Association of operative approach with postoperative outcomes in neonates undergoing surgical repair of esophageal atresia and tracheoesophageal fistula

Introduction: Minimally invasive surgery (MIS) is gaining traction as a first-line approach to repair congenital anomalies. This study aims to evaluate outcomes for neonates undergoing open versus MIS repairs for esophageal atresia/tracheoesophageal fistula (EA/TEF). Methods: Neonates undergoing EA/TEF repair from 2013-2020 were identified using the National Surgical Quality Improvement Program-Pediatric database. Proportions of operative approach (open vs. MIS) over time were analyzed. A propensity score-matched analysis using preoperative characteristics was performed and outcomes were compared including composite morbidity and reintervention rates (overall, major [thoracoscopy, thoracotomy], and minor [chest/feeding tube placement, endoscopy]) between operative approaches. Pearson’s chi-square or Fisher’s exact test were used as appropriate. Results: We identified 1738 neonates who underwent EA/TEF repair. MIS utilization increased over time (p=0.019). Pre-match, neonates undergoing open repair were more likely premature, lower weight, and higher ASA class. Post-match, the groups were similar and included 183 neonates per group. MIS repair was associated with longer median operative time (206 vs. 180 minutes, p\u3c0.001), increased overall reintervention rates (MIS 9.8% vs. open 3.3%, p=0.011), and increased minor reintervention rates (MIS 7.7% vs. open 2.2%, p=0.016). There were no differences in composite morbidity (MIS 20.2% vs. open 26.8%, p=0.14) or major reinterventions (MIS 2.2% vs. open 1.1%, p=0.41). Discussion: MIS is gaining traction as a first-line approach for neonates with EA/TEF but appears to be associated with a higher rate of reinterventions. Further studies evaluating MIS approaches for the repair of EA/TEF are needed to better define short and long-term outcomes to optimize patient selection

National trends in pectus excavatum repair: patient age, facility volume, and outcomes

Background: There is limited data on the adult repair of pectus excavatum (PE). Existing literature is largely limited to single institution experiences and suggests that adults undergoing modified Nuss repair may have worse outcomes than pediatric and adolescent patients. Using a representative national database, this analysis is the first to describe trends in demographics, outcomes, charges, and facility volume for adults undergoing modified Nuss procedure. Methods: Because of a coding change associated with ICD-10, a retrospective cohort analysis using the National Inpatient Sample (NIS) for patients 12 or older undergoing modified Nuss repair between 2016-2018 was possible. Pearson\u27s χ2 and Student\u27s t-tests were utilized to compare patient, clinical, and hospital characteristics. Complications were sub-classified into major and minor categories. Facilities performing greater than the mean number of operations were categorized as high-volume. Results: Of 360 patients, 79.2% were male. There was near gender parity for patients over 30 undergoing repair (55.2% male, 44.8% female). In all age cohorts, patients were predominantly Caucasian. Rates of any postoperative complication differed by age (12-17 years: 30.6%; 18-29 years: 45.2%; 30+ years: 62.1%; P\u3c0.01); older patients had higher rates of all but two subclasses of complication. Age over 30 was associated with higher charges (12-17 years: $57,312; 18-29 years:$57,001; 30+ years: $67,014; P\u3c0.01). High-volume centers operate on older patients, had shorter lengths of stay, and comparable charges to low-volume centers. Conclusions: Women comprise nearly half of patients undergoing modified Nuss repair after 30 years of age. There are significant differences in complication rates and charges when comparing patients by age. Patients undergoing repair at high-volume facilities benefitted from shorter lengths of stay

sj-docx-1-gut-10.1177_26345161231151407 – Supplemental material for An Analysis of 30-Day Readmissions of Surgically Managed Hiatal Hernia in the United States, 2010 to 2018

