Impact of Surgeon Workload on Pregnancy Outcomes in Surgical Trainees and Faculty.

OBJECTIVE: To investigate the association between workload and pregnancy outcomes among US surgical faculty and trainees. SUMMARY BACKGROUND DATA: Despite the increased risk of pregnancy associated complications among surgeons, most US institutions do not have formalized support to help sustain a healthy pregnancy in surgeons. METHODS: An anonymous self-administered Qualtrics survey was distributed electronically to US surgeons across all surgical specialties. Female surgical trainees/faculty with current or previous pregnancy were invited to participate. Data pertaining to demographics, workload, and pregnancy outcomes were collected for each individual pregnancy resulting in live birth. Multivariate analysis was used to assess for workload and outcomes, controlling for age, race, gravidity, and use of assisted reproductive technology. A significance level of 0.0056 was used for each outcome (Bonferroni multiple-testing adjustment 0.05/9). RESULTS: 817 surgeons experiencing 1348 pregnancies resulting in live birth were included. The mean (SD) age at first live birth was 32(4). The most prevalent major and neonatal complications included preeclampsia/gestational hypertension (n=196, 14.5%) and preterm delivery (n=179, 12.8%), respectively. Most institutions did not have a policy regarding workload modification (n=1189, 88.5%). Most surgeons did not modify their workload (n=862, 63.9%). When looking at individual workload metrics, feeling overworked during the last week of pregnancy correlated with risk of major complication (P=0.0001), preeclampsia/gestational hypertension (P=0.0003), and intra/post-partum complication (P=0.0001). Association with unplanned cesarean section (P=0.0096) and preterm delivery (P=0.0036) reached nominal significance. CONCLUSIONS: Most surgeons do not modify their workload during pregnancy, potentially contributing to feeling overworked and peri-partum complications. There is an urgent need for a cultural shift and institutional policies to safeguard the health and wellbeing of pregnant surgeons.

Morbidity and mortality following hiatal hernia repair in geriatric patients: a multicenter research network study.

BACKGROUND: Hiatal hernia is a common surgical pathology. Such hernias can be found incidentally and patients may opt for an initial nonoperative approach though many will pursue surgery after symptom progression. Data on the effects of age on the outcomes of hiatal hernia repair may help inform this decision-making process. METHODS: The TriNetX database was queried for all adult patients undergoing hiatal hernia repair from 2000 to 2023. Patients were divided into elective and emergent cohorts on the basis of diagnosis codes indicating obstruction or gangrene. Patients aged 80-89 were compared against those aged 65-79 in unadjusted analysis. Logistic regression models controlling for additional health history covariates were created to calculate odds ratios for primary outcomes. RESULTS: There were 2310 octogenarians and 15,295 seniors who underwent elective hiatal hernia repair, and 406 octogenarians and 1462 seniors who underwent emergent repair during the study period. The vast majority of patients in both groups underwent minimally invasive operations. In the elective cohort, octogenarians had higher rates of mortality, malnutrition, sepsis, respiratory failure, pneumonia, DVT, blood transfusion, and discharge to nursing facility. In the emergent cohort, octogenarians had higher rates of mortality, malnutrition, sepsis, and respiratory failure. The odds ratios for mortality in the elective and emergent cohorts were 3.9 (95% CI 3.1-5.0) and 3.5 (95% CI 2.1-5.6), respectively. CONCLUSION: Octogenarians are at a meaningfully increased risk for mortality and morbidity after both elective and emergent hiatal hernia repair compared to senior-aged patients. Greater consideration should be given to surgical repair prior to the 8th decade of life.

SAGES guidelines for the use of laparoscopy during pregnancy.

BACKGROUND: When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD). METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient. RESULTS: The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy. CONCLUSIONS: Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.

Primary anastomosis with diverting loop ileostomy vs. Hartmann's procedure for acute diverticulitis: what happens after discharge? Results of a nationwide analysis.

BACKGROUND: Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge. METHODS: This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease. RESULTS: Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137]. CONCLUSION: Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.

What Happens After Discharge? A 2+ Year Follow-Up After Laparoscopic Subtotal Fenestrating and Reconstituting Cholecystectomy.

