementation of the ACA, utilization of bariatric surgery significantly increased, especially among Black patients, Medicaid beneficiaries, and low-income patients. Moreover, despite the inclusion of more high-risk surgical patients in the post-ACA period, there were better outcomes after surgery.

Characteristics and resolution of hypertension in obese African American bariatric cohort.

Weight reduction continues to be first-line therapy in the treatment of hypertension (HTN). However, the long-term effect of bariatric malabsorptive surgical techniques such as Roux-en-Y Gastric Bypass (RYGB) surgery in the management of hypertension (HTN) is less clear. African Americans (AA) are disproportionately affected by obesity and hypertension and have inconsistent outcomes after bariatric surgery (BS). Despite a plethora of bariatric literature, data about characteristics of a predominantly AA bariatric hypertensive cohort including hypertension in obese (HIO) are scarce and underreported. The aims of this study were, (1) to describe the preoperative clinical characteristics of HIO with respect to HTN status and age, and (2) to identify predictors of HTN resolution one year after RYGB surgery in an AA bariatric cohort enrolled at the Howard University Center for Wellness and Weight Loss Surgery (HUCWWS). In the review of 169 AA bariatric patients, the average BMI was 48.50 kg/m2 and the average age was 43.86 years. Obese hypertensive patients were older (46 years vs. 37.89 years; p < .0001); had higher prevalence of diabetes mellitus (DM, 43.09% vs. 10.87%; p < .0001) and dyslipidemia (38.2% vs. 13.04%; p 0.002). Hypertensive AA who were taking ≥ 2 antihypertensive medications prior to RYGB were 18 times less likely to experience HTN resolution compared to hypertensive AA taking 0-1 medications, who showed full or partial response. Also, HIO was less likely to resolve after RYGB surgery in patients who needed ≥ 2 antihypertensive medications prior to surgical intervention.

The heavy price of conversion from laparoscopic to open procedures for emergent cholecystectomies.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard operative intervention for gallbladder disease. Complications may necessitate conversion to an open cholecystectomy (OC). This study aims to determine the cost-consequences of laparoscopic-to-open conversion using a nationally-representative sample. METHODS: Using the National Inpatient Sample (2007-2011), adult patients undergoing emergent LC were identified. Patients undergoing secondary-conversion to OC were subsequently identified. Multivariable regression analyses, accounting for differences in propensity-quintile, mortality, length of stay, and hospital-level factors were then performed to assess for differences in the odds of conversion and total predicted mean costs per index-hospitalization. RESULTS: Of 225,805 observations, conversion to open occurred in 1.86% (n = 4203) of cases. Increased age, African-American ethnicity, public-insurance and teaching-hospital status were associated with a higher likelihood of conversion (p < 0.05) after risk-adjustment. Risk-adjusted odds of conversion increased by 34% (95%CI:1.33-1.36) for each day surgery was delayed. Risk-adjusted costs, were 259% higher (absolute-difference $23,358,p < 0.05) with conversion. Mortality was higher amongst patients undergoing conversion to open (4.98% vs 0.34%,p < 0.001). CONCLUSION: Patients undergoing conversion from laparoscopic to open cholecystectomy are at an increased risk of receiving disparate care and increased mortality.

Socioeconomic disparities in the complexity of hernias evaluated at Emergency Departments across the United States.

BACKGROUND: Hernias represent one of the most common surgical conditions with a high-burden on health expenditures. We examined the impact of socioeconomic-status and complexity of presentation among patients in the Emergency Department (ED). METHODS: Retrospective analysis of 2006-2014 data from the Nationwide Emergency Department Sample, identified adult discharges with a diagnosis of inguinal, femoral, and umbilical hernia. Cases were dichotomized: complicated and uncomplicated. Unadjusted and adjusted analyses were used to determine factors that influence ED presentation. RESULTS: Among 264,484 patients included, 73% presented as uncomplicated hernias and were evaluated at urban hospitals (86%). Uncomplicated presentation was more likely in Medicaid (OR 1.56 95%CI1.50-1.61) and uninsured (OR 1.73 95%CI 1.67-1.78), but less likely for patients within the third and fourth MHI quartile (OR 0.82 95%CI 0.80-0.84 and OR 0.77 95%CI 0.75-0.79), respectively. CONCLUSION: Uninsured, publicly-insured, and low-MHI patients were more likely to present to ED with uncomplicated hernias. This finding might reflect a lack of access to primary surgical care for non-urgent surgical diseases.