Supplemental material, sj-docx-1-gut-10.1177_26345161231151407 for An Analysis of 30-Day Readmissions of Surgically Managed Hiatal Hernia in the United States, 2010 to 2018 by Gregory L. Whitehorn, Micaela L. Collins, Shale J. Mack, Brian M. Till, Christina J. Tofani, Karen A. Chojnacki and Olugbenga T. Okusanya in Foregut: The Journal of the American Foregut Society</p

sj-pptx-1-gut-10.1177_26345161221137089 – Supplemental material for The Epidemiology of Surgically Managed Hiatal Hernia: A Nine Year Review of National Trends

Supplemental material, sj-pptx-1-gut-10.1177_26345161221137089 for The Epidemiology of Surgically Managed Hiatal Hernia: A Nine Year Review of National Trends by Brian M. Till, Shale J. Mack, Gregory Whitehorn, Micaela Langille Collins, Chi-Fu Jeffrey Yang, Tyler Grenda, Nathaniel R. Evans and Olubenga Okusanya in Foregut: The Journal of the American Foregut Society</p

sj-docx-1-gut-10.1177_26345161221137089 – Supplemental material for The Epidemiology of Surgically Managed Hiatal Hernia: A Nine Year Review of National Trends

Supplemental material, sj-docx-1-gut-10.1177_26345161221137089 for The Epidemiology of Surgically Managed Hiatal Hernia: A Nine Year Review of National Trends by Brian M. Till, Shale J. Mack, Gregory Whitehorn, Micaela Langille Collins, Chi-Fu Jeffrey Yang, Tyler Grenda, Nathaniel R. Evans and Olubenga Okusanya in Foregut: The Journal of the American Foregut Society</p

Is wedge a dirty word? Demographic and facility-level variables associated with high-quality wedge resectionCentral MessagePerspective

Objectives: Although sublobar resections have gained traction, wedge resections vary widely in quality. We seek to characterize the demographic and facility-level variables associated with high-quality wedge resections. Methods: The National Cancer Database was queried from 2010 to 2018. Patients with T1/T2 N0 M0 non–small cell lung cancer 2 cm or less who underwent wedge resection without neoadjuvant therapy were included. A wedge resection with no nodes sampled or with positive margins was categorized as a low-quality wedge. A wedge resection with 4 or more nodes sampled and negative margins was categorized as a high-quality wedge. Facility-specific variables were investigated via quartile analysis based on the overall volume and proportion of high-quality wedge or low-quality wedge resections performed. Results: A total of 21,742 patients met inclusion criteria, 6390 (29.4%) of whom received a high-quality wedge resection. Factors associated with high-quality wedge resection included treatment at an academic center (3005 [47.0%] vs low-quality wedge 6279 [40.9%]; P < .001). The 30- and 90-day survivals were similar, but patients who received a high-quality wedge resection had improved 5-year survival (4902 [76.7%] vs 10,548 [68.7%]; P < .001). Facilities in the top quartile by volume of high-quality wedge resections performed 69% (4409) of all high-quality wedge resections, and facilities in the top quartile for low-quality wedge resections performed 67.6% (10,378) of all low-quality wedge resections. A total of 113 facilities were in the top quartile by volume for both high-quality wedge and low-quality wedge resections. Conclusions: High-quality wedge resections are associated with improved 5-year survival when compared with low-quality wedge resections. By volume, high-quality wedge and low-quality wedge resections cluster to a minority of facilities, many of which overlap. There is discordance between best practice guidelines and current practice patterns that warrants additional study

Postoperative Respiratory Complications in SARS-CoV-2 Positive Pediatric Patients Across 20 United States Hospitals: A Cohort Study

IntroductionData examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.MethodsThis retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.ResultsOf 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n&nbsp;=&nbsp;214, 80.5%). The most common procedures were appendectomies (n&nbsp;=&nbsp;78, 29.3%) and fracture repairs (n&nbsp;=&nbsp;40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p&nbsp;=&nbsp;0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.ConclusionsPostoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.Level of evidenceIii, Respiratory complications