Endoscopic impedance planimetry versus high-resolution manometry (HRM) for pre-operative motility evaluation in anti-reflux surgery.

INTRODUCTION: Pre-operative evaluation of patients with gastroesophageal reflux disease (GERD) includes assessment of esophageal motility. High-resolution manometry (HRM) is the gold standard; endoscopic impedance planimetry (IP) with Endoflip 2.0 is increasingly utilized in esophageal disorders of motility. We hypothesized that normal IP motility would correlate with normal HRM motility and tested this in a prospective cohort study. METHODS: Patients presenting for surgical evaluation of GERD between 9/2020 and 10/2021 were prospectively enrolled under an IRB-approved protocol. Patients with prior esophageal/gastric surgery, known motility disorders, or large paraesophageal hernias were excluded. All underwent HRM and IP, with normal motility defined by Chicago 3.0 classification for HRM and the presence of repetitive antegrade contractions for IP. Logistic regression and t test were used to analyze the data; p value < 0.05 was considered significant. RESULTS: Of 63 patients enrolled, 48 completed both IP and HRM testing. The cohort was 50% male with a median age of 52.5 [42.0, 66.0] years, mostly ASA class 1-2 (75.1%, n = 36) and had an average BMI of 31.4 ± 6.3 kg/m2. Normal motility tracings were in 62.5% of IP and 75% of HRM tests. Using HRM as the gold standard, IP detected normal motility with a sensitivity of 65.8% and a specificity of 50% (positive predictive value 83.3%, negative predictive value 27.8%). Normal IP was not statistically significant in predicting normal HRM (OR 3.182, 95% CI 0.826-12.262, p = 0.0926). Tolerability of IP was significantly better than HRM with lower rates of discomfort (10.9% vs. 93.4%, p < 0.0001) and higher willingness to repeat testing (100% vs. 47.8%, p < 0.0001). CONCLUSION: Esophageal motility testing with Endoflip 2.0 is well tolerated by patients. The low specificity (50%), poor negative predictive value (27.8%), and lack of statistically significant concordance between IP and HRM raises concern for the reliability of this test as a stand-alone replacement for HRM in the pre-operative evaluation for GERD.

What would you do (WWYD)? Thinking outside the virtual lecture box during COVID-19 and beyond.

Background: The COVID-19 pandemic disrupted many aspects of personal and professional life for surgeons, with resulting suspension of many in-person educational opportunities in favor of virtual education programs. Adapting to these new challenges, we developed, implemented, and evaluated a novel approach to Department of Surgery Grand Rounds to meet the educational needs of residents. Methods: At the outset of COVID-19-related restrictions, educational leadership performed a needs assessment of resident education, leading to a quick pivot to video-based programming. We developed "What Would You Do?" (WWYD), a virtual case-based educational session. Junior residents worked with senior residents, fellows, and faculty to develop disease-specific cases and questions, which were then presented to a panel of invited national subject experts. Feedback was collected from attendees after each grand rounds session via electronic survey, and the panel logistics and "flipped classroom" style of questioning iteratively adapted based on survey responses, verbal feedback, and educational principles. A department-wide survey was conducted at the end of the first year of virtual sessions to assess faculty and trainee perceptions of virtual vs. in-person didactics. Results: While COVID-19 educational materials were widely available, needs assessment found that surgical educational programming for trainees was dramatically reduced. Over a period of 24 months, we hosted twelve WWYD sessions with 20 internal faculty and 22 national virtual guest panelists. WWYD covered core surgical topics, such as hernia, colorectal, trauma, endocrine, vascular, foregut, and transplant. Weekly attendance ranged from 40 to 100, including faculty, trainees, and students. Attendees at WWYD grand rounds reported more strong agreement that speakers communicated effectively (93.7% vs. 79.8%, p < 0.0001), and that topics were engaging (92.4% vs. 78.5%, p < 0.0001) and relevant (91.5% vs. 79.7%, p < 0.0001), when compared to didactic virtual grand rounds. Department-wide survey noted differences in faculty vs. trainee priorities for didactic sessions, with faculty both finding virtual didactics more convenient (92.1% vs. 71.4% strong agreement, p = 0.004) and more highly valuing convenience (89.7% vs. 69.1% highly value, p = 0.005). Conclusions: During an isolating time, the WWYD format leveraged affordances of a virtual platform to bring diverse content experts together for disease-specific discussions, aligning with problem-based, active learning pedagogical approaches which have proven more effective than lectures. Attendees found the format more engaging than virtual didactic lectures, but department-wide survey revealed a dichotomy of didactic priorities between faculty and trainees, with faculty more strongly favoring attendance convenience. WWYD is well-positioned to deliver a didactic educational experience with both engagement and convenience.

Optimal Timing of Fundamentals of Endoscopic Surgery (FES) Testing in General Surgery Residency: Early Is Better.