Laparoscopic subtotal cholecystectomy (LSC) is utilized to prevent complications in the difficult cholecystectomy. Medium-term outcomes are poorly studied for fenestrating and reconstituting operative techniques. A single-institution retrospective review was undertaken of all LSCs. A telephone survey was used to identify complications addressed at other institutions. We performed subgroup analyses by operative approach and of patients requiring postoperative endoscopic intervention (ERC). 28 patients met inclusion criteria. The median follow-up was 32.7 months. There were no bile duct injuries or reoperations. 21% of patients required a postoperative ERC and 50% were discharged home with a drain. Bile leaks were found to be more prevalent in the fenestrating LSC group (38% vs 0%, P = .003). The case series suggested more severe recurrent biliary disease in patients undergoing reconstituting LSC. Laparoscopic subtotal cholecystectomy appears to have satisfactory medium-term outcomes. The reconstituting LSC group trends toward more severe recurrent disease which warrants further investigation.

Supradiaphragmatic origin of the celiac trunk leading to median arcuate ligament syndrome with superior mesenteric artery involvement.

Median arcuate ligament (MAL) syndrome (MALS) is a rare condition caused by compression of the celiac artery by the MAL. Symptoms include abdominal pain, nausea, and weight loss. Rarely, the MAL can compress both the celiac artery and the superior mesenteric artery (SMA). We describe the case of a young man with MALS involving the celiac artery and SMA. Laparoscopic release of the MAL was performed, and the patient had resolution of his symptoms at 6 months of follow-up. A review of the literature identified only six cases of MALS involving the SMA and celiac artery, making this a rare occurrence.

Weight loss and clinical outcomes following primary versus secondary Roux-en-Y gastric bypass: a multi-institutional experience.

BACKGROUND: Revisional bariatric surgeries are increasing for weight recurrence and return of co-morbidities. Herein, we compare weight loss and clinical outcomes following primary Roux-en-Y Gastric Bypass (P-RYGB), adjustable gastric banding to RYGB (B-RYGB), and sleeve gastrectomy to RYGB (S-RYGB) to determine if primary versus secondary RYGB offer comparable benefits. METHODS: Participating institutions' EMRs and MBSAQIP databases were used to identify adult patients who underwent P-/B-/S-RYGB from 2013 to 2019 with a minimum one-year follow-up. Weight loss and clinical outcomes were assessed at 30 days, 1 year, and 5 years. Our multivariable model controlled for year, institution, patient and procedure characteristics, and excess body weight (EBW). RESULTS: 768 patients underwent RYGB: P-RYGB n = 581 [75.7%]; B-RYGB n = 106 [13.7%]; S-RYGB n = 81 [10.5%]. The number of secondary RYGB procedures increased in recent years. The most common indications for B-RYGB and S-RYGB were weight recurrence/nonresponse (59.8%) and GERD (65.4%), respectively. Mean time from index operation to B-RYGB or S-RYGB was 8.9 and 3.9 years, respectively. After adjusting for EBW, 1 year %TWL (total weight loss) and %EWL (excess weight loss) were greater after P-RYGB (30.4%, 56.7%) versus B-RYGB (26.2%, 49.4%) or S-RYGB (15.6%, 37%). Overall comorbidity resolution was comparable. Secondary RYGB patients had a longer adjusted mean length of stay (OR 1.17, p = 0.071) and a higher risk of pre-discharge complications or 30-day reoperation. CONCLUSION: Primary RYGB offers superior short-term weight loss outcomes compared to secondary RYGB, with decreased risk of 30-day reoperation.

A surgeon's framework for the unplanned intraoperative consultation.

PURPOSE: Surgeons will likely be called to assist with or offer advice regarding an unanticipated intraoperative event or finding many times during their careers. Yet, there is no practical framework of how to respond to these consults nor is there any formal training in this area. The review of the limited literature and expert senior opinions can help explain the ethical components involved but does not address some of the practical aspects that the consulting surgeon may need to confront when responding to an unplanned intraoperative consultation. METHODS: We reviewed the existing surgical literature on intraoperative consultation across surgical disciplines and interpreted it in light of our own experiences and the advice of senior surgical colleagues. RESULTS: We present a framework for the minimum professional expectations of a surgeon responding to an intraoperative consultation. CONCLUSION: In this manuscript, we present a selected review of the available literature on the topic, establish some of the guiding ethical principles, and offer an actionable and detailed framework that can support trainees and practicing surgeons dealing with these increasingly common and stressful unplanned circumstances.

Increased incidence of marginal ulceration following conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a multi-institutional experience.

