Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis.

BACKGROUND: We aimed to examine the outcomes and utilization of different hiatal hernia repair (HHR) approaches in elective and emergent/urgent settings. METHODS: Vizient 2015-2017 database was queried for adult patients who underwent HHR. Patients were grouped into open (OHHR), laparoscopic (LHHR), or robotic-assisted (RHHR), and further stratified by elective or urgent status and severity of illness at admission. Surgical outcomes and costs were compared across all groups. Statistical analysis were done using SPSS v.25.0. RESULTS: 9171 adults were included (OHHR N = 1534;LHHR N = 6796;RHHR N = 841). LHHR was the most utilized approach (74.1%), followed by OHRR (16.7%) and RHHR (9.2%). OHHR was employed three times as frequently in U settings, compared to elective. Overall, OHHR had longer mean length of stay (LOS; 9.41 vs. < 4 days) and higher postoperative complication rates (8.8% vs < 3.8%), mortality (2.7% vs < 0.5%) and mean direct cost ($27,842 vs < $10,407), when compared to both LHHR and RHHR, all p < 0.05. Analysis of mild to severely ill elective cases demonstrated LHHR and RHHR to be better than OHHR regarding complications (p < 0.05), cost (p < 0.001) and LOS (p < 0.013); there were insufficient extremely ill elective patients for meaningful analysis. In the urgent setting, minimally invasive approaches predominate, overtaken by OHHR only for the extremely ill. Despite the urgent setting, for mild-moderately ill patients, OHHR was statistically inferior to both LHHR and RHHR for LOS (p = 0.002, p < 0.0001) and cost (p = 0.0133, p < 0.001). In severe-extremely ill patients, despite being more utilized, OHHR was not superior to LHHR; in fact, complication, cost, and mortality trends (all p > 0.05) favored LHHR. CONCLUSION: Our analysis demonstrated LHHR to currently be the most employed approach overall. LHHR and RHHR were associated with lower cost, decreased LOS, complications, and mortality compared to OHHR, in all but the sickest of patients. Patients should be offered minimally invasive HHR, even in urgent/emergent settings, if technically feasible.

Current state of robotic use in inguinal hernia repair: a survey of minimally invasive hernia surgeons.

Little is known about how robot technology is employed by surgeons in minimally invasive surgery (MIS). We evaluated the needs of established robotic surgeons and of those who are new to this technology. A survey was designed and sent electronically to MIS surgeons. Questions included fellowship training, area of expertise, experience with robotic simulation and in clinical use, mentorship, likelihood of switching to a different approach, and expectations for the robot. Descriptive analysis was conducted using STATA/MP 15.1. 189 interviewees self-identified as hernia surgeons. 73.8% had additional fellowship, with majority practicing for 3-6 years (54%). Nearly 40% were MIS surgeons (N = 73), followed by general surgery (34.4%), and bariatrics (13.8%). 146 interviewees (77.7%) have used the daVinci® in clinical scenarios. Among robotic surgeons, majority were performing less than ten robotic cases per month. Inguinal hernia repairs were the leading procedures (49%), followed by foregut-related (19.5%), and colorectal-related surgeries (17.5%). Nearly 40% of surgeons stated inguinal hernia repairs to be the most often performed procedure using the robot. Nearly 40% of open and laparoscopic hernia surgeons are willing to adopt robotic-assisted procedures for their inguinal hernia repairs. Level 1 evidence (47.9%) and cost (24.1%) were the most pressing needs for robotic research. Majority of interviewees have used the daVinci® in clinical settings. Hernia repair remains the primary application of the robot in general surgery, among specialized surgeons. Over 40% of hernia surgeons are interested in switching to robotic technology over its open or laparoscopic counterparts.

Socio-Economic Implications Of A Younger Aged Female Predilection In Malignant Transformation Of Oral Sub Mucous Fibrosis.

BACKGROUND: This study was conducted to determine the age, gender and pattern of associated chewing habits among cases of oral squamous cell carcinoma (OSCC) presenting with, (OSMFCa) and without, (Ca-OSMF) pre-existing clinical oral submucous fibrosis in Karachi, Pakistan. METHODS: A cross sectional, multi centric study of (n=1009) cases with histologically confirmed oral squamous cell carcinoma seen at both public, private tertiary care hospitals and clinics over a period of eight years. A non-probability convenience sampling was used for selection of cases. Of these n=472 cases were reported as malignant transformation of clinical OSMF into OSCC: (OSMFCa) and n=537 were of OSCC without clinical evidence of OSMF: (Ca-OSMF). Qualitative analysis for gender and chewing patterns as well as chi square was performed for association. Age comparison between the OSMFCa and Ca-OSMF groups were performed by independent t test.. RESULTS: A total of n=1009 cases presenting with OSCC were examined. Of these 46.78% (n=472) cases were reported as OSMFCa and 53.22% (n=537) as Ca-OSMF. The comparison of age differences at presentation of OSMFCa and Ca- OSMF cases by independent t test was statistically significant (p<0.049). Both gender and chewing habits showed significant association with OSMFCa and Ca-OSMF. CONCLUSIONS: Common to both affected groups was consumption of betel quid, chewing tobacco and variants with males tending to move on to more complex combinations. An overall male trend was noted in OSCC, particularly in Ca- OSMF. However, proportion of females with OSMFCa was significantly higher than males. A significantly younger female affectation in this group has significant potential socio-economic consequences.

High risk of malignant transformation of oral submucous fibrosis in Pakistani females: A potential national disaster.

OBJECTIVE: To determine the relationship of age, gender and other associated risk factors linked with malignant transformation of oral submucous fibrosis into oral squamous cell carcinoma. METHODS: This cross-sectional, multi-centre study was conducted at both public and private tertiary care hospitals and clinics of Karachi, Pakistan, from 2004 to 2012, and comprised patients with oral submucous fibrosis and/or oral squamous cell carcinoma. Out of the total sample, malignant transformations of oral submucous fibrosis to oral squamous cell carcinoma were included. Cases of oral squamous cell carcinoma without clinical evidence of pre-existing oral submucous fibrosis were excluded. Sample selection was based on non-probability convenience sampling. SPSS 18 was used for data analysis. RESULTS: Of the 1774 cases, 765(43.12%) were of oral submucous fibrosis alone, 472(26.60%) were reported as malignant transformation of oral submucous fibrosis into oral squamous cell carcinoma and 537(30.27%) were of oral squamous cell carcinoma without clinically visible oral submucous fibrosis. Of the malignant transformation cases,370(78.4%) involved women and 102(21.6%)men.Besides,5(1.1%)patients were aged below 25 years, 266(56.4%)were 26-50 years and 201(42.6%)were aged 51 years or above, with the mean age of 21.80±3.1, 34.02±2.1 and 40.28±13.1 years, respectively (p=0.001).Moreover, 228(48.3%)patients used betel quid with tobacco, 108(22.9%) consumed areca nut only, 55(11.7%) chewed betel quid without tobacco, 36(7.6%)used naswar, while 45(9.5%)had no chewing habits (p=0.001).. CONCLUSIONS: The risk of developing oral squamous cell carcinoma was high, especially women.