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Equipoise exists regarding whether mesh cruroplasty during laparoscopic large hiatal hernia repair improves symptomatic outcomes compared with suture repair. Systematic literature review (MEDLINE and EMBASE) identified 13 studies (1,194 patients; 521 suture and 673 mesh) comparing mesh versus suture cruroplasty during laparoscopic repair of large hiatal hernia. We abstracted data regarding symptom assessment, objective recurrence, and reoperation and performed meta-analysis. The majority of studies reported significant symptom improvement. Data were insufficient to evaluate symptomatic versus asymptomatic recurrence. Time to evaluation was skewed toward longer follow-up after suture cruroplasty. Odds of recurrence (odds ratio .51, 95% confidence interval .30 to .87; overall P = .014) but not need for reoperation (odds ratio .42, 95% confidence interval .13 to 1.37; overall P = .149) were less after mesh cruroplasty. Quality of evidence supporting routine use of mesh cruroplasty is low. Mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.

Background Despite decades of craniofacial surgeons repairing cleft palates, there is no consensus for the rate of fistula formation following surgery. The authors present a meta-analysis of studies that reported on primary cleft palate to determine the rate of oronasal fistula and to identify risk factors for their development. Methods A literature search for the period between 2000 and 2012 was performed. Articles were queried and strict inclusion and exclusion criteria were applied to focus on primary cleft palate repair. A meta-analysis of these data was conducted. Results The meta-analysis included 11 studies, comprising 2505 children. The rate of oronasal fistula development was 4.9% (95% confidence interval, 3.8% to 6.1%). When analyzing a larger cohort, there was a significant relationship between Veau classification and the occurrence of a fistula (P < .001), with fistulae most prevalent in patients with a Veau IV cleft. The most common location for a fistula was at the soft palate-hard palate junction. One study used decellularized dermis in cleft repair with a fistula rate of 3.2%. Conclusions Using 11 studies comprising 2505 children, we find the rate of reported fistula occurrence to be 4.9%. Furthermore, patients with a Veau IV cleft are significantly more likely to develop an oronasal fistula. When fistulae do occur, they do so most often at the soft palate-hard palate junction. A deeper understanding of fistula formation will help cleft palate surgeons improve their outcomes in the operating room and will allow them to effectively communicate expectations with patients' families in the clinic.

Despite centuries of research, much about the barbarian migrations that took place between the fourth and sixth centuries in Europe remains hotly debated. To better understand this key era that marks the dawn of modern European societies, we obtained ancient genomic DNA from 63 samples from two cemeteries (from Hungary and Northern Italy) that have been previously associated with the Longobards, a barbarian people that ruled large parts of Italy for over 200 years after invading from Pannonia in 568 CE. Our dense cemetery-based sampling revealed that each cemetery was primarily organized around one large pedigree, suggesting that biological relationships played an important role in these early medieval societies. Moreover, we identified genetic structure in each cemetery involving at least two groups with different ancestry that were very distinct in terms of their funerary customs. Finally, our data are consistent with the proposed long-distance migration from Pannonia to Northern Italy. The Longobards invaded and conquered much of Italy after the fall of the Western Roman Empire. Here, the authors sequence and analyze ancient genomic DNA from 63 samples from two cemeteries associated with the Longobards and identify kinship networks and two distinct genetic and cultural groups in each.

Pediatric abdominal pain visits to emergency departments (ED) are common. The objectives of this study are to assess variation in imaging (ultrasound ±computed tomography [CT]) and factors associated with isolated CT use. This was a retrospective cohort study of ED visits for pediatric abdominal pain resulting in discharge from 16 regional EDs from 2007 to 2013. Primary outcome was ultrasound or CT imaging. Secondary outcome was isolated CT use. We used multivariable logistic regression to evaluate patient- and hospital-level covariates associated with imaging. Of the 21 152 visits, imaging was performed in 29.7%, and isolated CT in 13.4% of visits. In multivariable analysis, black patients (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.4-0.5) and Medicaid (OR, 0.6; 95% CI, 0.5-0.7) had lower odds of advanced imaging compared with white patients and private insurance, respectively. General EDs were less likely to perform imaging (OR, 0.6; 95% CI, 0.5-0.7) compared with the pediatric ED; however, for visits with imaging, 3.5% of visits to the pediatric ED compared with 76% of those to general EDs included an isolated CT (P<.001). Low pediatric volume (OR, 1.8; 95% CI, 1.5-2.2) and rural (OR,1.8; 95% CI, 1.3-2.5) EDs had higher odds of isolated CT use, compared with higher pediatric volumes and nonrural EDs, respectively. There are racial and insurance disparities in imaging for pediatric abdominal pain. General EDs are less likely than pediatric EDs to use imaging, but more likely to use isolated CT. Strategies are needed to minimize disparities and improve the use of “ultrasound first.”

