Comparative Analysis of Perioperative Outcomes and Costs Between Laparoscopic and Open Antireflux Surgery

Enteral formula compared to Nissen-Fundoplication: Data from a retrospective analysis on tolerance, utility, applicability, and safeness in children with neurological diseases

Objectives and study

Approximately 46–90% of children with neurological disorders (NDs) suffer from gastrointestinal diseases, such as gastro-esophageal reflux disease (GERD), constipation, or malnutrition. Therefore, enteral feeding is often necessary to achieve nutritional requirements. The treatment of GERD could be based on pharmacological therapy, nutritional treatment (changing the type of formula), or surgical treatment (Nissen Fundoplication, NF). The aim of this study was to describe and compare resource consumption between NE based on different formulas and NF in patients with ND.

Methods

We performed a retrospective analysis on all children with neurological damage (age: 29 days−17 years) treated from January 2009 to January 2019 due to nutritional problems and food and/or gastrointestinal intolerances. For all patients, demographic and anthropometric characteristics, symptoms, type of nutrition (formula and enteral access), and number and type of outpatient or emergency room visits were collected. Patients with <24 months of age at the closing of the database and with <24 months of follow-up were excluded.

Results

Out of 376 children, 309 children (M: 158; median age: 4 IQR 1–10) were enrolled, among which, 65 patients (NF group M: 33; median age: 5.3 IQR 1.8–10.7) underwent NF. Vomit, GERD, and dysphagia were more represented in the NF group (p < 0.05). Our analysis shows that the NF group seems to present a lower number of hospitalization and a lower number of visits for non-GI disorders, but a higher number of visits for GI disorders compared to non-NF. In the NF group, a higher prevalence of the use of amino-acid-based formula and free diet is observed, with a trend for the lower prevalence of casein-based or whey+casein-based formula (Fisher test p = 0.072). The median cost of a patient enrolled in the database is € 19,515 ± 540 ($ 20,742.32 ± 573.96) per year, with no significant difference between the two groups. Regarding formula, at baseline, 76 children consumed a free diet, 24 a casein-based formula, 139 a whey+casein-based formula, 46 a whey-based formula, and 24 an amino-acid-based formula.

Conclusions

In conclusion, compared to EN, NF may not improve the clinical aspect and related costs in children with NDs. Considering the psychological and QoL burden for patients, in a “step-up” strategy, EN could be proposed as an efficient alternative to NF.

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

BACKGROUND

Major abdominal surgery is associated with bleeding and venous thromboembolism (VTE) risks. Chemoprophylaxis prevents VTE but increases bleeding risk. When compared with pre- and intra-operative chemoprophylaxis, recent evidence suggests that starting chemoprophylaxis postoperatively lowers the risk of bleeding without compromising VTE protection. This study investigates whether an optimal window exists in the postoperative period for initiating chemoprophylaxis in patients undergoing major abdominal surgery.

METHODS

Analysis of pooled data from four multicenter PROTECTinG studies, which investigated the timing of perioperative chemoprophylaxis on bleeding and VTE outcomes following major abdominal surgery. Patients that commenced chemoprophylaxis postoperatively were separated into quartiles based on timing of administration within the first 24 h post-surgery.

RESULTS

Overall, 4729 (Abdominal visceral resection N = 668, cholecystectomies N = 573, major ventral hernia repair N = 1701, antireflux surgery N = 1787) consecutive patients had chemoprophylaxis commenced within 24 h following elective surgery. Baseline characteristics were comparable between quartiles. Across quartiles and within each procedural type, the timing of starting chemoprophylaxis was not associated with bleeding (2.6, 1.7, 2.7 and 3.2%, p = 0.130) or clinical VTE (0.8, 0.2, 0.8 and 0.5%, p = 0.131), and did not predict their occurrences on multivariate analysis.

CONCLUSION

Chemoprophylaxis can be safely started at any time within 24 h post-skin closure in major abdominal surgery, without affecting bleeding or VTE risks. This finding encourages the standardization of chemoprophylaxis timing in the postoperative period to pre-defined times during the day to improve workflow efficiency and chemoprophylaxis compliance.

Robotic single port anti-reflux surgery: Initial worldwide experience of two cases with a novel surgical approach to treat gastroesophageal reflux disease

INTRODUCTION

To date, no anti-reflux operations have been reported with the new da Vinci Single-Port (single port (SP)) robotic platform. We aimed to describe this novel surgical approach and evaluate its safety and feasibility.

