Neil H. Bhayani

Esophageal cancer is the eighth most common cancer worldwide. Better use of multimodality therapy and advances in chemotherapy and radiotherapy have enhanced survival.¹ Surgical resection remains the preferred treatment for curable esophageal adenocarcinoma, although it is accompanied by significant morbidity.² Morbidity rates may be influenced by institutional volume, comorbid conditions, and surgical technique.³ Pulmonary morbidity, which frequently complicates the postoperative course, may be averted by avoiding thoracic incisions.

Incarceration and obstruction of an intrathoracic stomach are potentially devastating complications of paraesophageal hernias (PEH). Gastric decompression and resuscitation are important elements of preoperative management of acutely presenting PEH. The optimal time for surgical repair after decompression is unknown. We hypothesized that in obstructed PEH, early surgery may improve outcomes. From the 2005–2010 National Surgical Quality Improvement Project database, we selected PEH repairs with a diagnosis of obstruction. Patients were divided by time to surgery: ≤1 day of admission (early) or >1 day (interval). Outcomes were mortality and morbidity. Multivariable regression controlled for age and cardiopulmonary comorbidities. Of 224 patients, 149 (67 %) were early and 75 (33 %) were interval, with mean 3.6 days. Repairs were 89 % transabdominal, 9 % included fundoplication, and 18 % gastrostomy. Early and interval groups experienced similar morbidity 23 versus 31 % (p = 0.2) and mortality 5.4 versus 4 % (p = 0.7). Pulmonary, wound, or VTE complications were equivalent. Sepsis was less (2.7 vs. 13 %, p = 0.002) and length of stay was shorter (5 vs. 11 days, p < 0.001) for early vs. interval patients. On adjusted analysis, the early group had an 80 % reduction in sepsis (95 % confidence interval (CI), 0.05–0.6, p = 0.005). Odds of overall or other morbidity or mortality were statistically similar between groups. Patients who required emergency surgery for PEH have disease complicated by strangulation, perforation, bleeding, or sepsis. Emergency surgery for PEH repair is inherently high-risk and preoperative resuscitation and decompression is critical. In our analysis, patients with an obstructed PEH had less postoperative sepsis and fewer days in the hospital if surgery was performed within the first hospital day. However, there was no difference in mortality between early and delayed treatment. Deferring surgery for resuscitation permits optimization, but prolonged delay may worsen patient outcomes.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) requires specialized training commonly acquired during a fellowship. We hypothesized that fellows affect patient outcomes and this effect varies during training. We included all LRYGB from the 2005 to 2009 American College of Surgeons-National Surgical Quality Improvement Program database. Cases without trainees (attending) were compared to those with trainees of ≥6 years (fellow). Outcomes were pulmonary, infectious, and wound complications and deep venous thrombosis (DVT). Multivariable regression controlled for age, BMI, and comorbidities. Of the 18,333 LRYGB performed, 4,349 (24 %) were fellow cases. Fellow patients had a higher BMI (46.1 vs. 45.7, p < 0.001) and fewer comorbidities. Mortality was 0.2 and 0.1 % and overall morbidity was 4.8 and 6.0 % for attending and fellow groups, respectively. On adjusted analysis, mortality was similar, but fellow cases had 30 % more morbidity (p = 0.001). Specifically, fellows increased the odds of superficial surgical site infections (SSSIs) [odds ratio (OR) = 1.4, p = 0.01], urinary infections (UTIs) (OR = 1.7, p = 0.002), and sepsis (OR = 1.5, p = 0.05). During the first 6 months, fellows increased the odds of DVT (OR = 4.7, p = 0.01), SSIs (OR = 1.5, p = 0.001), UTIs (OR = 1.8, p = 0.004), and sepsis (OR = 1.9, p = 0.008). By the second half of training, fellow cases demonstrated outcomes equivalent to attending cases. Involving fellows in LRYGB may increase DVT, SSIs, UTIs, and sepsis, especially early in training. By completion of their training, cases involving fellows exhibited outcomes similar to cases without trainees. This supports both the need for fellowship training in bariatric surgery and the success of training to optimize patient outcomes.