Advancing geriatric surgical outcomes in elective ventral and incisional hernia repair surgeries: An American college of surgeons national surgical quality improvement program study

INTRODUCTION

Increasing age is known to be associated with increased risk for postoperative morbidity and mortality, however, the goal of this study was to determine if an increase in age correlates to differences in surgical outcomes for elective ventral hernia repair.

METHODS

Retrospective cohort study using American College of Surgeons NSQIP database from 2016 to 2020. Included diagnosis codes were laparoscopic or open incisional or ventral hernia repairs, categorized into three age groups: 18-64y, 65-74y, and ≥75y. Thirty-day perioperative outcomes analyzed using bivariate χ2 test and multivariate logistic regression.

RESULTS

We identified 116,643 people who had elective ventral or incisional hernia repair. Compared to 18-64y and 65-74y age groups, patients ≥75y were significantly more likely to develop any post-operative complication, be re-admitted post-operatively for any reason, have an extended hospital stay, and require a reoperation.

CONCLUSIONS

Patients ≥75y have significantly higher rates of perioperative complications after elective hernia repair compared to younger patients.

The impact of minimally invasive surgery and frailty on post-hepatectomy outcomes

BACKGROUND

The impact of patient frailty on post-hepatectomy outcomes is not well studied. We hypothesized that patient frailty is a strong predictor of 30-day post-hepatectomy complications.

METHODS

The liver-targeted National Surgical Quality Improvement Program (NSQIP) database for 2014-2019 was reviewed. A validated modified frailty index (mFI) was used.

RESULTS

A total of 24,150 hepatectomies were reviewed. Worsening frailty was associated with increased incidence of Clavien-Dindo grade IV complications (mFI 0, 1, 2, 3, 4 was 3.9%, 6.3%, 10%, 8.1%, 50% respectively; p < 0.001). Minimally invasive hepatectomies had a lower rate of Clavien-Dindo grade IV complications for non-frail (Laparoscopic: 1%, Robotic: 2.6%, Open: 4.6%; p < 0.001) and frail patients (Laparoscopic: 3%, Robotic: 2.3%, Open: 7.7%; p < 0.001). Frail patients experienced higher incidence of post-hepatectomy liver failure (5.4% vs 4.1% for non-frail; p < 0.001) and grade C liver failure (28% vs 21.1% for non-frail; p = 0.03). Incorporating mFI to Albumin-Bilirubin score (ALBI) improved its ability to predict Clavien-Dindo grade IV complications (AUC improved from 0.609 to 0.647; p < 0.001) and 30-day mortality (AUC improved from 0.663 to 0.72; p < 0.001).

CONCLUSION

Worsening frailty correlates with increased incidence of Clavien-Dindo grade IV complications post-hepatectomy, whereas minimally invasive approaches decrease this risk. Incorporating frailty assessment to ALBI improves its ability to predict major postoperative complications and 30-day mortality.

Gastrointestinal melanoma: Outcomes of surgery and immunotherapy

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Background: Most knowledge on gastrointestinal (GI) melanoma is limited to anal melanoma. Our aim is to examine the impact of surgical treatment and the utility of immunotherapy on GI (other than anal) melanoma. Methods: The National Cancer Database (2004-2016) was reviewed for patients who were treated for GI melanoma. Kaplan-Meier method and log-rank test were used to make survival comparisons. Results: We analyzed data from 731 patients with gastrointestinal melanoma (esophageal:97, gastric:57, small bowel:87, colonic:31, rectal:459). A minority of patients had metastatic disease at the time of diagnosis (esophageal:14.4%, gastric:17.5%, small bowel:4.6%, colonic:19.4%, rectal: 16.3%) and small proportion received immunotherapy (esophageal:16.5%, gastric:15.8%, small bowel:15%, colonic:6.5%, rectal:20.3%). Patients who had resection with negative margins had an improved survival irrespectively of the magnitude of surgery (for example rectal melanoma: OS: no surgery:7.9mo, local excision:23.3mo, partial proctectomy:23.5mo, total proctectomy:18.4mo; p < 0.001 and OS for R0 margins:29.4mo vs R1:13.5mo vs R2:5mo;p < 0.001). The use of immunotherapy was associated with improved survival in metastatic disease for rectal melanoma (OS:10.8mo vs 5.7mo; p = 0.01). Conclusions: Excision with negative margins is associated with improved outcomes in gastrointestinal melanoma. The use of immunotherapy should be considered in the presence of metastatic disease.