METHODS

All robotic SP operations were performed under an Institutional Review Board approved protocol.

RESULTS

Two patients underwent robotic SP anti-reflux surgery through a single incision of 2.7 cm (one Nissen-fundoplication and one re-Redo Nissen-fundoplication). The mean docking-time was 2.5 (2-3) minutes and mean console-time was 147 (119-155) minutes. No additional ports were needed, and no intraoperative complications occurred. Patients tolerated a soft diet on postoperative day 1 and were discharged on POD-2 and 3.

CONCLUSION

Robotic SP anti-reflux surgery appears to be safe and feasible. This platform offers similar advantages to the multiport robotic surgery, while adding lower invasiveness and an improved cosmesis. Further studies are needed to confirm our results and evaluate long-term outcomes of this surgical approach.

Induction and maintenance of healing in erosive esophagitis in the United States

INTRODUCTION

Erosive esophagitis (EE) occurs when refluxate from the stomach causes T-lymphocyte infiltration of the esophageal mucosa, resulting in mucosal breaks. Currently, therapy with proton-pump inhibitors (PPIs) is the standard treatment for EE in the United States, but few comprehensive reviews exist on the efficacy of PPIs in US populations. Here, we present the most contemporary, thorough analysis of PPI efficacy rates, and identify and characterize patient subgroups at risk for poor healing outcomes.

AREAS COVERED

We searched the literature to identify studies reporting rates of endoscopic healing and maintained healing of EE with PPI therapies in the US and found a paucity of recent evidence and real-world evidence. Twenty-two studies from 2009 and earlier were included in the final dataset.

EXPERT OPINION

Rates of EE healing with PPIs were highest after 8 weeks of treatment, with over 80% of patients in most treatment arms demonstrating endoscopic healing, compared to lower efficacy (<80%) at 4 weeks. Rates of maintained healing with PPIs at 6 and 12 months were mostly lower than 80%, although the data were limited. Symptomatic patients and those with severe EE were less likely to achieve healing. Obese patients experienced similar healing rates as non-obese patients.

Medium-term safety and efficacy profile of paraesophageal hernia repair with Phasix-ST® mesh: a single-institution experience

BACKGROUND

Hernia recurrence after laparoscopic repair is a perplexing problem. In an effort to reduce anatomical and clinical recurrences, different type of meshes have been used to bolster the esophageal hiatus.

OBJECTIVE

The aim of this study was to assess safety, medium-term efficacy, and quality of life improvement after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (Phasix-ST^®).

METHODS

Observational single-center retrospective single-arm cohort study (November 2015-February 2021). We included all adult patients (> 18 years old) who underwent laparoscopic paraesophageal hernia repair with Phasix-ST^® mesh and Toupet fundoplication.

RESULTS

Sixty-eight patients were included. The median postoperative stay was 3.2 days (range 2-9) and the postoperative complication rate was 11.7%. The median follow-up time was 27 months (range 1-53). No mesh-related complications were detected. Hernia recurrence was diagnosed in six patients (8.8%). The recurrence-free probability at 34 months was 0.89 (95% CI 0.807-0.988) while at 60 months was 0.86 (95% CI 0.76-0.97). Hernia recurrences were mostly observed between 21 and 36 months after the operation. None of the patients required surgical revision and all were managed with PPI. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 2.9% of patients. Compared to baseline, both the GERD-HRQL (15.2 ± 6.2 vs. 3.2 ± 3.1; p = 0.026) and all SF-36 items were significantly improved (p < 0.001).

CONCLUSIONS

Laparoscopic crura augmentation with Phasix-ST^® mesh combined with a Toupet fundoplication is safe and seems effective in the medium-term follow-up. Phasix-ST^® crural reinforcement resulted in low hernia recurrence rate with a sustained symptoms and quality of life improvement.

Laparoscopic Paraesophageal Hernia Repair: To Mesh or not to Mesh. Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to compare outcomes after laparoscopic paraesophageal hernia repair (LPEHR) with mesh or primary repair alone.

SUMMARY OF BACKGROUND DATA

High recurrence rates after LPEHR have been reported. Whether the use of mesh improves outcomes remains elusive.

METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) comparing LPEHR with mesh repair versus suture repair alone. Early (≤6 months) and late (>6 months) recurrence rates were used as primary endpoints to assess efficacy. Intraoperative complications, overall morbidity, and reoperation rates were used as secondary endpoints to assess safety. A meta-analysis was conducted using relative risks (RR) with 95% confidence intervals (CI) for the analyzed outcomes.

