Purpose: Patients with paraesophageal hernias (PEHs) typically present in the sixth and seventh decades of life. Frequently, elderly patients are not offered elective repair due to historical data on high operative risk. Given the broad adoption of minimally-invasive (MIS) techniques, we hypothesized that risk would be more acceptable in elderly patients. Methods: A retrospective study of the National Inpatient Sample (NIS) from 2016 to 2018 was performed. Patients were divided by age (50–79 and ≥80 years) and compared using Pearson’s Chi-squared and Student’s t-tests. Propensity score-match using age, race, gastroesophageal reflux disease, frailty, and 11 comorbidities was performed. Results: 10 456 patients were included, 90.4% 50–79 (9,454) and 9.6% ≥ 80 (1002). The cohort was predominantly female (76.3%). Younger patients had fewer overall comorbidities and lower likelihood of frailty (2.5% vs. 9.3%, P < .01). Younger patients had shorter lengths of stay (2 days vs. 3 days, P < .01), fewer overall complications (26% vs. 36.8%, P < .01), and major complications (20.8% vs. 29.2%, P < .01). In-hospital mortality was higher for those over 80 (0.3% vs. 2.3%, P < .01). Propensity matching selected 942 pairs. Age remained associated with more frequent minor complications (23% vs. 28.7%, P < .01), major complications (12.1% vs. 16.1%, P < 0.01), and in-hospital mortality (0.5% vs. 2.3%, P < .01). Conclusions: There remains a significant association between age and risk of minor complication, major complication, and in-hospital mortality for elective repair of PEH despite the broad adoption of MIS techniques. This data may support the elective repair of PEHs at a younger age.
BACKGROUND Cervical spinal cord injuries often necessitate ventilator support (VS). Prolonged endotracheal tube use has conveyed substantial morbidity in prospective study. Tracheostomy is recommended if VS is anticipated to be 7 days or longer, which defines prolonged ventilation (PV). Identifying these patients on arrival and before tracheostomy need is readily evident could prevent morbidity while lowering hospital costs. We aimed to create a tracheostomy score (trach score) to identify patients requiring PV and who could benefit from immediate tracheostomy. METHODS A review of patients with cervical spine fractures and cervical spinal cord injuries from 2005 to 2017 from the Pennsylvania Trauma Outcome Study database was performed. Patients were excluded for missing data, no use of VS or death in less than 7 days. Patients were selected for a training set or validation set by state identification number. We used automated forward stepwise selection to select a logistic model. Significant continuous variables were dichotomized to create a simplified screening score (trach score) and this was applied to the validation set. RESULTS Needing ventilation for 7 or more days was positively associated with higher Injury Severity Scores having a complete or anterior injury, and having a motor cord injury from C1 to C4. Application of the logistic model to the validation data produced a receiver operating characteristic curve with area under the curve of 0.7712, with 95% confidence limit (CL) of 0.6943 to 0.8481. The validation receiver operating characteristic curve was statistically better than chance using a contrast test with χ2 with p value less than 0.01. In the validation set, a trach score of 0 correlated to 33% needing PV, a score of 1 with 67% needing PV, 2 with 85%, and 3 with 98%. CONCLUSION Use of the trach score identified the majority of patients requiring prolonged VS in our study. An early tracheostomy protocol using predictive modeling could aid in reduction of intensive care unit length of stay and improving ventilator weaning in these patients. External verification of this predictive tool and of an early tracheostomy protocol is needed. LEVEL OF EVIDENCE This work is a retrospective prognostic cohort study and meets evidence Level III criteria.
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's χ 2 and Student's 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<0.01); older patients had higher rates of all but two subclasses of complication.
Background: Lung cancer screening has led to the discovery of many incidental findings including hiatal hernias (HH). However, the clinical significance and work up of these HH varies widely and there is no standardized approach toward follow-up studies or interventions. Therefore, we sought to identify the prevalence, symptoms, and describe our approach toward management of incidentally found HH on lung cancer screening CT scans. Methods: We conducted a retrospective chart review of patients who had HH incidentally found on their lung cancer screening CT scans, at our institution between June 2021 and January 2022. We then analyzed the collected data to determine the prevalence of HH in lung cancer screening patients, presence of symptoms, and management of these HH. Results: About 638 patients underwent lung cancer screening, of which 8.8% (n = 56) were found to have HH. Although 64.3% of patients with HH were symptomatic, 51.8% had not seen a gastroenterologist and 64.3% never had prior esophagogastroduodenoscopy. Of the patients with HH, 25% were evaluated by a thoracic surgeon based on symptoms or type of HH, and 10.7% qualified for surgical intervention. Patients not eligible for surgical intervention were referred to gastroenterology for follow-up. Conclusions: Hiatal hernias are common incidental findings on lung cancer screening CT scans. Many of these patients with HH are symptomatic and some have large HH. Therefore, these patients should be referred to specialists who can monitor their symptoms, initiate appropriate work-up when needed, and offer medical or surgical treatment when indicated.
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