Concomitant Hiatal Hernia Repair with Sleeve Gastrectomy: A 5-Year Analysis

Background: The sleeve gastrectomy (SG) can be associated with postoperative gastroesophageal reflux and when a hiatal hernia (HH) is present, it should be fixed. Earlier studies have shown that 20% of SG have a concomitant hiatal hernia repair (SG+HHR). The aim of this project is to determine the rate of SG+HHR in a large state administrative database.

Methods: The Texas Inpatient Public Use Data File (IPUDF) and Outpatient Public Use Data File (OPUDF) for the years 2013-2017 were examined for patients that underwent SG+HHR at the same time. Patient demographics, diagnosis, and charge data were also examined. A t-test was performed between groups and P was considered significant at < 0.05.

Results: In the OPUDF, there were 6,193 (33.7%) patients who underwent SG+HHR out of 18,403 patients who underwent SG. Mean charges were $94,741 [standard deviation (SD) = $87,284]. Length of stay (LOS) was 2.1 (SD = 3.5) vs 2.3 days (SD = 3.3) with a shorter stay for SG+HHR vs SG alone (P < 0.001). In the IPUDF, there were 11,536 (21.1%) patients who underwent SG+HHR out of 54,545 patients who underwent SG. Mean charges were $69,006 (SD = $46,365). LOS was 1.59 days (SD = 3.7) for SG+HHR vs 1.63 days (SD = 1.6) for SG (P = .043). The rate of SG+HHR increased over the study period.

Conclusions: SG+HHR is common in both the outpatient and inpatient setting. There is a yearly trend of increasing rates of SG+HHR.

Role of tumor necrosis factor and gamma interferon in acquired resistance to Cryptococcus neoformans in the central nervous system of mice

Although naive C.B-17 and BALB/cBy mice die of meningoencephalitis within 5 weeks of intravenous infection with an opportunistic strain of Cryptococcus neoformans, immunized mice express an acquired, CD4+ T-cell-dependent immunity and survive an intravenous infection. Infusion of lymphocytes from immune mice into severe combined immunodeficiency (SCID) mice renders these mice more resistant to cryptococcal brain infection than uninfused controls. We have investigated the role of gamma interferon (IFN-gamma) and tumor necrosis factor (TNF) in acquired resistance to C. neoformans. Neutralization of either IFN-gamma or TNF impaired resistance of immune BALB/cBy or C.B-17 mice to cryptococci. At 10 days postinfection, there were approximately 10 times as many yeast cells in the brains of mice treated with either anticytokine antibody as in the brains of mice treated with control antibody. Simultaneous neutralization of IFN-gamma and TNF further exacerbated infection. Neutralization of IFN-gamma or TNF also impaired resistance in immune lymphocyte-infused SCID mice, resulting in significantly higher yeast burdens in brains of cytokine-neutralized mice than in brains of controls. Concurrent neutralization of IFN-gamma and TNF rendered SCID recipients of immune cells equivalent to uninfused SCID mice with respect both to brain yeast burdens at 10 days and to survival. Anti-TNF treatment alone also curtailed survival. Histological examination of the brains of cytokine-neutralized mice revealed deficiencies in ability to focus inflammatory cells at brain lesions. These data demonstrate that both IFN-gamma and TNF are important mediators of acquired resistance to cryptococcal meningoencephalitis.