RESULTS

Seven RCTs comparing mesh (n = 383) versus suture only (n = 352) repair were included for analysis. Patients undergoing LPEHR with mesh reinforcement had similar early (RR = 0.74, 95% CI = 0.26-2.07, P = 0.46) and late (RR = 0.75, 95% CI = 0.27-2.08, P = 0.48) recurrence rates as those with primary repair. Similar recurrence rates were also found when stratifying the analysis by the type of mesh utilized (absorbable and nonabsorbable). Intraoperative complications (RR = 1.03, 95% CI = 0.33-3.28, P = 0.92) and reoperation rates (RR = 0.75, 95% CI = 0.29-1.92, P = 0.45) were also similar in both groups. Overall morbidity, however, was higher after mesh repair with nonabsorbable mesh (RR = 1.45, 95% CI = 1.24-1.71, P < 0.01).

CONCLUSIONS

Patients undergoing LPEHR have similar early and late recurrence rates with either mesh reinforcement or suture only repair, regardless of the type of mesh utilized. Overall morbidity, however, seems to be higher in patients repaired with nonabsorbable mesh.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF).

SUMMARY OF BACKGROUND DATA

Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair.

METHODS

A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS

A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%).

CONCLUSIONS

LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

Healthcare spending and utilization following antireflux surgery: examining costs and reasons for readmission

BACKGROUND

While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair.

METHODS

Data were analyzed from the Truven Health MarketScan^® Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012-2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code.

RESULTS

A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175).

CONCLUSION

The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.

Antireflux Surgery in the USA: Influence of Surgical Volume on Perioperative Outcomes and Costs-Time for Centralization?

BACKGROUND

Few studies have analyzed the relationship between surgical volume and outcomes after antireflux procedures. The aim of this study was to determine the effect of surgical volume on postoperative results and costs for patients undergoing surgery for gastroesophageal reflux disease.

METHODS

We analyzed the National Inpatient Sample (period 2000-2013). Adult patients (≥18 years old) with gastroesophageal reflux disease who underwent fundoplication were included. Hospital surgical volume was determined using the 30th and 60th percentile cut points using weighted discharges and categorized as low (<10 operations/year), intermediate (10-25 operations/year), or high (>25 operations/year). We performed multivariable logistic regression models to assess the effect of surgical volume on patient outcomes.

RESULTS

The studied cohort comprised 75,544 patients who had antireflux surgery. When operations performed at low-volume hospitals, postoperative bleeding, cardiac failure, renal failure, respiratory failure, and inpatient mortality were more common. In intermediate-volume hospitals, patients were more likely to have postoperative infection, esophageal perforation, bleeding, cardiac failure, renal failure, and respiratory failure. The length of hospital stay was longer at low- and intermediate-volume hospitals (1.08 and 0.55 days longer, respectively). There was an increase in charges of 5120 dollars per patient at low-volume centers, and 4010 dollars per patient at intermediate-volume centers.

CONCLUSIONS

When antireflux surgery is performed at high-volume hospitals, morbidity is lower, length of hospital stay is shorter, and costs for the healthcare system are decreased.

Surgery for benign esophageal disorders in the US: risk factors for complications and trends of morbidity

BACKGROUND

Gastroesophageal reflux disease (GERD), paraesophageal hernia (PEH), and achalasia are the most frequent benign esophageal disorders that may need surgical treatment. We aimed to identify risk factors for postoperative complications and to characterize trends of morbidity for surgery for benign esophageal disorders in a national cohort.

METHODS

A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2013. Adult patients (≥ 18 years old) diagnosed with GERD, PEH, and achalasia, and who underwent fundoplication, PEH repair, and esophagomyotomy were included. The yearly incidence of complications, stratified by procedure, was calculated using Poisson regression, and multivariable logistic regression was used to determine risk factors for complications.

RESULTS

A total of 79,622 patients were included; 38,695 (48.6%) underwent PEH repair, 38,719 (48.6%) fundoplication, and 2208 (2.8%) esophagomyotomy. While the rate of postoperative complications dropped from 26.5 to 10.0% and from 16.1 to 12.2% for PEH repair and esophagomyotomy, respectively, the complication rate after fundoplication increased from 5.7 to 12.7% during the same period (p < 0.0001). Age, black race, diabetes, renal insufficiency, coronary artery disease, peripheral vascular disease, chronic obstructive pulmonary disease, and open surgery were independent risk factors for postoperative complications. The rate of laparoscopic procedures for PEH repair increased from 4.9 to 91.4%, while for fundoplication it increased from 24.2 to 78.3% (p < 0.0001).

