Feasibility and Outcomes of Same-Day Surgery in Primary and Reoperative Laparoscopic Hiatal Hernia Repair.

OBJECTIVE: To assess the feasibility and outcomes of same-day surgery in primary and reoperative laparoscopic hiatal hernia repairs. METHODS: Same-day surgery was planned in elective procedures with ASA II-IV. An Enhanced Recovery After Surgery (ERAS) protocol was implemented to achieve same-day surgery, and opioid-based anesthesia was replaced by opioid-free anesthesia. Outcomes were assessed by length of stay, transition from same-day surgery to observation or inpatient, and postoperative emergency department visits/readmissions. The predictors of same-day surgery were assessed. Values are presented as median (interquartile range). RESULTS: From 04/13/2017 to 09/29/2022, there were 518 laparoscopic hiatal hernia repairs in 491 patients, 428/518 (82.6%) were primary, and 90/518 (17.4%) were reoperative. In the primary group, 314/428 (73.4%) were planned as same-day surgery and 246/314 (78.3%) were performed as same-day surgery. Same-day surgery with opioid-based anesthesia protocol was performed in 77/314 (24.5%) vs. same-day surgery with opioid-free anesthesia protocol in 169/314 (53.8%), p < 0.001, 41/246 (16.7%) same-day surgery primary procedures had emergency department visit post-discharge, and 26/246 (10.6%) were readmitted. In the reoperative group, 51/90 (56.7%) were planned as same-day surgery, and 27/51 (52.9%) were performed as same-day surgery. Same-day surgery with opioid-based anesthesia protocol was performed in 2/51 (3.9%) vs. same-day surgery with opioid-free anesthesia protocol in 25/51 (49.0%), p < 0.001, 3/27 (11.1%) same-day surgery reoperative procedures had emergency department visit post-discharge, and 3/27 (11.1%) were readmitted. Opioid-free anesthesia protocol was the positive predictor of same-day surgery compared to opioid-based anesthesia protocol (OR 7.44 [95% CI: 2.94, 18.83]), p < 0.001. Negative predictors were ASA III compared to II (OR 0.52 [95% CI: 0.28, 0.94]), p = 0.031, and duration of operation (OR 0.98 [0.97, 0.99]) p < 0.001. CONCLUSION: Laparoscopic hiatal hernia repair can be performed as same-day surgery in the majority of primary and reoperative procedures with good outcomes and low postoperative emergency department visits and readmissions. The odds of same-day surgery are higher with opioid-free anesthesia, lower ASA, and shorter operative time.

Opioid-Free Anesthesia and Same-Day Surgery Laparoscopic Hiatal Hernia Repair.

BACKGROUND: Laparoscopic hiatal hernia repair is commonly performed with a 1 to 2 night hospitalization. Our aim was to compare the feasibility and short-term outcomes of same-day surgery (SDS) laparoscopic hiatal hernia repair with an opioid-based anesthesia protocol (OBAP) vs an opioid-free anesthesia protocol (OFAP). STUDY DESIGN: Outcomes and pharmacy costs of repairs with OBAP were compared with OFAP. Values were expressed as median (interquartile range) and costs as means. RESULTS: There were 244 primary laparoscopic repairs. OBAP was used in 191 of 244 (78.3%) vs OFAP in 53 of 244 (21.7%). The length of stay was 1 day (0 to 2) vs 0 days (0 to 1), p = 0.006. There was no difference between the percentage of patients requiring analgesics and dosage between the 2 groups. SDS was planned in 157 and performed in 74 of 122 (60.7%) vs 33 of 35 (94.3%), p < 0.001. The age was 56 years (45 to 63) vs 60 years (56 to 68), p = 0.025. There were more type I hiatal hernia in SDS-OBAP and more type III and IV in SDS-OFAP, p = 0.031. American Society of Anesthesiologists Physical Status was II (II-III) vs III (II-III), p = 0.045. SDS was not performed in 50 of 157 (31.8%), 48 of 122 (39.3%) vs 2 of 35 (5.7%), p < 0.001. Out of 157 planned SDS, nausea/retching were causes of transition in 19 of 122 (15.6%) vs 0 of 35 (0%), p = 0.020. Multivariable logistic regression showed the odds of SDS were 8.21 times (95% CI 3.10 to 21.71; p < 0.001) greater in OFAP compared with OBAP, adjusting for sex, age, body mass index, American Society of Anesthesiologists Physical Status, type of hiatal hernia, type of procedure, and duration of the operation. Patients with opioid medication after SDS discharge were 74 of 74 (100%) vs 22 of 33 (66.7%), p < 0.001. CONCLUSIONS: Opioid-free anesthesia increases the feasibility of SDS hiatal hernia repair with less perioperative nausea and comparable pain control and pharmacy cost.