BACKGROUND: Marginal ulcer (MU) formation is a serious complication following Roux-en-Y Gastric Bypass (RYGB). Incidental data suggested a higher incidence of MU following conversion of Sleeve Gastrectomy to RYGB (S-RYGB). Herein, we evaluate the incidence of MU after primary versus secondary RYGB. METHODS: After IRB approval, each institution's electronic medical record and MBSAQIP database were queried to retrospectively identify adult patients who underwent primary RYGB (P-RYGB), Gastric Banding to RYGB (B-RYGB), or S-RYGB between 2014 and 2019, with minimum 1 year follow-up. Patient demographics, operative data, and post-operative outcomes were compared. Numeric variables were compared via two-sample t test, Wilcoxon test or Kruskal Wallis rank sum test. Two-sample proportion test or Fisher's exact test was employed for categorical and binary variables. p < 0.05 marked statistical significance. RESULTS: 748 patients underwent RYGB: P-RYGB n = 584 [78.1%]; B-RYGB n = 98 [13.1%]; S-RYGB n = 66 [8.8%]. Most patients were female (83.2%). Mean age was 45.7 years. Forty-six (n = 6.1%) patients developed MU, a median of 14 ± 32.2 months (range 0.5-82) post-operatively. Incidence of MU was significantly higher for patients undergoing S-RYGB (n = 9 [13.6%]), compared to P-RYGB (n = 34 [5.8%]) and B-RYGB (n = 3 [3.1%]) (p = 0.023). Median time (months) to MU was significantly shorter for patients who underwent S-RYGB (5 ± 6) compared to P-RYGB or B-RYGB (19 ± 37.5) (p = 0.035). Among those who developed MU, there was no significant difference in H. pylori status, NSAID, steroid, or tobacco use, irrespective of operation performed. CONCLUSION: In this multi-institutional cohort, patients who underwent S-RYGB had a significantly higher incidence of MU than those with P-RYGB or B-RYGB. Further research is needed to elucidate its pathophysiology and prevention strategies.

Cessation of Routine Jejunostomy Tube Placement at Time of Minimally Invasive Ivor Lewis Esophagectomy and Impact on Body Mass Index.

Jejunostomy tubes are frequently placed at time of esophagectomy. The purpose of this study is to evaluate cessation of routine j-tube placement on postoperative body mass index (BMI), return to the emergency room, and time until adjuvant therapy. We performed a retrospective review of an institutional database for consecutive patients undergoing minimally invasive Ivor Lewis Esophagectomy from 2014-2021 (after January 2019, routine j-tube placement was abandoned). Data was analyzed using Pearson's Chi-squared tests and Student's t test with 2-sided significance level of P < 0.05. In total,179 patients were included, 95 underwent j-tube placement and 84 did not. Cohorts had comparable baseline BMI's (no j-tube: 30.48 vs j-tube: 28.64, P = 0.06) and anastomotic leak rates (2.4% vs 4.2%, P = 0.5). Patients with no jejunostomy tubes were more likely to receive total parenteral nutrition (14.3% vs 5.3%, P < 0.05), but were no more likely to require total parenteral nutrition at discharge and had comparable durations of TPN requirement (7 days vs 12 days, P = 0.53). There was no difference in mean BMI reduction at 2 weeks (2.54 vs 2.09, P = 0.49) and 3-6 months postoperatively (6.11 vs 4.45 P = 0.15). There was no difference in return to the emergency room (8.3% vs 8.4%, P = 0.98) or readmissions (13.1% vs 11.6%, P = 0.76). There was a no difference in mean time to adjuvant therapy (83.5 days vs 72.6 days, P = 0.67). At esophagectomy centers with low anastomotic leak rates, cessation of routine j-tube placement at time of minimally esophagectomy can be undertaken without increasing risk of readmission, time until initiation of adjuvant therapy, or significantly impacting postoperative BMI loss.

Toward Zero Prescribed Opioids for Outpatient General Surgery Procedures: A Prospective Cohort Trial.

INTRODUCTION: Achieving satisfactory post-operative pain control for common elective general surgical procedures, while minimizing opioid utilization, remains challenging. Utilizing pre-operative educational strategies, as well as multimodal analgesia, we sought to reduce the post-operative opioid use in elective general surgery cases. METHODS: Between November 2019 and July 2021, patients undergoing elective inguinal hernia repair or cholecystectomy were enrolled in the study. Patients were divided into three cohorts: Control, opioid sparing (OS), or zero-opioid (ZO). Control patients did not have any intervention; OS patients had an opioid reduction intervention protocol applied (patient education and perioperative multimodal analgesia) and were provided an opioid prescription at discharge; the ZO had the same protocol, however, patients were not provided opioid prescriptions at discharge. Two weeks after discharge, patients were interviewed to record opioid consumption, pain scores, and level of satisfaction since discharge. RESULTS: A total of 129 patients were recruited for the study. Eighty-eight patients underwent inguinal hernia repair and 41 patients underwent cholecystectomy. Median post-operative morphine equivalents consumed in the Control cohort (n = 58); 46 (37.5-75) were significantly reduced when the OS protocol was enacted (n = 42); 15 (11-22.5) and further reduced to zero for every patient in the ZO cohort (n = 29) (P = 0.0001). There were no differences in patient-reported average pain scores after discharge (P = 0.08) or satisfaction levels with experience (P = 0.8302). CONCLUSIONS: Our study demonstrates that patient education and preoperative interventions can result in zero opioids prescribed after common general surgery procedures with equivalent patient satisfaction and pain scores.