Introduction and hypothesis In 2008 and 2011, the US Food and Drug Administration (FDA) released notifications regarding vaginal mesh. In describing prolapse surgery trends over time, we predicted vaginal mesh use would decrease and native tissue repairs would increase. Methods Operative reports were reviewed for all prolapse repairs performed from 2008 to 2011 at our large regional hospital system. The number of each type of prolapse repair was determined per quarter year and expressed as a percentage of all repairs. Surgical trends were examined focusing on changes with respect to the release of two FDA notifications. We used linear regression to analyze surgical trends and chi-square for demographic comparisons. Results One thousand two hundred and eleven women underwent 1,385 prolapse procedures. Mean age was 64 ± 12, and 70 % had stage III prolapse. Vaginal mesh procedures declined over time ( p  = 0.001), comprising 27 % of repairs in early 2008, 15 % at the first FDA notification, 5 % by the second FDA notification, and 2 % at the end of 2011. The percentage of native tissue anterior/posterior repairs ( p  < 0.001) and apical suspensions ( p  = 0.007) increased, whereas colpocleisis remained constant ( p  = 0.475). Despite an overall decrease in open sacral colpopexies ( p  < 0.001), an initial increase was seen around the first FDA notification. We adopted laparoscopic/robotic techniques around this time, and the percentage of minimally invasive sacral colpopexies steadily increased thereafter ( p  < 0.001). All sacral colpopexies combined as a group declined over time ( p  = 0.011). Conclusions Surgical treatment of prolapse continues to evolve. Over a 4-year period encompassing two FDA notifications regarding vaginal mesh and the introduction of laparoscopic/robotic techniques, we performed fewer vaginal mesh procedures and more native tissue repairs and minimally invasive sacral colpopexies.

Introduction Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting. Methods We abstracted data for patients undergoing PEHR ( n  = 924; non-elective n  = 171 (19 %); 1997–2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined. Results Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p  < 0.001) and death (8 versus 1 %; p  < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07–2.61) and mortality nearly three times greater (OR 2.74, CI 0.93–8.1) than for elective repair. Conclusions Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.

Introduction In critically ill patients, re-intubation is common and may be a high-risk procedure. Anticipating a difficult airway and identifying high-risk patients can allow time for life-saving preparation. Unfortunately, prospective studies have not compared the difficulty or complication rates associated with reintubation in this population. Methods We performed a secondary analysis of a prospective registry of in-hospital emergency airway management, focusing on patients that underwent multiple out-of-operating room intubations during a single hospitalization. Our main outcomes of interest were technical difficulty of intubation (number of attempts, need for adjuncts to direct laryngoscopy, best Cormack-Lehane grade and training level of final intubator) and the frequency of procedural complications (aspiration, arrhythmia, airway trauma, new hypotension, new hypoxia, esophageal intubation and cardiac arrest). We compared the cohort of reintubated patients to a matched cohort of singly intubated patients and compared each repeatedly intubated patient’s first and last intubation. Results Our registry included 1053 patients, of which 151 patients (14%) were repeatedly intubated (median two per patient). Complications were significantly more common during last intubation compared to first (13% versus 5%, P  = 0.02). The most common complications were hypotension (41%) and hypoxia (35%). These occurred despite no difference in any measure of technical difficultly across intubations. Conclusion In this cohort of reintubated patients, clinically important procedural complications were significantly more common on last intubation compared to first.

