RESUMO
BACKGROUND: The natural history of hiatal herniation of small and/or large bowel post-esophagectomy (HHBPE) in the current era of improving long-term survival and evolving surgical technique is unknown. The aim of this study was to describe the rate and risk factors of HHBPE at our hospital. METHODS: Patients undergoing esophagectomy between January 2011 and June 2017 were included if both follow-up information and axial imaging were available beyond 3 months post-esophagectomy. Patient characteristics, disease information, and treatment factors were all included in univariate analysis comparing patients with and without HHBPE, and multivariate regression was used to identify significant independent risk factors associated with HHBPE. RESULTS: Of 310 esophagectomy patients analyzed, 258 patients were included in the study, with 79 patients (31%) showing evidence of an HHBPE and an overall median follow-up of 24 months; 44 of 79 patients (56%) had symptoms possibly referable to HHBPE and 17 of 79 patients (22%) underwent surgical repair. On univariate analysis, neoadjuvant therapy (n = 176), higher clinical stage, minimally invasive approach (n = 154), and transhiatal esophagectomy (n = 189) were significant predictors of HHBPE (p < 0.05). On multivariate analysis, neoadjuvant therapy and transhiatal approach remained significant independent predictors (p < 0.05). The rate of HHBPE was 44% in the 131 patients (51%) that had both factors. CONCLUSIONS: HHBPE in the current era of neoadjuvant therapy and minimally invasive esophagectomy is common. HHBPE can cause gastrointestinal symptoms, but operation to repair HHBPE is uncommon on intermediate follow-up. Additional study and long-term follow-up are required to fully assess the impact of HHBPE and to potentially modify surgical practice to prevent or minimize HHBPE.
Assuntos
Esofagectomia/efeitos adversos , Hérnia Hiatal/epidemiologia , Hérnia Hiatal/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Although laparoscopic Heller myotomy (LHM) has been the standard of care for achalasia, per oral endoscopic myotomy (POEM) has gained popularity as a viable alternative. This retrospective study aimed to compare patient-reported outcomes between LHM and POEM in a consecutive series of achalasia patients with more than 1 year of follow-up. STUDY DESIGN: We reviewed demographic and procedure-related data for patients who underwent either LHM or POEM for achalasia between January 2011 and May 2016. Phone interviews were conducted assessing post-procedure achalasia symptoms via the Eckardt score and achalasia severity questionnaire (ASQ). Demographics, disease factors, and survey results were compared between LHM and POEM patients using univariate analysis. Significant predictors of procedure failure were analyzed using univariate and multivariate analysis. RESULTS: There were no serious complications in 110 consecutive patients who underwent LHM or POEM during the study period, and 96 (87%) patients completed phone surveys. There was a nonsignificant trend toward better patient-reported outcomes with POEM. There were significant differences in patient characteristics including sex, achalasia type, mean residual lower esophageal pressure (rLESP), and follow-up time. The only univariate predictors of an unsatisfactory Eckardt score or ASQ were longer follow-up and lower rLESP, with follow-up length being the only predictor on multivariate analysis. CONCLUSIONS: There were significant demographic and clinical differences in patient selection for POEM vs LHM in our group. Although the 2 procedures have similar patient-reported effectiveness, subjective outcomes seem to decline as a result of time rather than procedure type.
Assuntos
Acalasia Esofágica/cirurgia , Miotomia de Heller , Laparoscopia , Cirurgia Endoscópica por Orifício Natural , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Medidas de Resultados Relatados pelo Paciente , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: A large proportion of patients presenting for ventral hernia repair are obese. It remains unclear, however, whether the degree of obesity is an independent risk factor for adverse outcomes after ventral hernia repair. This study aims to characterize the influence of body mass index class on postoperative complications after open ventral hernia repair. METHODS: A retrospective analysis was conducted using data from the database of the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2015. Patients were stratified into 7 body mass index classes, as well as by type of hernia (reducible versus strangulated) and time of repair (initial versus recurrent). We determined the relationships between body mass index class and patient demographics, comorbidities, and risk of perioperative complications. RESULTS: Our cohort consisted of 102,191 patients, 58.5% of whom were obese. When stratified by body mass index class, higher classes were associated with all postoperative complications (P < .0001) with a steady increase in complication rates with increasing body mass index class. Patients with strangulated hernias had greater complication rates than those with reducible hernias (P < .0001). Patients with recurrent hernias also had greater complication rates than those with initial hernias (P < .0001). CONCLUSION: Increased body mass index is a risk factor for operative, medical, and respiratory complications after open ventral hernia repair. Patients with body mass index >40 kg/m2 have greater than twice the risk for complications with odds ratios increasing with increasing body mass index class. Strategies to encourage weight loss may need to be considered seriously prior to open ventral hernia repair, especially for patients with body mass index >40 kg/m2.