Non-operative management of adhesive small bowel obstruction: Should there be a time limit after which surgery is performed?

The management of adhesive small bowel obstruction (ASBO) has evolved from "the sun should not rise and set on a small bowel obstruction", implying mandatory immediate surgical exploration to selective non-operative management. Not every patient with adhesive small bowel obstruction meets criteria for non-operative management and treating all comers the same way can lead to catastrophic outcomes. Water Soluble Contrast Medium (WSCM) has important diagnostic and therapeutic utility in the management of ASBO and should be employed ab initio. Laparoscopy has emerged as a reasonable and safe alternative to laparotomy for surgical management of ASBO in carefully selected patients and has distinct advantages.

Bariatric surgery outcomes in black patients with super morbid obesity: a 1-year postoperative review.

BACKGROUND: Super morbid obesity (body mass index [BMI] > 50 kg/m2) is associated with significant comorbidities and is disparagingly prevalent among the black population. There is paucity of data regarding bariatric surgery outcomes among super morbid obese (SMO) blacks. Our aim is to evaluate the reduction in weight and resolution of comorbidities after bariatric surgery among SMO black patients at an urban academic institution. METHODS: A retrospective review of SMO black patients who underwent bariatric surgery from August 2008 to June 2013 at Howard University Hospital. Outcomes of interest include weight loss, improvement or resolution of hypertension, type 2 diabetes, and hyperlipidemia at 12 months. RESULTS: Eighty-seven patients met our inclusion criteria. Mean preoperative weight and BMI were 347.2 lbs and 56.8 kg/m2, respectively. At 12 months, mean weight and BMI were 245.3 lbs and 40.1 kg/m2, respectively. There was also significant improvement or resolution of hypertension, type 2 diabetes, and hyperlipidemia. CONCLUSIONS: Bariatric surgery may result in significant weight loss and improvement or resolution of comorbidities in SMO black patients.

Revision of Roux-En-Y Gastric Bypass for Weight Regain: a Systematic Review of Techniques and Outcomes.

BACKGROUND: Weight regain has led to an increase in revision of Roux-en-Y gastric bypass (RYGB) surgeries. There is no standardized approach to revisional surgery after failed RYGB. We performed an exhaustive literature search to elucidate surgical revision options. Our objective was to evaluate outcomes and complications of various methods of revision after RYGB to identify the option with the best outcomes for failed primary RYGB. METHOD: A systematic literature search was conducted using the following search tools and databases: PubMed, Google Scholar, Cochrane Clinical Trials Database, Cochrane Review Database, EMBASE, and Allied and Complementary Medicine to identify all relevant studies describing revision after failed RYGB. Inclusion criteria comprised of revisional surgery for weight gain after RYGB. RESULTS: Of the 1200 articles found, only 799 were selected for our study. Of the 799, 24 studies, with a total of 866 patients, were included for a systematic review. Of the 24 studies, 5 were conversion to Distal Roux-en-y gastric bypass (DRYGB), 5 were revision of gastric pouch and anastomosis, 6 were revision with gastric band, 2 were revision to biliopancreatic diversion/duodenal switch (BPD/DS), and 6 were revision to endoluminal procedures (i.e., stomaphyx). Mean percent excess body mass index loss (%EBMIL) after revision up to 1 and 3-year follow-up for BPD/DS was 63.7 and 76 %, DRYGB was 54 and 52.2 %, gastric banding revision 47.6 and 47.3 %, gastric pouch/anastomosis revision 43.3 and 14 %, and endoluminal procedures at 32.1 %, respectively. Gastric pouch/anastomosis revision resulted in the lowest major complication rate at 3.5 % and DRYGB with the highest at 11.9 % when compared to the other revisional procedures. The mortality rate was 0.6 % which only occurred in the DRYGB group. CONCLUSION: All 866 patients in the 24 studies reported significant early initial weight loss after revision for failed RYGB. However, of the five surgical revision options considered, BPD/DS, DRYGB, and gastric banding resulted in sustained weight loss, with acceptable complication rate.