Background and ObjectivesPostoperative neurologic symptoms after interscalene block and shoulder surgery have been reported to be relatively frequent. Reports of such symptoms after ultrasound-guided block have been variable. We evaluated 300 patients for neurologic symptoms after low-volume, ultrasound-guided interscalene block and arthroscopic shoulder surgery.MethodsPatients underwent ultrasound-guided interscalene block with 16 to 20 mL of 0.5% bupivacaine or a mix of 0.2% bupivacaine/1.2% mepivacaine solution, followed by propofol/ketamine sedation for ambulatory arthroscopic shoulder surgery. Patients were called at 10 days for evaluation of neurologic symptoms, and those with persistent symptoms were called again at 30 days, at which point neurologic evaluation was initiated. Details of patient demographics and block characteristics were collected to assess any association with persistent neurologic symptoms.ResultsSix of 300 patients reported symptoms at 10 days (2%), with one of these patients having persistent symptoms at 30 days (0.3%). This was significantly lower than rates of neurologic symptoms reported in preultrasound investigations with focused neurologic follow-up and similar to other studies performed in the ultrasound era. There was a modest correlation between the number of needle redirections during the block procedure and the presence of postoperative neurologic symptoms.ConclusionsUltrasound guidance of interscalene block with 16- to 20-mL volumes of local anesthetic solution results in a lower frequency of postoperative neurologic symptoms at 10 and 30 days as compared with investigations in the preultrasound period.

Staging for esophagogastric adenocarcinoma lacked sufficient prognostic accuracy and was revised. We compared survival prognostication between American Joint Committee on Cancer (AJCC) 6th and 7th editions. We abstracted data for 836 patients who underwent minimally invasive esophagectomy for esophagogastric adenocarcinoma (n = 256 neoadjuvant). Monotonicity and strength of survival trends, by stage, were assessed (log-rank test of trend chi-square statistic) and compared using permutation testing. Overall survival (Cox regression) and model fit (Akaike Information Criterion) were determined. A greater log-rank test of trend statistic indicated stronger survival trends by stage in AJCC 7th (152.872 vs 167.623; permutation test P < .001) edition. Greater Cox likelihood chi-square value (162.957 vs 173.951) and lower Akaike Information Criterion (4,831.011 vs 4,820.016) indicated better model fit. Superior performance was also shown after neoadjuvant therapy. AJCC 7th edition staging for esophagogastric adenocarcinoma provides superior prognostic stratification after minimally invasive esophagectomy, overall and after neoadjuvant therapy compared with AJCC 6th edition.

Introduction and hypothesis The aim was to determine factors associated with performing concurrent apical support procedures in hysterectomies carried out for uterovaginal prolapse. Methods Hysterectomies performed for uterovaginal prolapse from 2000 to 2010 were identified by ICD-9 codes. Uterovaginal prolapse was a proxy for apical descent. Primary outcome was the rate of concurrent apical procedures. Secondary outcomes included concurrent surgeries, complications, and surgeon training. Chi-squared tests compared categorical variables. Logistic regression determined factors associated with concurrent apical support. Results A total of 2,465 hysterectomies were performed for uterovaginal prolapse. In only 1,358 cases (55.1 %) were concurrent apical support procedures carried out. Cases without apical procedures were more likely to undergo cystocele repair (23.8 % vs 9.4 %, p  < 0.001), but less likely to have rectocele (3.4 % vs 12.2 %, p  < 0.001) or combined cystocele/rectocele repair (16.4 % vs 25.6 %, p  < 0.001). Of those without apical procedures, 95.7 % were performed by generalists. Urogynecologists and minimally invasive gynecologists were more likely to perform apical procedures (97.1 % and 88.8 % vs 23.6 %, p  < 0.001). Older patients (>75 years) were more likely to undergo apical procedures (OR 5.096, 95 % CI 3.127–8.304). Surgeons practicing for 10–14 years and >20 years were less likely to perform apical procedures than those practicing <5 years ( p  < 0.001 vs. p  = 0.01). Conclusions At a tertiary hospital, a significant proportion of hysterectomies are carried out for uterovaginal prolapse without concurrent apical support procedures, with the majority performed by generalists. Urogynecologists and minimally invasive gynecologists are more likely to perform an apical suspension at the time of hysterectomy for uterovaginal prolapse than generalists. This supports the need for continued education about apical support to appropriately manage uterovaginal prolapse.