Laparoscopic hiatal hernia repair as same day surgery: Feasibility, short-term outcomes and costs.

INTRODUCTION: Laparoscopic hiatal hernia repair is commonly performed with 1 night hospitalization. The aim was to assess repairs as same-day-surgery (SDS). METHODS: Costs/short-term outcomes of SDS were compared to hospital-stay < 24-h: observation (OBS) and hospital-stay ≥ 24-h: inpatient (INP). Outcomes were assessed by postoperative 30-day ER visits/readmissions. RESULTS: There were 262 procedures, excluding 50 reoperative repairs, 212 procedures were included: There were 66 SDS, 65 OBS and 81 INP. SDS vs. OBS: OBS were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. SDS vs. INP: INP were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. CONCLUSION: Laparoscopic hiatal hernia repair can be performed as SDS in majority of elective repairs with good short-term outcomes and reduced cost.

Laparoscopic Heller myotomy and Dor fundoplication in the same day surgery setting with a trained team and an enhanced recovery protocol.

BACKGROUND: The length of stay after Heller myotomy is 1-5 days. The aim was to report feasibility of the procedure as same day surgery (SDS). METHODS: Three steps of Enhanced Recovery After Surgery protocol: preoperatively, clear liquid diet for 24 hours, in preoperative area: antiemetics as dermal patch/IV form, 2: Intraoperatively, intubation in semi upright position, IV analgesics and antiemetics. 3: Postoperatively, clear liquid diet and discharge instructions. Patients were followed using a phone questionnaire. Values are median (interquartile range). RESULTS: Fifty-seven patients, 32 M (56%)/25F (44%), age 48 (35-59). First 45 were inpatient with LOS of 1 day. Last 12 were planned as same day surgery, 1/12 was discharged on POD#2, 11/12 (92%) were performed as same day surgery. The duration of operation: 139.5 min (114-163) inpatient: vs 123 (107-139) same day surgery, P < .01. Questionnaires were obtained in 78% inpatient at 40 months (25.6-67) vs 82% same day surgery at 8 (4-12). All were satisfied with the operation with no difference between the 2 groups. CONCLUSION: Heller myotomy can be planned as same day surgery and performed successfully in majority of patients with a trained team and an Enhanced Recovery After Surgery protocol focused on prevention of nausea, and pain control in perioperative period.

Patient-related risk factors associated with symptomatic recurrence requiring reoperation in laparoscopic hiatal hernia repair.

BACKGROUND: Recurrent hiatal hernia remains a challenge. METHODS: For initial repairs at our center: patients with 1 repair were compared to those who required reoperation for symptomatic recurrence. Subsequently, patients who had 1 repair at our center were compared to all patients who required reoperation (including initial repair at another center). RESULTS: There were 401 repairs: 308 primary repairs at our center and 93 reoperations, 287/308 (93%) required 1 repair and 21/308 (7%) required reoperation. Comparing 1 repair versus 21 reoperations, risk factors were abdominoplasty odds ratio = 32.0 (4.1-250.6), P < .001, postoperative lifting/vomiting odds ratio = 11.6 (3.2-42.1), P < .0002, tubal ligation odds ratio = 4.9 (1.1-22.6), P < .04 and height < 160 cm odds ratio = 3.9 (1.1-13.3) P < 0.03. Comparing 287 with 1 repair versus all 93 reoperations, risk factors were post-operative vomiting odds ratio = 22.7 (2.3-218.0), P < .007, abdominoplasty odds ratio = 5.6 (1.0-31.4), P < .0495, post-operative lifting odds ratio = 5.4 (2.2-12.9), P < .0002, age < 52 odds ratio = 3.6 (1.8-7.3), P < .0003, tubal ligation odds ratio = 3.2 (1.2-8.7), P < 0.019 and height < 160 cm odds ratio = 3.0 (1.5-6.1), P < 0.003. CONCLUSIONS: Younger age, shorter stature, heavy lifting or vomiting after surgery, abdominoplasty and tubal ligation are risk factors associated with symptomatic recurrence requiring reoperation.