Minor Sea Turtle Nesting Areas May Remain Unnoticed without Specific Monitoring: The Case of the Largest Mediterranean Island (Sicily, Italy).

Identifying coastal tracts suitable for sea turtle reproduction is crucial for sea turtle conservation in a context of fast coastal development and climate change. In contrast to nesting aggregations, diffuse nesting is elusive and assessing nesting levels is challenging. A total of 323 nesting events by the loggerhead sea turtle Caretta caretta have been reported in Sicily, the largest Mediterranean island, in the 1944-2021 period, mostly in the last decade. Specific monitoring efforts are the most likely explanation for such an increase and shows that sea turtle nesting may be underestimated or completely ignored in many areas with scattered nesting. The real nesting level along the 464 km sandy shores of Sicily is still unknown and more research is needed. The observed incubation period was relatively long (57 d) suggesting that a majority of males are produced in Sicily, in contrast to the typical female-biased sex ratio of sea turtles. In a context of climate warming producing sex ratios more skewed towards females, the potential of Sicily as a male-producing area should be further investigated. Other reproductive parameters are provided, such as clutch size and hatching and emergence success. A negative effect of relocation on the latter two was observed.

Neuromuscular response to the stimulation of plantar cutaneous during walking at different speeds.

BACKGROUND: A lot of authors have been studied the consequence of postural control strategies through investigating the effects of foot-surface contact. In this context an important variable of textured surfaces or insoles could be related to material stiffness. We apply a particular textured insoles to evaluate neuromuscular response of plantar stimulation during walking. RESEARCH QUESTION: Could textured insoles alter the human locomotion during walking at different speeds? METHODS: Ten adults (age: 27 ± 5 years) completed three trials on the multifunction treadmill at 0.42 ms-1, 0.89 ms-1, and 1.5 ms-1 walking speed. Temporal-spatial parameters, gait line, and kinetic parameters were analyzed. The Co-Contraction Index (CCI) and electromyography (EMG) of the right leg muscles were assessed during four phases of gait: first half stance (FHS), half stance (HS), second half stance (SHS), swing phase (SP). Textured insole and soft control insole were worn while walking. RESULTS: Plantar stimulation improved cadence, stride time, stride length and gait line parameters with increasing speed. First force peaks and maximum force forefoot were always significant. The maximum force midfoot was significant at 0.42 and 0.89 ms-1. The maximum force heel only was significant in lower velocity. The maximum pressure showed different significant values except for the heel. Significant differences in the CCI were always found in the FHS and SHS for the plantar muscles, and in the FHS and HS for the knee muscles. The differences in gait analysis in biomechanical and in electromyographic parameters were more significant in the higher speed tested. SIGNIFICANCE: The perception of shape and texture through its linear response to skin deformation over a wide range of deformations could be the reason why the significant differences increase in the higher speed. In conclusion, sensory interventions fallowing appropriate insoles can influence significantly gait. Walking strategy positively adjusts locomotion with high efficiency.

National recurrence of pancreatitis and readmissions after biliary pancreatitis.