Morbid obesity is an independent risk factor for postoperative renal dysfunction in young adults: a review of the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Little information exists on the acute effects of elective surgery on renal function. Our aim was to determine if obesity was an independent risk factor for postoperative renal complications (RCs). METHODS: A total of 119,142 patients aged 18 to 35 years with body mass index (BMI) ≥18 kg/m(2) obtained from American College of Surgeons National Surgical Quality Improvement Project (2005 to 2010) were classified into standard BMI categories. Association between BMI and preoperative estimated glomerular filtration rate (eGFR; calculated using modification of diet in renal disease formula) was analyzed. Postoperative changes in eGFR and RCs were measured. Multivariate regression analysis was performed adjusting for all variables. RESULTS: Postoperatively, there was a reduction in eGFR among the overweight (-3.4 mL/min/1.73 m(2), P < .001), obese class I (-3.9 mL/min/1.73 m(2), P = .001), and obese class II (-5.3 mL/min/1.73 m(2), P < .001). The odds of any postoperative RC was significantly higher in obese class III patients (odds ratio = 2.01 95% confidence interval 1.07 to 3.76, P = .029). CONCLUSIONS: Results seen in patients with BMI greater than 40 indicate that BMI can serve as an independent predictor of RCs.

Race and socioeconomic disparities in national stoma reversal rates.

BACKGROUND: Many temporary stomas are never reversed leading to significantly worse quality of life. Recent evidence suggests a lower rate of reversal among minority patients. Our study aimed to elucidate disparities in national stoma closure rates by race, medical insurance status, and household income. METHODS: Five years of data from the Nationwide Inpatient Sample (2008 to 2012) was used to identify the annual rates of stoma formation and annual rates of stoma closure. Stomas labeled as "permanent" or those created secondary to colorectal cancers were excluded. Temporary stoma closure rates were calculated, and differences were tested with the chi-square test. Separate analyses were performed by race/ethnicity, insurance status, and household income. Nationally representative estimates were calculated using discharge-level weights. RESULTS: The 5-year average annual rate of temporary stoma creation was 76,551 per year (46% colostomies and 54% ileostomies). The annual rate of stoma reversal was 50,155 per year that equated to an annual reversal rate of 65.5%. Reversal rates were higher among white patients compared with black patients (67% vs 56%, P < .001) and among privately insured patients compared with uninsured patients (88% vs 63%, P < .001). Reversal rates increased as the household income increased from 61% in the lowest income quartile to 72% in the highest quartile (P < .001). CONCLUSIONS: Stark disparities exist in national rates of stoma closure. Stoma closure is associated with race, insurance, and income status. This study highlights the lack of access to surgical health care among patients of minority race and low-income status.

Body mass index in blunt trauma patients with hemorrhagic shock: opposite ends of the body mass index spectrum portend poor outcome.

BACKGROUND: There are controversial data on the relationship between trauma and body mass index. We investigated this relationship in traumatic hemorrhagic shock. METHODS: The "Glue Grant" database was analyzed, stratifying patients into underweight, normal weight (NW), overweight, Class I obesity, Class II obesity, and Class III obesity. Predictors of mortality and surgical interventions were statistically determined. RESULTS: One thousand nine hundred seventy-six patients were included with no difference in injury severity between groups. Marshall's score was elevated in overweight (5.3 ± 2.7, P = .016), Class I obesity (5.8 ± 2.7, P < .001), Class II obesity (5.9 ± 2.8, P < .001), and Class III obesity (6.3 ± 3.0, P < .001) compared with NW (4.8 ± 2.6). Underweight had higher lactate (4.8 ± 4.2 vs 3.3 ± 2.5, P = .04), were 4 times more likely to die (odds ratio 3.87, confidence interval 2.22 to 6.72), and were more likely to undergo a laparotomy (odds ratio 2.06, confidence interval 1.31 to 3.26) than NW. CONCLUSION: Early assessment of body mass index, with active management of complications in each class, may reduce mortality in traumatic hemorrhagic shock.

The sleepy surgeon: does night-time surgery for trauma affect mortality outcomes?

