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Diaphragmatic hernia repair is a common operation performed at all types of hospitals. The variation in costs and repeat episodes of care after this operation is not known.The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing diaphragmatic hernia repair between 2011 and 2018 and the associated inpatient and outpatient encounters within 12 months postoperatively. Hospitals were ranked by cost and grouped into quintiles. All costs and charges were reliability and case-mix adjusted with the use of hierarchical multivariable regression.In total, 8,848 patients underwent diaphragmatic hernia operations at 158 hospitals. The most expensive hospital quintile had lower surgical volume, location in rural settings, and fewer than 100 beds. There was a wide variation in costs after diaphragmatic hernia repair. On unadjusted comparison, index costs were $23,041 more expensive in hospitals in the highest quintile than in the lowest quintile. Cost differences were persistent even after case-mix and reliability adjustment. The variation in adjusted aggregate charges for associated outpatient and inpatient encounters in the first year after the index operation was considerably lower than that of the index hospitalization.There is nearly a 2-fold variation in the cost of a diaphragmatic hernia repair across hospitals. Most of the variation occurs during the index surgical encounter and not for repeat encounters during the first postoperative year. As bundled payment models mature, hospitals and payers will need to target this variation to ensure cost-efficiency.

Published studies evaluating the effect of robotic assistance on clinical outcomes and costs of care in diaphragmatic hernia repair (DHR) have been limited.The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing transabdominal DHR between 2011 and 2018 and associated inpatient and outpatient encounters within 12 months after the index operation. Patients undergoing robotic DHR were 1:1:1 propensity score-matched for age, sex, race, Elixhauser comorbidity score, case priority, payer, and facility volume with patients undergoing open and laparoscopic DHR.There were 5,962 patients (67.3%) who underwent laparoscopic DHR, 1,520 (17.2%) who underwent open DHR, and 1,376 (15.5%) who underwent robotic DHR. On comparison of matched cohorts, median index length of stay (3 days; interquartile range [IQR] 2 to 5 days vs 2 days; IQR 1 to 4 days; p0.001) and index hospitalization costs ($17,236; IQR $13,231 to $22,183 vs $12,087; IQR $8,881 to $17,439; p0.001) for robotic DHR were greater than for laparoscopic DHR. Median length of stay for open DHR (6 days; IQR 4 to 10 days) was longer than that for both laparoscopic and robotic DHR. Median index hospitalization costs for open DHR ($16,470; IQR $11,152 to $23,768) were greater than those for laparoscopic DHR, but less than those for robotic DHR. There were no significant differences between cohorts in the overall rate of post-index care.Laparoscopic DHR is the most cost-effective approach to DHR. Robotic assistance provides clinical outcomes comparable with laparoscopic DHR, but is associated with increased index cost.

Background Management of pneumothorax has traditionally been tube thoracostomy and −20 cm H 2 O suction. The purpose of our study was to determine if underwater seal in iatrogenic and spontaneous pneumothoraces is safe and efficacious and if small-caliber chest tubes are appropriate for routine use in pneumothorax. Study design From April 2001 through October 2003 patients with iatrogenic or spontaneous pneumothorax were enrolled in this prospective, randomized trial. Small-bore catheters were inserted. Initial management was 1 hour −20 cm H 2 O suction, chest radiography, and randomization into −20 cm H 2 O suction, −10 cm H 2 O suction, or underwater seal. Tubes were discontinued at 48 hours if there were no pneumothoraces and no air leaks. Those with air leaks and recurrent pneumothoraces persisting 5 days underwent pleurodesis. The primary end point was successful chest tube removal at 48 hours. The secondary end point was need for pleurodesis. Results Twenty-nine patients were analyzed. Seven were randomized to −20 cm H 2 O suction, 11 to −10 cm H 2 O suction, and 11 to underwater seal. Most (59%, 17 of 29) chest tubes were successfully removed 48 hours after placement: 57% (4 of 7) after −20 cm H 2 O suction, 73% (8 of 11) after −10 cm H 2 O suction, and 45% (5 of 11) after underwater seal (p = 0.48). Seven (24%) required pleurodesis: 29% (2 of 7) after −20 cm H 2 O suction, 27% (3 of 11) after −10 cm H 2 O suction, and 18% (2 of 11) after underwater seal (p = 0.70). Conclusions Early underwater seal appears to be safe for treating iatrogenic and spontaneous pneumothoraces. It can achieve comparable frequencies of early chest tube removal and avoidance of operation compared with traditional management. A larger, multi-institutional study should be performed to demonstrate that pneumothorax treatment can effectively incorporate small-caliber tubes and underwater seal.