BACKGROUND: National and international guidelines support early cholecystectomy after mild gallstone pancreatitis but a recent nationwide study suggested these recommendations are not universally followed. Our study sought to quantify the national utilization of same hospitalization cholecystectomy versus non-operative management (NOM) and its association with pancreatitis recurrence, readmissions, and costs after mild gallstone pancreatitis (GP). METHODS: Adult patients admitted with mild GP were identified from the Nationwide Readmission Database 2010-2015. Primary outcomes included the rate of cholecystectomy during the index admission as well as pancreatitis recurrence and readmission at 30 and 180 days (30d, 180d) comparing NOM to same hospitalization cholecystectomy. Mortality upon readmission, total length of stay (LOS), and total costs (combined index-readmission hospital costs) were also explored. Cox proportional hazards regression and generalized linear models controlled for patient/hospital confounders. RESULTS: Among the 65,067 patients identified, 30% underwent cholecystectomy. The NOM cohort was older (58 vs. 50 years), had more comorbidities (Charlson index > 2, 23.5% vs. 11.5%), fewer female patients (56.7% vs. 67%) and less discharge-to-home (84.9% vs. 94.4%) (all p < 0.001). NOM was associated with increase in recurrence and unplanned readmissions at 30d [Hazard Ratio 3.53 (95% CI 2.92-4.27), 2.41 (2.11-2.74), respectively], and 180d [4.27 (3.65-4.98), 2.78 (2.54-3.04), respectively], as well as increased mortality during 180d readmission 1.88 (1.06-3.35). This approach was also associated with significant increase in LOS [predicted mean difference 2.79 days (95% CI 2.46-3.12)] and total costs [$2507.89 ($1714.4-$3301.4)]. CONCLUSIONS: In the USA, most patients presenting with mild GP do not undergo same hospitalization cholecystectomy. This strategy results in higher recurrent pancreatitis, mortality during readmission, and an additional $4.85 M/year in hospital costs nationwide. These data support same hospitalization cholecystectomy as the gold standard for mild GP.

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

BACKGROUND: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques. METHODS: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication. CONCLUSIONS: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

The effect of age, sex and a firm-textured surface on postural control.

In previous studies, the influence of plantar sensation has been examined using various textured surfaces with different stiffness materials to assess static balance. This study investigated the effects of a Firm Textured Surface (FTS) along with age and sex-related influences on postural control under different visual conditions. Forty subjects (20 elderly, 10 males, mean age 68.30, 10 females, mean age 68.00, and 20 young people, 10 males, mean age 25.45, 10 females, mean age 27.30) participated in this study maintained a quiet standing on FTS, foam and firm surfaces with eyes open and closed. The center of pressure displacement (CoPDISP), CoP velocity (CoPVEL), and sway velocity of the CoP in anteroposterior (AP) and mediolateral (ML) direction (VA/P and VM/L) were measured. FTS was associated with lower postural sway measures in both the groups with eyes open and closed. However, the foam surface showed the worst results in all postural parameters under all experimental conditions. Separate four-way ANOVAs were applied to each dependent variable. The main effects of surface (p < 0.0001), vision (p < 0.0001) and age (p < 0.0001 for CoPDISP, CoPVEL and VA/P; p = 0.0003 for VM/L) were significant in each of the four fitted models. Sex was never significant, either as a main effect or an interaction with other experimental factors. Eyes open were able to reduce the negative effects of the foam surfaces but without vision the proprioceptive sensory system cues of the body state become more important for maintaining balance. A good stimulation with rigid texture should be considered as relief to reduce the physiological-related decline of afferent information with age.

The Effect of Postoperative Complications After Minimally Invasive Esophagectomy on Long-term Survival: An International Multicenter Cohort Study.

BACKGROUND: Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity. OBJECTIVE: Although the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival. METHODS: Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival. RESULTS: A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication [ie, (re)intervention, organ dysfunction, or death]. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25-2.24]. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30-2.58). For all other complications, no significant association with long-term survival was found. CONCLUSION: The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients.

Is the placement of jejunostomy tubes in patients with esophageal cancer undergoing esophagectomy associated with increased inpatient healthcare utilization? An analysis of the National Readmissions Database.

BACKGROUND: Patients undergoing esophagectomy often receive jejunostomy tubes (j-tubes) for nutritional supplementation. We hypothesized that j-tubes are associated with increased post-esophagectomy readmissions. STUDY DESIGN: We identified esophagectomies for malignancy with (EWJ) or without (EWOJ) j-tubes using the 2010-2015 Nationwide Readmissions Database. Outcomes include readmission, inpatient mortality, and complications. Outcomes were compared before and after propensity score matching (PSM). RESULTS: Of 22,429 patients undergoing esophagectomy, 16,829 (75.0%) received j-tubes. Patients were similar in age and gender but EWJ were more likely to receive chemotherapy (24.2% vs. 15.1%, p < 0.01). EWJ was associated with decreased 180-day inpatient mortality (HR 0.72 [0.52-0.99]) but not with higher readmissions at 30- (15.2% vs. 14.0%, p = 0.16; HR 0.9 [0.77-1.05]) or 180 days (25.2% vs. 24.3%, p = 0.37; HR 0.94 [0.79-1.10]) or increased complications (p = 0.37). These results were confirmed in the PSM cohort. CONCLUSION: J-tubes placed in the setting of esophagectomy do not increase inpatient readmissions or mortality.