BACKGROUND: Sleepiness and fatigue affect surgical outcomes. We wished to determine the association between time of day and outcomes following surgery for trauma. METHODS: From the National Trauma Data Bank (2007 to 2010), we analyzed all adults who underwent an exploratory laparotomy between midnight and 6 am or between 7 am and 5 pm. We compared hospital mortality between these groups using multivariate logistic regression. Additionally, for each hour, a standardized mortality ratio was calculated. RESULTS: About 16,096 patients and 15,109 patients were operated on in the night time and day time, respectively. No difference was found in the risk-adjusted mortality rate between the 2 time periods (odds ratio .97, 95% confidence interval .893 to 1.058). However, hourly variations in mortality during the 24-hour period were noted. CONCLUSION: Trauma surgery during the odd hours of the night did not have an increased risk-adjusted mortality when compared with surgery during the day.

The diverse surgeons' initiative: longitudinal assessment of a successful national program.

BACKGROUND: The Diverse Surgeons Initiative (DSI) is a program that was created to provide underrepresented minority surgical residents with the clinical knowledge and minimally invasive surgical skills necessary to excel in surgical residency and successfully transition into surgical practice. The early success of the graduates of the program has been published; however, a more longitudinal assessment of the program was suggested and warranted. This study provides a 5-year follow-up of the 76 physicians that participated in the DSI from 2002 to 2009 to determine if the trend toward fellowship placement and academic appointments persisted. Additionally, this extended evaluation yields an opportunity to assess these young surgeons' professional progress and contributions to the field. STUDY DESIGN: The most current professional development and employment information was obtained for the 76 physicians that completed the DSI from 2002 to 2009. The percentage of DSI graduates completing surgical residency, obtaining subspecialty fellowships, attaining board certification, receiving fellowship in the American College of Surgeons, contributing to the peer-reviewed literature, acquiring academic faculty positions, and ascending to professional leadership roles were calculated and compared with the original assessment. RESULTS: Of the 76 DSI graduates, 99% completed general surgery residency. Of those eligible, 87% completed subspecialty fellowships; 87% were board certified; 50% received fellowship in the American College of Surgeons; 76% had contributed to the peer-reviewed literature; 41% had obtained faculty positions; and 18% held local, regional, or national professional leadership positions. CONCLUSIONS: This longitudinal analysis has revealed sustained success of the DSI in preparing underrepresented minority residents to excel in their training and transition into practice, obtain postsurgical fellowships, acquire faculty appointments, and contribute to the advancement of the field of surgery.

Laparoscopic surgery for trauma: the realm of therapeutic management.

BACKGROUND: The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients. METHODS: We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups. RESULTS: Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001). CONCLUSION: Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes.

Optimal time for early laparoscopic cholecystectomy for acute cholecystitis.

IMPORTANCE: There is growing evidence in support of performing early laparoscopic cholecystectomy (LC) for acute cholecystitis. However, the definition of early LC varies from 0 through 10 days depending on the research protocol. The optimum time to perform early LC is still unclear. OBJECTIVES: To determine whether outcomes after early LC for acute cholecystitis vary depending on time from presentation to surgery and to determine the optimum time to perform LC for acute cholecystitis. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective review of prospectively collected data from the Nationwide Inpatient Sample (NIS) for 2005 through 2009. The population-based sample included 95,523 adults (18 years and older) who underwent LC within 10 days of presentation for acute cholecystitis. INTERVENTIONS: Patients were categorized and analyzed in 2 ways based on length of time from presentation to surgery. First, patients were categorized into 3 groups: 0 through 1 day, 2 through 5 days, and 6 through 10 days. Second, we compared outcomes for each incremental preoperative day (days 0-5). MAIN OUTCOMES AND MEASURES: Outcomes of interest were mortality, length of stay, complications, and cost. Propensity score matching and generalized linear modeling were used. The hypothesis being tested was formulated after data collection was complete. RESULTS: A total of 95,523 patients were selected. After matching the 3 groups based on propensity scores, patients who underwent surgery during days 2 through 5 and days 6 through 10 had increasingly worse outcomes when compared with those undergoing surgery on days 0 through 1. The odds of mortality were 1.26 (95% CI, 1.00-1.58) and 1.93 (95% CI, 1.38-2.68), and the odds of postoperative infections were 0.88 (95% CI, 0.69-1.12) and 1.53 (95% CI, 1.05-2.23) for days 2 through 5 and days 6 through 10, respectively. Adjusted mean hospital cost increased from $8974 (days 0-1) to $17,745 (days 6-10). Analysis by each incremental day revealed the optimal time of surgery to be within the first 48 hours of presentation. CONCLUSIONS AND RELEVANCE: Laparoscopic cholecystectomy performed within 2 days of presentation of acute cholecystitis yielded the best outcomes and lowest costs. Although causality could not be established, delaying LC was associated with more complications, higher mortality, and higher costs.

