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Background Racial disparity in surgical access and postoperative outcomes after pulmonary lobectomy continues to be a concern and target for improvement; however, evidence of independent impact of race on complications is lacking. The objective of this study was to investigate the impact of race/ethnicity on surgical outcomes after lobectomy for lung cancer and estimate the distribution of racial/ethnic groups among expected resectable lung cancer cases using a large national database. Methods Patients who underwent lobectomy for lung cancer between 2005 and 2016 were identified in the American College of Surgeon National Surgical Quality Improvement Program. Preoperative characteristics and postoperative outcomes were compared between race/ethnicity groups in all patients and in propensity-matched cohorts, controlling for pertinent risk factors. Distribution of each race/ethnicity in the database was calculated relative to estimated numbers of patients with resectable lung cancer in the United States. Results A total of 10,202 patients (age 67.6 ± 9.7, 46.7% male, 86.4% white) underwent nonemergent lobectomy (46.8% thoracoscopic). Blacks had higher rates of baseline risk factors. In propensity score–matched cohorts of whites, blacks, and Hispanics/Asians (n = 498 each), postoperatively, blacks had higher rates of prolonged intubation and longer hospital stay while whites had a higher rate of pneumonia. Race was independently associated with these adverse outcomes on multivariate analysis. Proportion of blacks and Hispanics in the American College of Surgeon National Surgical Quality Improvement Program was lower than their respective proportion of resectable lung cancer in the United States. Conclusions In a large national-level surgical database, there was lower than expected representation of black and Hispanic patients. Black race was independently associated with extended length of stay and prolonged intubation, whereas white was independently associated with postoperative pneumonia.

Appendiceal adenocarcinoma is rare with variable presentations. Perforation of the appendix within prolapsed ostomy can have peritoneal spread for which intraperitoneal chemotherapy should be considered. Surveillance is essential for these patients.

Hepatic hydrothorax is the formation of transudative pleural effusion as a consequence of portal hypertension. Only a minority of cases resolve after sodium restriction and diuretics. Despite the relatively low incidence of 5-15% among patients with cirrhotic portal hypertension, the high morbidity and serious clinical implications associated with hepatic hydrothorax necessitate a well-defined treatment strategy to guide patient care. Management is typically multidisciplinary, involving hepatologists, interventional pulmonologists, interventional radiologists, surgeons, and other specialties. In this manuscript, we assemble a multidisciplinary team to critically review the available literature and provide an evidence-based guidance for management of hepatic hydrothorax.

Deglutition syncope is a rare, neurally mediated reflex syncope associated with swallowing. It is typically associated with pharyngoesophageal disorders with secondary abnormal vagal reflex causing atrioventricular cardiac block and cerebral hypoperfusion. Diagnosis can be delayed and challenging. Various treatment options have been reported, including withholding cardiac blocker agents, diet modifications, and pacemaker placement. We present a case of persistent deglutition syncope secondary to esophagogastric junction outflow obstruction that failed medical therapy and was managed successfully with peroral endoscopic myotomy with excellent long-term outcome.

We agree with Kulkarni et al on the potential role of splanchnic and peripheral vasoconstrictors in the treatment of HH. In our review (1), we summarize the sparse data on octreotide and terlipressin in HH management. However, there are currently no large studies or randomized trials on the use of these medications in HH, and evidence for their use is limited to case reports and case series. Most of the studies cited by Kulkarni et al examine these pharmacologic agents in the control of ascites, not HH per se.

A 43 years old female with laparoscopic sleeve gastrectomy (SG) and an ‘anterior’ hiatal hernia repair 11 years ago, presented with 3 years history dysphagia and heartburn. Upper gastrointestinal barium showed an almost complete intrathoracic migration of the SG with a partial organoaxial volvulus. Upper endoscopy revealed a 10 cm hiatal hernia with grade B esophagitis. Laparoscopic revision surgery with reduction of the gastric sleeve, standard posterior hiatal hernia repair, resection of the narrowed remnant of the SG and conversion to a gastric bypass was performed. No postoperative complications occurred. The patient is asymptomatic at 2 years of follow-up. We present the technical standards for the management and discuss the suspected pathophysiology of this rare but challenging condition.

Omental infarction is a rare phenomenon that can be idiopathic or secondary to a surgical intervention. Greater omentum division has been advocated to decrease tension at the gastro-jejunal anastomosis during laparoscopic Roux-en-Y gastric bypass (RYGB). We report a case of omental infraction complicated by liquefied infected necrosis presenting 3 weeks after antecolic antegastric RYGB. The patient underwent laparotomy and subtotal omentectomy with a protracted hospital course due to intra-abdominal abscesses, acute kidney injury and small bowel obstruction that were successfully managed non-operatively. We reviewed the available literature on omental infarction after RYGB, focusing on associated symptoms, possible etiology, timing of presentation, management and propose an alternative technique without omental division.

Chronic constipation is a common cause of morbidity in the elderly and institutionalized population. It can be associated with significant morbidity and socioeconomical burden. Chronic resistance constipation can rarely be associated with megarectum. Herein, we present the case of a patient with physical and mental disability that presented with refractory constipation associated with extreme stool burden and a massive megarectum. We discuss chronic constipation in the elderly population, its etiologies and diagnostic work-up including surgical options. The management of chronic constipation with megarectum should be on a case-by-case basis.