Laparoscopic Repair of Large Hiatal Hernia Without the Need for Esophageal Lengthening With Low Morbidity and Rare Symptomatic Recurrence.

The aim of this study was to assess symptomatic recurrence in patients who underwent a laparoscopic repair of large hiatal hernia without an esophageal lengthening procedure. Patients who underwent a laparoscopic repair of a large hiatal hernia from September 2009 to September 2015 by a single surgeon were identified in the retrospective review. The patients were followed up prospectively by the operating surgeon using a structured questionnaire, administered by telephone, to assess the symptoms. Symptomatic recurrence was defined as the requirement for a reoperative procedure for symptomatic recurrent hiatal hernia. There were 215 laparoscopic repairs. Reoperations (n = 35) and type I hernias of <4 cm (n = 49) were excluded. The study population included 131 patients: 36 had type I hernia, 4 had type II hernia, 37 had type III hernia, and 54 had type IV hernia. There were 102 women and 29 men, aged 63 (56-74) years. For repair, 102 Toupet, 28 Nissen, and 1 Dor fundoplications were performed. The duration of the operation was 138 (119-172) minutes. Adequate esophageal length was obtained by mediastinal esophageal mobilization in all patients, without Collis gastroplasty. A mesh was used in 106 patients. There was 1 conversion and 2 delayed esophageal leaks. The length of stay was 2 (1-3) days. Perioperative complications included atrial fibrillation in 5 patients, gastric distension or ileus in 5 patients, reintubation in 3 patients, heparin-induced thrombocytopenia in 1 patient, and temporary dialysis in 1 patient. There was no 30-day or in-hospital mortality. The questionnaire was completed by 99 out of 131 patients (76%) at 24 (9-38) months; of the 99 patients, 85 (86%) were free of preoperative symptoms; 91 (92%) were satisfied with the operation; and 73 (74%) were off proton pump inhibitors. Reoperation for symptomatic recurrent hiatal hernia occurred in 8 of the 99 patients (8%), 2 in the perioperative period and 6 at 25 (8-31) months. Laparoscopic repair of large hiatal hernia can be performed with low morbidity and results in excellent patient satisfaction. Tension-free, intra-abdominal esophageal length can be achieved laparoscopically without Collis gastroplasty. Reoperation for symptomatic recurrence is rare.

Laparoscopic Reoperative Antireflux Surgery Is More Cost-Effective than Open Approach.