Ureteral injury after laparoscopic versus open colectomy.

BACKGROUND AND OBJECTIVES: Ureteral injury is an infrequent but potentially lethal complication of colectomy. We aimed to determine the incidence of intraoperative ureteral injury after laparoscopic and open colectomy and to determine the independent morbidity and mortality rates associated with ureteral injury. METHODS: We analyzed data from the National Surgical Quality Improvement Program for the years 2005-2010. All patients undergoing colectomy for benign, neoplastic, or inflammatory conditions were selected. Patients undergoing laparoscopic colectomy versus open colectomy were matched on disease severity and clinical and demographic characteristics. Multivariate logistic regression analyses and coarsened exact matching were used to determine the independent difference in the incidence of ureteral injury between the 2 groups. Multivariate models were also used to determine the independent association between postoperative complications associated with ureteral injury. RESULTS: Of a total of 94,526 colectomies, 33,092 (35%) were completed laparoscopically. Ureteral injury occurred in a total of 585 patients (0.6%). The crude incidence in the open group was higher than that in the laparoscopic group (0.66% versus 0.53%, P=.016). CEM produced 14 630 matching pairs. Matched analysis showed the likelihood of ureteral injury after laparoscopic colectomy to be 30% less than after open colectomy (odds ratio, 0.70; 95% confidence interval, 0.51-0.96). Patients with ureteral injury were independently more likely to have septic complications and have longer lengths of hospital stay than those without ureteral injury. CONCLUSION: Laparoscopic colectomy is associated with a lower incidence of intraoperative ureteral injury when compared with open procedures. Ureteral injury leads to significant postoperative morbidity even if identified and repaired during the colectomy.

Is laparoscopy a risk factor for bile duct injury during cholecystectomy?

BACKGROUND AND OBJECTIVES: Previously, risk factors for bile duct injury have been identified as acute cholecystitis, male gender, older age, aberrant biliary anatomy, and laparoscopic cholecystectomy. METHODS: A retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2006 was performed with an inclusion criterion of cholecystectomy performed on hospital day 0 or 1. Patient- and hospital-level factors potentially associated with bile duct injury were examined by logistic regression. RESULTS: A total of 377,424 cholecystectomy patients were identified. There were 1124 bile duct injuries (0.30%), with 177 (0.06%) in the laparoscopic cholecystectomy group and 947 (1.46%) in the open cholecystectomy group (P < .001). On multivariate analysis, significant risk factors for bile duct injury were male gender (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.06-1.38; P = .006), age >60 years (OR, 2.23; 95% CI, 1.61-3.09; P < .001), and academic hospital status (OR, 1.37; 95% CI, 1.05-1.79; P = .02). Acute cholecystitis was associated with a lower risk of bile duct injury (OR, 0.67; 95% CI, 0.46-0.99; P = .044). CONCLUSION: Independent risk factors for bile duct injury included male gender, age >60 years, and academic hospital status. Laparoscopic cholecystectomy, obesity, insurance status, or hospital volume was not associated with an increased risk of bile duct injury.

Surgical management of esophageal diverticulum: a review of the Nationwide Inpatient Sample database.

