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.

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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.

Treatment of malignant biliary obstruction (MBO) requires the coordination of multiple specialties, including oncologists, surgeons, gastroenterologists, and interventional radiologists. If the tumor is resectable, surgical candidates can usually proceed to surgery without preoperative biliary drainage. For patients who undergo biliary drainage, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) combined with biliary stenting are techniques with comparable technical success and mortality, each with distinct advantages and risks. Advances in endoscopic ultrasound allow drainage in patients with challenging anatomy. There are a multitude of devices used for biliary decompression. Self-expanding metal stents (SEMS), with longer patency rates, are in most instances preferred over plastic stents for MBO, especially in patients with life expectancy more than 3 to 4 months. Advantages of covered SEMS versus uncovered SEMS remain controversial as covered stents can prevent tumor ingrowth but at the expense of potential increase in stent migrations. Extra-anatomic biliary drainage using lumen-apposing metal stents is an emerging technique which shows promise when conventional ERCP fails. It is imperative to understand these techniques when tailoring a treatment strategy. The goal of this article is to discuss a multidisciplinary approach for MBO to promote comprehensive care using case examples to highlight essential principles.

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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“Everyone has a plan until they get punched in the mouth.” Never has this quote, uttered in response to a challenger’s reported plan to take the title away from heavyweight champion Mike Tyson, rang truer than in the past 20 months as the global population wrestles with the fallout on the SARS-CoV-2 pandemic. While countless lives were disrupted both directly and indirectly during this time, members of the medical community bore the brunt of this fallout in their personal lives while being asked to perform above capacity in their professional lives simultaneously. Compounding this experience was the fact that injuries, illness, and death from other causes did not halt leaving many in the medical community, and community at large, to face personal tragedies in addition to the pandemic. Our goal is to create a series of discussions using the perspective of our surgical department that faced not only the fallout of the pandemic, but also the unexpected death of an influential mentor/physician and close family member to the department. Unfortunately, this pandemic is not the only time tragedy has struck a surgical department. For example, Louisiana State University and Hurricane Katrina in 2007, and a plane crash killing members of the University of Michigan transplant team. However, the pandemic is certainly the most globally widespread, relevant and recent. We leverage crisis-management strategies from other fields, responses from an internal survey, and thoughts from our surgical team on what worked during these crises, what did not, and how we can begin to create a strategic response for those unexpected moments where you get “punched in the mouth.”

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