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.

Morbidity of the abdominal wall resection and reconstruction after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

BACKGROUND: CRS/HIPEC has evolved as a therapeutic option for selected patients with peritoneal surface malignancies. To achieve complete cytoreduction (CC), some patients require extensive abdominal-wall resection (AWR) and subsequent complex reconstructions, which may be associated with wound complications (WC) and delay of postoperative cancer therapy. METHODS: Review of a prospective database of 350 patients revealed 213 patients with peritoneal carcinomatosis who underwent AWR due to suspected or proven wound/port site metastases during CRS/HIPEC. Tumor origin included: appendix, colon, ovarian, peritoneal mesothelioma, primary peritoneal, and others. WC were related to peritoneal carcinomatosis index (PCI), CC score, length of surgery, type of AWR and closure, blood transfusion, and albumin levels using binary logistic regression (odds ratios (OR) and 95 % CIs) analysis. RESULTS: PCI ≥ 20 was found in 151 (71 %), CC was achieved in 178 (84 %). Mean length of surgery was 613 min. Postoperative WC were detected in 49 of 213 (23 %) patients, 13 (6 %) had Grade III (according to Clavien-Dindo's classification) WC, and led to delay of postoperative chemotherapy. WC occurred in 21 of 64 (32.8 %) patients with excision of port sites (odds ratio [OR] = 2.11, confidence interval [CI] = 1.09-4.10, p = 0.026). Primary fascial closure was performed in 191 of 213 (89.7 %) patients, 40 (21 %) of whom had WC. Mesh-assisted abdominal wall reconstruction was required in 22 of 213 (10.3 %) patients, of whom 9 (40.9 %) had WC (OR = 2.61, CI = 1.04-6.55, p = 0.035). CONCLUSIONS: Port-site excision and mesh-assisted abdominal wall reconstruction were associated with higher incidence of postoperative WC following CRS/HIPEC. The implications of these preliminary findings may need to be considered during surgical planning for these patients.

Port-site metastases is an independent prognostic factor in patients with peritoneal carcinomatosis.

INTRODUCTION: Port-site metastases (PSMs) have been reported after laparoscopy in patients with peritoneal carcinomatosis (PC). We hypothesize that PSM is an independent negative predicting factor of survival in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). METHODS: A retrospective review of a prospective database was conducted to search patients who underwent laparoscopy prior to CRS/HIPEC. Most of the tumors were of appendiceal origin. All previous laparoscopy port sites were excised regardless of macroscopic tumor involvement. Patients were divided into two groups: patients with PSM [PSM (+)] and patients without PSM [PSM (-)]. Overall survival (OS) was estimated by Kaplan-Meier curves and the log-rank test. Cox regression [hazard ratios (HRs) and 95 % confidence intervals (CIs)] was used to test for independent effects of the PSM (+) and the associated clinicopathological variables. RESULTS: Sixty-five patients had laparoscopy before CRS/HIPEC. One hundred and forty-four port-sites were resected; 41 (29 %) ports were positive for malignancy in a total of 22 (34 %) patients. Mean OS at 1, 3, and 5 years was 88, 66, and 63 %, respectively. Survival in patients with PSM was 73, 35, and 23 %, respectively, compared with 95, 82, and 82 %, respectively, in patients without PSM (p ≤ 0.001). Positive lymph nodes (LNs) were detected in 13/22 patients with PSM and 11/43 patients without PSM. Independent effects on survival shows an HR of 3.136, 95 % CI 1.150-8.549 (p = 0.026) for LN metastases, and an HR of 3.462, 95 % CI 1.198-10.006 (p = 0.022) in patients with positive PSM. CONCLUSION: PSMs are common in patients with PC undergoing CRS/HIPEC and are independently associated with a worse prognosis. Resection of previous laparoscopy port sites is advocated in patients with PC to ensure complete cytoreduction.

Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Mesothelioma: Experience of a Peritoneal Surface Malignancy Center.

Diffuse malignant peritoneal mesothelioma (DMPM) is an uncommon malignancy, which can be difficult to treat. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have evolved as the treatment of choice when complete cytoreduction is to be achieved. This study reports the outcomes of CRS/HIPEC for peritoneal mesothelioma performed in a center for peritoneal surface malignancy. A retrospective analysis of a prospective database of 389 CRS/HIPEC procedures identified 23 patients who underwent CRS/HIPEC for DMPM from 1999 to 2014. Gender, age at diagnosis, age at surgery, previous surgeries, follow-up time, peritoneal cancer index (PCI) score, completeness of cytoreduction (CC), pathology, and overall survival (OS) were analyzed. The univariate analysis was used to determine the prognostic value of age, gender, neoadjuvant chemotherapy, histopathology of the tumor, PCI, CC, and lymph node status on survival. Mean follow-up time from surgery was 31 months (range = 0.5-124). The median PCI score was 28, and 77 per cent had PCI ≥20. CC 0-1 was achieved in 65 per cent of cases. One- and 5-year actuarial OS rates from diagnosis were 86 per cent and 60 per cent, respectively. One- and 5-year actuarial OS from HIPEC was 70 per cent and 64 per cent, respectively. The univariate analysis showed that the CC was the only significant prognostic factor. Patients with DMPM may achieve long-term survival when treated with CRS/HIPEC. The CC is the most significant prognostic factor for long-term survival.

Azygous vein laceration secondary to blunt thoraco-abdominal trauma.

Less than 25 cases of azygous vein lacerations secondary to blunt trauma have been published in the medical literature, most of these injuries were resulting from motor vehicle accidents, but have been described due to falls or assaults. These lesions should be considered as thoracic great vessels injuries and if not recognized promptly carry a high morbidity and mortality. We report a case of a young male involved in a high-speed car collision, admitted to the emergency room in an unstable condition secondary to hypovolemic shock due to azygous vein injury. The patient underwent emergent right antero-lateral thoracotomy followed by sternotomy for surgical control of the vascular injury and resuscitation. Laparotomy and splenectomy were also required, the abdomen was closed. The thoracic cavity was left packed and closure was delayed for 48 h. The patient survived and was transferred to another hospital seven days later.