Background

There is no published data regarding the relationship between hospital volume and outcomes in patients undergoing laparoscopic diaphragmatic hernia repair. We hypothesize that hospitals performing high case volume have improved outcomes compared to low-volume hospitals.

Materials and methods

We reviewed the National Inpatient Sample (NIS) database between 2008 and 2012 for adults with the diagnosis of diaphragmatic hernia who underwent elective laparoscopic repair of diaphragmatic Hernia and/or Nissen fundoplication. Pediatric, emergent, and open cases were excluded. Main outcome measures included logistic regression analysis of factors predictive of in-hospital mortality and outcomes according to annual hospital case volume.

Results

A total of 31,228 laparoscopic diaphragmatic hernia operations were analyzed. The overall in-hospital mortality was 0.14%. Risk factors for higher in-hospital mortality included renal failure (AOR: 6.26; 95% CI: 2.48-15.78; p < 0.001), age>60 years (AOR: 5.06; 95% CI: 2.38-10.76; p < 0.001), and CHF (AOR: 3.80; 95% CI: 1.39-10.38; p = 0.009) while an incremental increase in volume of 10 cases/year (AOR: 0.89; 95% CI: 0.81-0.98; p = 0.019) and diabetes (AOR: 0.34; 95% CI: 0.12-0.93; p = 0.036) decreases mortality. There was a small but significant inverse relationship between hospital case volume and mortality with a 10% reduction in adjusted odds of in-hospital mortality for every increase in 10 cases per year. Using 10 cases per year as the volume threshold, low-volume hospitals (≤10 cases/year) had almost a twofold higher mortality compared to high-volume hospitals (0.23 vs. 0.12%, respectively, p = 0.02).

Conclusions

There was a small but significant inverse relationship between the hospitals' case volume and mortality in laparoscopic diaphragmatic hernia repair.

Complete situs inversus is a rare congenital anomaly characterized by transposition of organs. We report a case of renal transplantation using a kidney from a living complete situs inversus donor. The recipient was a 59-year-old female with end-stage renal disease because of type 2 diabetes mellitus. The donor was the 56-year-old sister of the recipient with complete situs inversus. CT angiogram of the abdomen and pelvis showed complete situs inversus and an otherwise normal appearance of the bilateral kidneys with patent bilateral single renal arteries and longer renal vein in the right kidney. The patient was taken to the operating room for a hand-assisted laparoscopic right donor nephrectomy. The patient tolerated the procedure well and was discharged home in good condition on postoperative day 1. The recipient experienced no episodes of acute rejection or infection, with serum creatinine levels of 0.8-1.2 mg/dL. Laparoscopic donor nephrectomy in a patient with complete situs inversus remains a technically feasible operation and the presence of situs inversus should not preclude consideration for living kidney donation.

Background

HIV has become a chronic disease, which may render this population more prone to developing the colorectal pathologies that typically affect older Americans.

Methods

A retrospective review of the Nationwide Inpatient Sample was performed to identify patients who underwent colon and rectal surgery from 2001 to 2010. Multivariate analysis was used to evaluate outcomes among the general population, patients with HIV, and patients with AIDS.

Results

Hospital admissions for colon and rectal procedures of patients with HIV/AIDS grew at a faster rate than all-cause admissions of patients with HIV/AIDS, with mean yearly increases of 17.8 and 2.1 %, respectively (p < 0.05). Patients with HIV/AIDS undergoing colon and rectal operations for cancer, polyps, diverticular disease, and Clostridium difficile were younger than the general population (51 vs. 65 years; p < 0.01). AIDS was independently associated with increased odds of mortality (OR 2.11; 95 % CI 1.24, 3.61), wound complications (OR 1.53; 95 % CI 1.09, 2.17), and pneumonia (OR 2.02; 95 % CI 1.33, 3.08). Risk-adjusted outcomes of colorectal surgery in patients with HIV did not differ significantly from the general population.

Conclusion

Postoperative outcomes in patients with HIV are similar to the general population, while patients with AIDS have a higher risk of mortality and certain complications.