BACKGROUND: Esophageal diverticulum is rare in the United States. The mainstay treatment of symptomatic esophageal diverticulum is surgical correction. Much of the available information regarding esophageal diverticulum and its surgical management has been derived from small studies and institutional reviews. Our study objective was to investigate the demographics, perioperative conditions, and predictors of outcomes after surgical treatment of acquired esophageal diverticulum using a nationally representative database. METHODS: A retrospective review using the Nationwide Inpatient Sample database from 2000-2009 was performed for patients with acquired esophageal diverticulum. The patients were stratified into Zenker's diverticulum (ZD) or non-Zenker's diverticulum (NZD) subgroups. The covariates retrieved included age, gender, ethnicity, insurance type, and Charlson comorbidity index. A multivariate analysis was performed to determine the predictors of postoperative morbidity. Discharge-level weights were applied. RESULTS: Overall, a total of 4253 patients met our inclusion criteria, 3197 (75%) with ZD and 1056 (25%) with NZD. In the ZD group, the mean age was 73 ± 12.3 y, and most were men (55%) and white (67%). The mean length of stay was 5.82 ± 8.08 d, and the mortality rate was 1.2%. The most common complication was septicemia or sepsis (2.0%). The black patients had higher odds of postoperative morbidity than the white patients (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.02-5.17). The risk of overall postoperative morbidity was 52% greater for women (OR 1.52, 95% CI 1.01-2.29). An increasing Charlson comorbidity index was an independent predictor of morbidity. In the NZD group, the mean age was 69 ± 13.9 y, and most were also men (51%) and white (63%). The mean length of stay was 8.13 ± 10.56 d, and the mortality rate was 1.6%. The most common complication was air leak (3.1%). The black and Hispanic patients had higher odds of postoperative morbidity than the white patients (OR 1.97, 95% CI 1.05-3.72 and OR 2.37, 95% CI 1.06-5.30, respectively). An increasing Charlson comorbidity index was an independent predictor of morbidity. Compared with laparoscopy, the risk of developing postoperative morbidity was higher with the thoracotomy procedure (OR 7.45, 95% CI 1.11-50.18). CONCLUSIONS: Using a nationally representative database, our study found that female gender, black race, and the presence of comorbidities were associated with increased postoperative morbidity among patients with ZD. Among the patients with NZD, black and Hispanic patients had worse postoperative morbidity than the white patients, and the presence of comorbidities was associated with increased postoperative morbidity. Thoracotomy for the correction of NZD was associated with increased postoperative morbidity compared with the laparoscopic approach.

Open versus laparoscopic hiatal hernia repair.

BACKGROUND: The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database. METHOD: The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for demographics and comorbidities while looking for independent risk factors for mortality. RESULTS: In total, 23,514 patients met the inclusion criteria. By surgical approach, 55% of patients underwent open abdominal, 35% laparoscopic, and 10% open thoracic repairs. Length of stay was significantly reduced for all patients after laparoscopic repair (P < .001). Age ≥60 years and nonwhite ethnicity were associated with significantly higher odds of death. Laparoscopic repair and obesity were associated with lower odds of death in the uncomplicated group. CONCLUSION: Laparoscopic repair of paraesophageal hiatal hernia is associated with a lower mortality in the uncomplicated group. However, older age and Hispanic ethnicity increased the odds of death.

Surgical management of complicated diverticulitis: a comparison of the laparoscopic and open approaches.

BACKGROUND: Laparoscopy has become a commonly used method of performing colectomies, but the outcomes associated with laparoscopy in the emergency setting have not been well studied. STUDY DESIGN: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients with diverticulitis without hemorrhage who underwent a colectomy. Patient data retrieved included demographics and preoperative comorbidities. Each member of the cohort received either a primary anastomosis (PA) or a colostomy. Open and laparoscopic procedures were compared within these subgroups. Multivariate logistic regression analyses were performed to compare the risk-adjusted odds of postoperative morbidity and mortality for laparoscopic and open procedures. The risk-adjusted impact of preoperative comorbidities was also assessed. RESULTS: A total of 11,981 patients in the database met the study criteria. The majority were female (53%) and Caucasian (82%), and the mean age was 58 (±13) years. Comorbidities of the cardiovascular, pulmonary, or renal systems were present in 47%, 5%, and 1% of the cohort, respectively. On bivariate analysis, patients undergoing laparoscopy experienced lower rates of complications with both PA (14% vs 26%, p < 0.001) and colostomy (30% vs 37%, p = 0.02). The laparoscopic approach was associated with decreased mortality rates for patients undergoing PA (0.24% vs 0.79%, p < 0.001). Multivariate analysis revealed that preoperative cardiovascular and pulmonary comorbidities were each associated with increased postoperative morbidity, and that the laparoscopic approach was associated with lower postoperative morbidity for patients undergoing PA. The reduced risk of death for patients undergoing laparoscopic PA (vs open approach) did not achieve statistical significance (odds ratio 0.68, p = 0.3). A small number of patients underwent laparoscopic colostomy (n = 237, 2.4%), and they did not have a significantly different risk of death. CONCLUSIONS: The laparoscopic approach is associated with lower complication rates compared with the open approach for the surgical treatment of diverticulitis with a primary anastomosis.