BACKGROUND: We previously reported on the outcomes of laparoscopic and open reoperative antireflux surgery. The aim of this study was to compare the costs of these procedures. STUDY DESIGN: We performed a retrospective review. Financial and procedure coding data were obtained using a cost accounting system. There were 49 procedures in 46 patients (36 female and 10 male). There were 38 laparoscopic (including 4 conversions) and 11 open procedures (7 transabdominal repairs and 4 gastric-preserving Roux-en-Y esophagojejunostomy). Values are median and interquartile range (IQR) and mean costs. RESULTS: Median age was 54 years (IQR 49 to 67 years) for the laparoscopic group vs 56 years (IQR 50 to 65 years) for the open group (p = 0.675). Mean direct costs per case for the laparoscopic group vs open group were $12,655 vs $24,636 (p < 0.002); operating room costs: $3,788 vs $5,547 (p = 0.011); hospital room costs: $1,948 vs $6,438 (p < 0.005); and supply costs: $4,386 vs $5,386 (p = 0.077). Median duration of the operation for the laparoscopic group was 185 minutes (IQR 147 to 254 minutes) vs 308 minutes (IQR 259 to 416 minutes) for the open group (p < 0.002). Median length of stay for the laparoscopic group was 3 days (IQR 2 to 4 days) vs 9 days (IQR 8 to 14 days) for the open group (p < 0.001). There was no 30-day or in-hospital mortality. Excluding the 4 Roux-en-Y procedures, direct costs for the laparoscopic group (n = 38) were $12,655 vs $23,678 for the transabdominal group (n = 7) (p = 0.035); duration of operation: 185 minutes (IQR 147 to 254 minutes) vs 292 minutes (IQR 218 to 309 minutes) (p = 0.003); and length of stay: 3 days (IQR 2 to 4 days) vs 9 days (IQR 7 to 15 days) (p = 0.017). There were 3 recurrences in the laparoscopic group. Two were repaired laparoscopically and 1 required a gastric-preserving Roux-en-Y esophagojejunostomy because the patient had undergone 2 earlier failed repairs. Including the cumulative costs of 3 recurrent hiatal hernia repairs, the driving force to reduce costs remained length of stay, manifested by the costs of the hospital rooms. CONCLUSIONS: Laparoscopic reoperative antireflux surgery is more cost-effective than open repair. The laparoscopic approach, when feasible, should be considered the surgical option for treatment of recurrent hiatal hernia in specialized esophageal centers with highly experienced surgical teams.

Characteristics, length of stay, and hospital bills associated with severe odontogenic infections in Houston, TX.

BACKGROUND: There were 2 main purposes of this retrospective chart review study. The first was to describe the demographic, social, and financial characteristics of patients with severe odontogenic infections. The second was to assess the relationships among several demographic, social, and treatment variables and length of stay (LOS) in the hospital and hospital bill (charges). METHODS: The authors conducted a retrospective chart review for patients admitted to the hospital and taken to the operating room for treatment of severe odontogenic infections at 3 hospitals in Houston, TX (Ben Taub, Memorial Hermann Hospital, and Lyndon B. Johnson) from January 2010 through January 2015. RESULTS: The authors included data from severe odontogenic infections in 298 patients (55% male; mean age, 38.9 years) in this study. In this population, 45% required admission to the intensive care unit, and the mean LOS was 5.5 days. Most patients (66.6%) were uninsured. The average cost of hospitalization for this patient population was $13,058, and the average hospital bill was $48,351. At multivariable analysis, age (P = .011), preadmission antibiotic use (P = .012), diabetes mellitus (P = .004), and higher odontogenic infection severity score (P < .001) were associated with increased LOS. Higher odontogenic infection severity score, diabetes mellitus, and an American Society of Anesthesiologists score of 3 or more were associated with an increased charge of hospitalization. CONCLUSIONS: Severe odontogenic infections were associated with substantial morbidity and cost in this largely unsponsored patient population. The authors identified variables associated with increased LOS and charge of hospitalization. PRACTICAL IMPLICATIONS: Clinicians should consider these findings in their decision-making processes and prioritize early treatment of odontogenic infections potentially to decrease the number of patients admitted to the hospital, LOS, and overall costs of treatment for these infections.

Laparoscopic reoperative antireflux surgery: A safe procedure with high patient satisfaction and low morbidity.