BACKGROUND: The timing for debridement of necrotizing pancreatitis is controversial. We reviewed our experience with early and delayed surgical debridement in patients with necrotizing pancreatitis. STUDY DESIGN: The records of patients diagnosed with acute necrotizing pancreatitis from January 1993 through June 2000 were reviewed retrospectively. Data were analyzed with respect to Ranson's, APACHE II, and multiple organ failure scores, etiology, presence of infection, overall and ICU length of stay, time to first debridement, number of debridements, fluid requirements, days to enteral feeding, transfusion requirements, complications, and mortality. RESULTS: Twenty-six patients (18 males, 8 females, mean age 51 years) were diagnosed with acute necrotizing pancreatitis. The admission Ranson's score was 4.8, the APACHE II score was 11.7, and multiple organ failure score was 4.2. All but one patient underwent pancreatic debridement (4.3 debridements per patient). Eighteen patients (69%) had infected pancreatic necrosis. The timing of debridement was based on patients' condition and surgeon's preference. The presentation and demographics of patients who underwent early ( 2 weeks) debridement did not differ significantly. Patients debrided early had a trend toward higher mortality (29% versus 18%) and experienced a higher number of major complications (p Candida in the infected necrosis (p CONCLUSIONS: Early debridement for acute necrotizing pancreatitis might not improve survival and might even be associated with increased number of complications. Most patients diagnosed with necrotizing pancreatitis eventually need debridement, but it might be beneficial to delay debridement if the patient's condition allows for it.

Background: Blunt carotid artery trauma remains a rare but potentially devastating injury. Early detection and treatment remain the goals of management. Our objective was to identify patients sustaining blunt carotid injuries at a regional trauma center and report on the incidence, demographics, diagnostic workup, management, and outcome. Study Design: A retrospective chart review was performed of patients sustaining blunt carotid artery injury between 1990 and 1996. Results: Twenty patients were identified during the 7-year period. All patients suffered blunt trauma, with motor vehicle accidents being the most common mechanism, and the internal carotid the most frequently injured vessel. Associated injuries were present in all patients, with head (65%) or chest (65%) injuries being the most common. The combination of head and chest trauma (45%) was found to be associated with a 14-fold increase in the likelihood of carotid injury. Cerebral angiography was diagnostic in all patients and the majority were treated nonoperatively with anticoagulation. Twenty percent of patients were discharged with a normal neurologic exam, while 45% left with a significant neurologic deficit. Overall mortality was 5%. Conclusions: Blunt carotid injuries are rare but are associated with significant morbidity and mortality. The combination of craniofacial and chest wounds should raise the index of suspicion for blunt carotid injury. Anticoagulation was associated with the least morbidity.

Received March 16, 2013; Revised May 28, 2013; Accepted May 2 From the Departments of Critical Care Medicine (Tisherman, Surgery (Tisherman), and Emergency Medicine (Emlet), University burgh, Pittsburgh, PA, Department of Surgery, University of M Ann Arbor, MI (Alam), Department of Surgery, University of M Baltimore, MD (Chiu), Department of Acute Care Surgery, So Hospital/Northshore LIJ Trauma Network, Bay Shore, NY (Gro Department of Surgery, Loyola University, Maywood, IL (Lu Departments of Emergency Medicine and Neurology, Yale U New Haven, CT (Marcolini), and Departments of Surgery and Em Medicine, Virginia Commonwealth University, Richmon (Mayglothling). Correspondence address: Samuel A Tisherman, MD, FACS, Department of Critical Care Medicine, University of Pittsburg 1215, Lillian S Kaufmann Bldg, 3471 Fifth Ave, Pittsburgh, PA email: tishermansa@upmc.edu

The timing for debridement of necrotizing pancreatitis is controversial. We reviewed our experience with early and delayed surgical debridement in patients with necrotizing pancreatitis.The records of patients diagnosed with acute necrotizing pancreatitis from January 1993 through June 2000 were reviewed retrospectively. Data were analyzed with respect to Ranson's, APACHE II, and multiple organ failure scores, etiology, presence of infection, overall and ICU length of stay, time to first debridement, number of debridements, fluid requirements, days to enteral feeding, transfusion requirements, complications, and mortality.Twenty-six patients (18 males, 8 females, mean age 51 years) were diagnosed with acute necrotizing pancreatitis. The admission Ranson's score was 4.8, the APACHE II score was 11.7, and multiple organ failure score was 4.2. All but one patient underwent pancreatic debridement (4.3 debridements per patient). Eighteen patients (69%) had infected pancreatic necrosis. The timing of debridement was based on patients' condition and surgeon's preference. The presentation and demographics of patients who underwent early (2 weeks) or late (2 weeks) debridement did not differ significantly. Patients debrided early had a trend toward higher mortality (29% versus 18%) and experienced a higher number of major complications (p0.05). The six patients (23%) who died were older, had multiple organ failure scores, and more often had Candida in the infected necrosis (p.05).Early debridement for acute necrotizing pancreatitis might not improve survival and might even be associated with increased number of complications. Most patients diagnosed with necrotizing pancreatitis eventually need debridement, but it might be beneficial to delay debridement if the patient's condition allows for it.