Assuntos
Índice de Massa Corporal , Hérnia Ventral/cirurgia , Herniorrafia , Obesidade/complicações , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Bases de Dados Factuais , Feminino , Hérnia Ventral/complicações , Herniorrafia/métodos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Obesity is a risk factor for cholelithiasis leading to acute cholecystitis which is treated with cholecystectomy. The purpose of this study was to analyze the associations between body mass index class and the intended operative approach (laparoscopic versus open) for and outcomes of cholecystectomy for acute cholecystitis. METHODS: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program data from 2008-2013. The effects of body mass index class on intended procedure type (laparoscopic versus open), conversion from laparoscopic to open operation, and outcomes after cholecystectomy were examined using multivariable logistic regression. RESULTS: Data on 20,979 patients who underwent cholecystectomy for acute cholecystitis showed that 18,228 (87%) had a laparoscopic operation; 639 (4%) of these patients required conversion to an open approach; and 2,751 (13%) underwent intended open cholecystectomy. There was an independent association between super obesity (body mass index 50+) and an intended open operation (odds ratio 1.53, 95% confidence interval 1.14-2.05, P = .01). An intended open procedure (odds ratio 3.10, 95% confidence interval 2.40-4.02, P < .0001) and conversion (odds ratio 3.45, 95% confidence interval 2.16-5.50, P < .0001) were associated with increased risk of death/serious morbidity in a model, even when controlling for all other important factors. In the same model, body mass index class was not associated with increased death/serious morbidity. Outcomes after conversion were not substantially worse than outcomes after intended open cholecystectomy. CONCLUSION: This study supports the possibility that an intended open approach to acute cholecystitis, not body mass index class, is associated with worse outcomes after cholecystectomy. An initial attempt at laparoscopy may benefit patients, even those at the highest end of the body mass index spectrum.
Assuntos
Índice de Massa Corporal , Colecistectomia Laparoscópica , Colecistite Aguda/cirurgia , Conversão para Cirurgia Aberta , Obesidade Mórbida/complicações , Adulto , Idoso , Colecistite Aguda/complicações , Colecistite Aguda/mortalidade , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Melhoria de Qualidade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To compare the efficacy of adjuvant chemoradiotherapy (CRT) and chemotherapy alone (CA) in gastric adenocarcinoma patients undergoing gastrectomy in the United States (US). BACKGROUND: A majority of US gastric adenocarcinoma patients are inadequately staged (<15 nodes examined). Despite this, and limited data comparing adjuvant CRT with CA in US patients, national guidelines endorse CA in selected patients undergoing D2 lymphadenectomy. METHODS: Resected stage IB-III gastric adenocarcinoma patients receiving adjuvant CRT or CA (n = 3008) were identified in the National Cancer Database (1998-2006). Cox regression identified covariates associated with overall survival (OS). CRT and CA cohorts were matched (3:1) by propensity scores based on the likelihood of receiving CA. OS was compared by Kaplan-Meier estimates. RESULTS: Adjuvant CA was associated with an increased risk of death (HR 1.29, P < 0.001) relative to CRT. Inadequate lymph node staging (LNS) and nodal positivity were strong predictors of risk-adjusted mortality (P < 0.001). After propensity score-matching, CRT demonstrated superior median OS compared with CA (36.1 vs 28.9 m; P < 0.0001), regardless of stage. CRT was superior to CA in inadequately staged patients (33.1âm vs 24.5 m; P < 0.001); this benefit was less pronounced with increasing nodal examination. CRT improved OS in node-positive disease (29.8 vs 22.2 m; P < 0.001), regardless of LNS adequacy. In node-negative disease, OS did not differ significantly between CRT and CA cohorts; however, node-negative patients undergoing inadequate LNS benefited from CRT. CONCLUSIONS: CRT is associated with improved stage-stratified OS compared with CA. Lymph node status and adequacy of surgical staging should influence adjuvant therapy selection in the United States.