BACKGROUND: Laparoscopic reoperative antireflux surgery remains challenging and the advantages compared to an open approach remain unclear. METHODS: Retrospective chart review and follow-up questionnaire via phone. RESULTS: 50 reoperative hiatal hernia repairs were performed in 47 patients. VALUES: median and interquartile range (IQR). There were 10 males, 37 females, 55 (49-66) years. Reoperative procedures: 38 laparoscopic vs. 12 open transabdominal. Length of operation: 185 (147-254) vs. 325 (276-394) minutes (p < 0.0008). Length of stay: 3 (2-4) vs.10 (8-13) days (p < 0.0001). None required Collis gastroplasty. There was no 30-day mortality. Follow-up questionnaire was obtained in 36/45 (80%) at 21 (11-40) months (2 cancer related deaths). In all, 24/36 (67%) were free of preoperative symptoms and 33/36 (92%) were satisfied with the operation. There was no difference between the laparoscopic and open group. CONCLUSIONS: Laparoscopic reoperative antireflux surgery is a safe approach with high patient satisfaction and low morbidity. Tension-free esophageal length can be achieved laparoscopically without Collis gastroplasty. The duration of the operation and length of stay are less in the laparoscopic vs. open group. Symptomatic relief and patient satisfaction are similar in both approaches.

Empyema necessitans caused by actinomycosis: A case report.

INTRODUCTION: Pulmonary actinomycosis is an uncommon clinical entity that the practicing thoracic surgeon rarely encounters. Empyema necessitans represents an even less common presentation of this pathology, and the often indolent disease course leads to early misdiagnosis in many cases. Familiarity with the varied presentations and possible operative strategies is essential to obtaining successful outcomes. PRESENTATION OF CASE: A 56-year-old male presented with swelling and pain over the lateral chest wall. Initial imaging studies demonstrated a mass concerning for infection vs. neoplasia. Further studies were obtained to confirm the diagnosis, with rapid progression of the mass. Surgical exploration with aggressive debridement of the chest wall without thoracotomy was performed. Actinomyces was identified on final pathology, confirming the diagnosis of Actinomycosis empyema necessitans. DISCUSSION: Traditional management strategies often involve pulmonary resection in addition to extended duration antimicrobial therapy. This report describes the uncommon clinical presentation and successful management of actinomycosis empyema necessitans with early limited operative intervention. CONCLUSION: In the event of minimal pulmonary involvement and absence of lung abscess, as was seen in this case, a thoracotomy with pulmonary resection can be avoided, and antibiotic duration limited.

Pneumomediastinum: etiology and a guide to diagnosis and treatment.

BACKGROUND: Pneumomediastinum may be associated with mediastinal organ injury. The aim of this study was to identify predictive factors of mediastinal organ injury in patients with pneumomediastinum to guide diagnosis and treatment. METHODS: A retrospective review was conducted including patients aged ≥18 years with Current Procedural Terminology code 518.1 (interstitial emphysema) from 2005-2011. RESULTS: There were 279 of 343 patients (81%) with and 64 of 343 (19%) without history of trauma. In the trauma population, 13 patients (5%) were found to have mediastinal organ injuries, 10 (4%) had airway injuries, and 3 (1%) had esophageal injuries. In the nontrauma population, 36 patients (56%) had spontaneous pneumomediastinum, esophageal injuries were seen in 17 (27%), pneumothorax in 9 (14%), and airway injuries in 2 (3%). The predictors of esophageal injury were instrumentation (odds ratio [OR], 45.7; P < .0001), pleural effusion (OR, 10.5; P < .0001), and vomiting (OR, 9.3; P < .0001). Previous instrumentation was the most significant predictor of airway injury (OR, 9.05; P < .02). CONCLUSIONS: Mediastinal organ injury in patients with pneumomediastinum is uncommon. Patients presenting with pneumomediastinum without a history of instrumentation, pleural effusion, or vomiting most commonly do not have mediastinal organ injuries.

A surgical team with focus on staff education in a community hospital improves outcomes, costs and patient satisfaction.