CONCLUSIONS

Opposite to PEH repair and esophagomyotomy, antireflux surgery has shown an increase in the morbidity rate in the last decade. Patient selection and embracement of laparoscopic techniques are critical to improve the perioperative outcome in surgery for benign esophageal disorders.

Fundamentals of Laparoscopic Surgery: Not Only for Senior Residents

OBJECTIVE

Fundamentals of laparoscopic surgery (FLS) was developed by the Society of American Gastrointestinal and Endoscopic Surgeons to teach the physiology, fundamental knowledge, and technical skills required for basic laparoscopic surgery. We hypothesize that residents are doing more laparoscopic surgery earlier in residency, and therefore would benefit from an earlier assessment of basic laparoscopic skills. Here, we examine FLS test results and ACGME case logs to determine whether it is practical to administer FLS earlier in residency.

DESIGN

FLS test results were reviewed for the 42 residents completing FLS between July 2011 and July 2016. ACGME case logs for current and former residents were reviewed for laparoscopic cases logged by each postgraduate year. Basic and complex laparoscopic cases were determined by ACGME General Surgery Defined Category and Minimums Report. Descriptive statistics were used for analysis.

SETTING

Academic general surgery residency, Washington University in St. Louis School of Medicine.

PARTICIPANTS

Current and former general surgery residents.

RESULTS

A total of 42 residents took and passed FLS between July 2011 and July 2016. All residents successfully passed the FLS knowledge and skills examinations on the first attempt regardless of their postgraduate year (PGY 3n = 13, PGY 4n = 15, and PGY 5n = 14). Total laparoscopic case volume has increased over time. Residents who graduated in 2012 or 2013 completed 229 laparoscopic cases compared to 267 laparoscopic cases for those who graduated from 2014 to 2016 (p = 0.02). Additionally, current residents completed more laparoscopic cases in the first 2 years of residency than residents who graduated from 2012 to 2016 (median current = 38; former = 22; p < 0.001). Examining laparoscopic case numbers for current residents by PGY demonstrated that the number of total and complex laparoscopic cases increased in each of the first 3 years of residency with the largest increase occurring between the PGY 2 and PGY 3 years. In the PGY 4 and PGY 5 years, most laparoscopic cases were complex.

CONCLUSION

Increased use of laparoscopic surgery has led to a corresponding increase in laparoscopic case volume among general surgery residents. We would advocate for FLS testing to serve as an early assessment of laparoscopic knowledge and skill and should be performed before a significant increase in complex laparoscopic surgery during training.

Laparoscopic Versus Open Surgery Still an Open Debate

Many would think that today minimally invasive surgery is the standard of care in the United States and that the conventional "open" approach would be relegated to few complex procedures or difficult redo operations. However, a great variability still exists in the utilization of laparoscopic surgery in the United States. This variability in surgical care of common diseases raises important ethical and economic issues and warrants a serious look by healthcare providers, insurance companies, and patients.

Paraesophageal Hernia Repair in the USA: Trends of Utilization Stratified by Surgical Volume and Consequent Impact on Perioperative Outcomes

BACKGROUND

The impact of surgical volume on perioperative results after a paraesophageal hernia (PEH) repair has not yet been analyzed. We sought to characterize the trend of utilization of this procedure stratified by surgical volume in the USA, and analyze its impact on perioperative outcomes.

METHODS

A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2013. Adult patients (≥18 years old) who underwent PEH repair were included. Surgical volume was categorized as small (<6 operations/year), intermediate (6-20 operations/year), or high (>20 operations/year). Multivariable linear and logistic regression models were used to assess the effect of surgical volume on patient outcomes.

RESULTS

A total of 63,812 patients were included. Over time, the rate of procedures across high-volume centers increased from 65.8 to 94.4%. The use of the laparoscopic approach was significantly different among the groups (small volume 38.4%; intermediate volume 41.8%; high volume 67.4%; p < 0.0001). Patients undergoing PEH repair at high-volume hospitals were less likely to experience postoperative bleeding, cardiac failure, respiratory failure, and shock. On average, patients at low- and intermediate-volume hospitals stayed 0.8 and 0.6 days longer, respectively.

CONCLUSIONS

A spontaneous centralization towards high-volume centers for PEH repair has occurred in the last decade. This trend is beneficial for patients as it is associated with higher rates of laparoscopic operations, decreased surgical morbidity, and a shorter length of hospital stay.