Emergent Repair of Paraesophageal Hernias and the Argument for Elective Repair.

BACKGROUND AND OBJECTIVES: A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients who require an emergent operation are subject to increased morbidity compared with patients undergoing elective operations. In this study, we detail patients who underwent hernia repair emergently and compare their outcomes with elective patients. METHODS: A retrospective analysis was performed of the paraesophageal hernia repair operations between 2010 and 2016. Patients were divided into 2 groups: patients with hernias that were repaired electively and patients with hernias that were repaired emergently. Perioperative complications and follow-up data regarding morbidity, mortality, and recurrence were also recorded. A propensity analysis was used to compare emergent and elective groups. RESULTS: Thirty patients had hernias repaired emergently, and 199 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a postoperative complication, and have a longer hospital stay. However, propensity analysis was used to demonstrate that when characteristics of the emergent and elective groups were matched, differences in these factors were no longer significant. Having an emergent operation did not increase a patient's risk for recurrence. CONCLUSION: Patients who had their hernias repaired emergently experienced complications at similar rates as those of elective patients with advanced age or comorbid conditions as demonstrated by the propensity analysis. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair, especially in younger patients who are otherwise good operative candidates.

Trends in splenectomy: where does laparoscopy stand?

BACKGROUND AND OBJECTIVES: Laparoscopic splenectomy (LS) has been shown to offer superior outcomes when compared to open splenectomy (OS). Despite the potential advantages associated with the minimally invasive technique, laparoscopy appears to be underused. We sought to evaluate the nationwide trends in LS. METHODS: The Nationwide Inpatient Sample (NIS) database was queried for both OS and LS procedures performed from 2005 through 2010. Partial splenectomies and those performed for traumatic injury, vascular anomaly, or as part of a pancreatectomy were excluded. The included cases were examined for age of the patient and comorbid conditions. We then evaluated the postoperative complications, overall morbidity, mortality, and length of hospital stay. RESULTS: A total of 37,006 splenectomies were identified. Of those, OS accounted for 30,108 (81.4%) cases, LS for 4,938 (13.3%), and conversion to open surgery (CS) for 1,960 (5.3%). The overall rate of morbidity was significantly less in the LS group than in the OS group (7.4% vs 10.4%; P < .0001). The LS group had less mortality (1.3% vs 2.5%, P < .05) and a shorter length of stay (5.6 ± 8 days vs 7.5 ± 9 days). CONCLUSIONS: Despite the benefits conferred by LS, it appears to be underused in the United States. There has been an improvement in the rate of splenectomies completed laparoscopically when compared to NIS data from the past (8.8% vs 13%; P < .05). The conversion rate is appreciably higher for LS than for other laparoscopic procedures, suggesting that splenectomies require advanced laparoscopic skills and that consideration should be given to referring patients in need of the procedure to appropriately experienced surgeons.

Treatment and outcomes of iatrogenic colon perforations at a community teaching hospital.

Despite the growing expertise in colonoscopy, it remains subject to complications. The previously published rate of colonoscopic perforation is 0.82 per 1000 examinations. The objective of this study was to describe the experience and management of colonoscopic perforations. A retrospective review of cases from a database of surgical complications was searched for perforations postcolonoscopy from January 1, 2001, to December 31, 2010 at a 527-bed community teaching hospital. Eighteen patients were identified, 11 of whom underwent examination at our institution. Ages ranged from 40 to 91 years with a mean age of 71 years. Eleven of the 18 patients were female and seven were male. Main outcome measures were treatment approach, treatment complications, and mortality. A total of 18 patients were identified in this database. Of these 18 patients, 11 underwent colonoscopy at our institution. During the studied time period, 7578 colonoscopies were performed at our hospital. The majority of the perforations were located in the rectosigmoid colon. Seventeen patients were treated with surgical exploration of the abdomen. Ten patients experienced complications postoperatively. There were two deaths in our series. Only cases in which the colonoscopy was performed at our institution were used when making incidence calculations. The incidence of perforation in our series was significantly higher than previously reported rates. When the perforation was discovered and treated within 24 hours, the patient was rescued. Timely recognition of surgical complications is critical in preventing patient mortality.