BACKGROUND: Outcomes, decreased costs, and patient satisfaction are the driving forces of a successful surgical practice. METHODS: A surgical team was assembled on October 1, 2010, and educational sessions were implemented. The outcomes and costs for patients who underwent laparoscopic fundoplication and Heller myotomy before and after October 1, 2010, were compared. A Press Ganey patient satisfaction survey was mailed to all patients. RESULTS: There were 268 procedures (103 before and 165 after October 1, 2010): 64 laparoscopic fundoplications and Heller myotomies (23 before and 41 after). There were significant reductions in median operating time (185 minutes [interquartile range {IQR}, 155 to 257 minutes] vs 126 minutes [IQR, 113 to 147 minutes]; P = .001), length of stay (2.0 days [IQR, 2.0 to 4.0 days] vs 1.0 day [IQR, 1.0 to 2.5 days]; P = .05), operating room costs ($2,407 [IQR, $2,171 to $2,893] vs $2,147 [IQR, $1,942 to $2,345]; P = .004), and hospital room costs ($937 [IQR, $799 to $2,159] vs $556 [IQR, $484 to $937]; P = .044). The survey showed significant improvements in patients' experiences in communication with nurses (P = .025), pain management (P = .000), communication about medications (P = .037), and discharge instructions (P = .024). CONCLUSIONS: Assembling a surgical team with focus on staff education has a significant impact on outcomes, costs, and patient satisfaction.

Mediastinal mature teratoma in a Jehovah's Witness: Discrepancy between imaging and intraoperative findings.

INTRODUCTION: Primary mediastinal germ cell tumors are exceedingly rare but may present with a wide spectrum of elements. The occasional mediastinal teratoma that presents completely comprised of mature elements is a benign tumor but the appearance on imaging studies may be more suggestive of an invasive tumor. The treatment is complete resection but the assessment of resectability based on computed tomographic imaging can be misleading. PRESENTATION OF CASE: We present a case of a 26 year old female, Jehovah's Witness who presented with a symptomatic mediastinal mass that on CT scan appeared to be unresectable due to presumed invasion of adjacent structures including the left pulmonary artery. Surgical exploration revealed an encapsulated, completely resectable mass which was excised without difficulty. Her early postoperative course was uneventful and at 18 months follow up is doing well without evidence of recurrence. DISCUSSION: The treatment of mature teratoma is complete surgical excision but the imaging studies may at times be misleading. We believe this case presents a unique clinical situation, since mediastinal mature teratomas are very rare and in addition, the preoperative decision to excise a mass becomes more complex in a case of a Jehovah's Witness. This case illustrates that the CT findings may be misleading when assessing a mediastinal mass. CONCLUSION: Resectability of a mediastinal mass can only be assessed at the time of operation and rarely should operation be denied solely on the basis of findings on imaging. Thus in these primary mediastinal tumors there should be a low threshold for proceeding with operation.

Changes in age, stage distribution, and survival of patients with esophageal adenocarcinoma over three decades in the United States.

BACKGROUND: Our aim was to evaluate the changes in age, stage distribution, and overall survival (OS) of patients with esophageal adenocarcinoma (EAC) over time. METHODS: Patients from the Surveillance, Epidemiology, and End Results (SEER) database aged ≥ 20 with invasive EAC, diagnosed from 1973-2003 were reviewed. Survival follow-up ended in 2006. RESULTS: There were 11,620 patients; 6580 (57%) aged ≥ 65. The stage distribution was 22%, 35%, and 43% for localized, regional, and distant metastasis for patients aged <65, and 33%, 33%, and 34% for patients aged ≥ 65. The number of patients ≥ 65 years with localized stage increased over time. Three-year OS for localized, regional, and distant disease increased from 19%, 10%, and 1% in 1973-1976, to 34%, 13%, and 2% in 1987-1991, and to 45%, 25%, and 4% in 2002-2003 (P < 0.001). A sub-analysis of 5475 patients from 1988-2002 showed better survival for patients with esophagectomy for all stages. Three-year OS for 2074 patients with esophagectomy improved every 5 years from 1988-2002 (39%, 43% to 54%, P < 0.001). Stratified by stage, year and esophagectomy status, patients aged <65 had better survival compared to patients aged ≥ 65 (P < 0.001). CONCLUSIONS: There has been a substantial improvement in overall survival among patients with invasive EAC over the last 3 decades. Patients receiving esophagectomy had longer survival. Survival with esophagectomy improved in each time period. Although younger EAC patients were diagnosed at more advanced stages over time, they had better survival.