In the original version of this article Sarath Sujatha- Bhaskar’s family name was misspelled. It is correct as reflected in this erratum. The original article has also been updated.

OBJECTIVE:The aim of this study is to examine the effect of postoperative chemotherapy on survival in patients with stage II or III rectal adenocarcinoma who undergo neoadjuvant chemoradiation (CRT) and surgical resection. METHODS:A retrospective review of the National Cancer Database (NCDB) from 2006 to 2013 was performed. Cases were analyzed based on pathologic complete response (pCR) status and use of adjuvant therapy. The Kaplan-Meier method was used to estimate overall survival probabilities. RESULTS:23,045 cases were identified, of which 5832 (25.31%) achieved pCR. In the pCR group, 1513 (25.9%) received adjuvant chemotherapy, and in the non-pCR group, 5966 (34.7%) received adjuvant therapy. In the pCR group, five-year survival probability was 87% (95% CI 84%-89%) with adjuvant therapy and 81% (95% CI 79%-82%) without adjuvant therapy. In the non-pCR group, five-year survival probability was 78% (95% CI 76%-79%) with adjuvant therapy and 70% (95% CI 69%-71%) without adjuvant therapy. In the non-pCR and node-negative subgroup (ypN-), five-year survival probability was 86% (95% CI 84%-88%) with adjuvant therapy and 76% (95% CI 74%-77%) without adjuvant therapy. In the non-pCR and node-positive subgroup (ypN+), five-year survival probability was 67% (95% CI 65%-70%) with adjuvant therapy and 60% (95% CI 58%-63%) without adjuvant therapy. CONCLUSIONS:Adjuvant chemotherapy in stage II or III rectal adenocarcinoma is associated with increased five-year survival probability regardless of pCR status. We observed similar survival outcomes among non-pCR ypN- treated with adjuvant chemotherapy compared with patients achieving pCR treated with adjuvant chemotherapy.

Objective

National examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS).

Background

Surgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined.

Methods

Retrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan-Meier analyses were used to estimate long-term OS.

Results

Of 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02-1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.037). Kaplan-Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198).

Conclusion

In the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.

Background

The management algorithm for appendiceal adenocarcinoma is not well defined. This study sought to determine whether tumor size or depth of invasion better correlates with the presence of lymph node metastases in appendiceal adenocarcinoma, and to compare these rates with colon adenocarcinoma.

Study design

A retrospective review of the National Cancer Database was performed to identify patients with appendiceal or colonic adenocarcinoma from 2004 to 2013 who underwent surgical resection. Cases were categorized by tumor size and by T stage. Rates of lymph node metastases were examined as a function of size and T stage.

Results

A total of 3,402 appendiceal and 314,864 colonic cases were identified. For appendiceal adenocarcinoma, larger tumor size was associated with higher T stage: Pearson correlation of 0.41 (95% CI 0.408 to 0.414; p < 0.001). Lymph node metastases were present in 19.1%, 27.8%, 39.6%, 39.4%, 42.4% and 39.1% for tumor sizes <1 cm, >1 to 2 cm, >2 to 3 cm, >3 to 4 cm, >4 to 5 cm, and >5 cm, respectively. Lymph node metastases were present in 0%, 11.2%, 12.3%, 35.5%, and 40.0% for in situ, T1, T2, T3, and T4 tumors, respectively. There was no difference in the rates of lymph node metastases between appendiceal and colonic adenocarcinoma for tumor sizes <3 cm, or for in situ and T1 tumors. Rates of lymph node metastases are higher in colonic adenocarcinoma for tumor sizes >3 cm and for T2, T3, and T4 tumors (p < 0.01).

Conclusions

In appendiceal adenocarcinoma, the rate of lymph node metastases is substantial, even for small tumors. Tumor size should play no role in the decision of whether to perform a hemicolectomy. Appendectomy alone does not produce an adequate lymph node sample. Right hemicolectomy should be performed for all appendiceal adenocarcinomas.