BACKGROUND: Fundamentals of endoscopic surgery (FES) completion is mandatory for certification by the American Board of Surgery (ABS). As early simulation and competency assessment can bolster development of trainee proficiency, we sought to determine the optimal timing for FES examination by evaluating pass rates based on training level and previous endoscopic experience. METHODS: PGY2-5 residents at a university-based medical center who were novice to FES were assigned to complete FES training and testing. Training year, prior endoscopic experience, and FES exam scores were recorded with pre- and post-test surveys. RESULTS: Most residents in the program (88%) were able to complete FES training and testing within a single academic year. Most required only a single faculty-led session (88%) to feel confident to take the exam, augmented by varying numbers of independent practice sessions (50% 1-2, 19% 3-5, 27% > 5). After training, most (84%) felt confident that they would pass the exam, and 93% did so on their first attempt. While higher written exam scores were noted in the PGY5 group, there were no other statistically significant differences in overall pass rates or technical exam scores based on PGY level (p = 0.24). A number of previously completed endoscopic cases did not correlate with exam scores (p = 0.24 written, p = 0.91 technical). CONCLUSION: Fundamentals of endoscopic surgery (FES) certification can be successfully completed by junior level general surgery residents regardless of previous endoscopic experience. Moving this exam to earlier training years can benefit resident development and preparedness in the clinical setting without negatively impacting pass rates.

Ten-year outcomes following ventral hernia repair: making the case for better post-market surveillance in the USA.

BACKGROUND: We sought to identify the 10-year complication and recurrence rates and associated sociodemographic and operative characteristics associated with non-mesh versus mesh-based ventral hernia repairs (VHRs). METHODS: This was an IRB-approved (2020H0317) retrospective longitudinal study of patients undergoing mesh or non-mesh VHR from 2009-2019 at a single tertiary-care institution. The electronic medical record was used to collect sociodemographic, clinical, and intraoperative details, and early (≤ 30 days) and long-term (> 30-day) postoperative complications. Up to ten-year follow-up was obtained for long-term complications, categorized as: hernia recurrence reoperation (HRR), major complications requiring emergency surgery (MCES) (defined as non-elective operations related to the abdominal wall), and non-recurrence procedural intervention (NRPI) (defined as any procedures related to the abdominal wall, bowel, or mesh). Kaplan-Meier survival curves were obtained for each long-term complication. RESULTS: Of the 645 patients identified, the mean age at index operation was 52.51 ± 13.57 years with 50.70% female. Of the index operations, 21.24% were for a recurrence. Procedure categories included: 57.36% incisional, 37.21% non-incisional umbilical, 8.22% non-incisional epigastric, 3.88% parastomal, 0.93% diastasis recti, and 0.47% Spigelian hernias. Operative approaches included open (n = 383), laparoscopic (n = 267), and robotic (n = 21). Fascial closure (81.55%) and mesh use (66.2%) were performed in the majority of cases. Median follow-up time was 2098 days (interquartile range 1320-2806). The rate of short-term complications was 4.81% for surgical site infections, 15.04% for surgical site occurrences, and 13.64% for other complications. At 10 years, the HRR-free survival probability was 85.26%, MCES-free survival probability was 94.44%, and NRPI-free survival probability was 78.11%. CONCLUSIONS: A high proportion of patients experienced long-term recurrence and complications requiring intervention after index VHR. For many patients, a ventral hernia develops into a chronic medical condition. Improved efforts at post-market surveillance of operative approaches and mesh location and type should be undertaken to help optimize outcomes.

Surgical treatment of hepatic oligometastatic pancreatic ductal adenocarcinoma: An analysis of the National Cancer Database.

BACKGROUND: Patients with liver-only metastatic pancreatic adenocarcinoma have traditionally been offered palliative chemotherapy alone. Recent studies have explored the role of surgical resection among patients with limited metastatic disease. National practice patterns and the impact of surgery among these patients remains unknown. METHODS: The National Cancer Database was queried for all patients with pancreatic adenocarcinoma between 2010 and 2015. The primary outcome was overall survival from the time of diagnosis. Patients with liver-only metastatic disease were included. Univariable and multivariable logistic regression models were constructed to determine the association of patient, hospital, and regional factors with receipt of surgical resection. A propensity score-matched cohort (1:1) was generated by matching patient- and tumor-related factors (age, sex, race, comorbidity burden, primary tumor site, primary tumor size) among patients with liver-only stage IV pancreatic adenocarcinoma who received chemotherapy alone compared to those who received chemotherapy and underwent pancreatectomy and liver metastatectomy. RESULTS: Among 312,426 patients who met the study criteria, one half (n = 140,043, 50.4%) had stage IV disease; metastatic sites included bone (n = 5493, 3.1%), brain (n = 620, 0.4%), lung (n = 16,580, 9.5%), and liver (n = 62,444, 35.7%). Patients with stage IV disease were more likely to be younger (odds ratio: 1.10, 95% confidence interval: 1.0-1.2; P = .03) and have poorly (odds ratio: 2.1, 95% confidence interval: 1.8-2.5; P < .001) or undifferentiated (odds ratio: 3.1, 95% confidence interval: 2.3-4.1; P < .001) tumors. Among stage IV patients with liver-only disease (n = 47,785, 14.9%), 891 patients (1.9%) underwent pancreatic resection. Patients who underwent resection were more likely to be younger (odds ratio 1.4, 95% confidence interval: 1.0-1.8; P = .03) and treated at an academic/research center (odds ratio 2.1, 95% confidence interval: 1.2-3.5; P = .006). Median overall survival among patients who underwent resection was 10.74 months versus 3.4 months among patients who did not undergo resection. After controlling for patient and disease-related factors, patients who underwent surgical resection had a lower risk of death versus patients who did not undergo surgery (hazard ratio: 0.5, 95% confidence interval: 0.4-0.6; P < .001). After propensity score matching, patients who received multimodality treatment for liver-only metastatic pancreatic adenocarcinoma (surgery, chemotherapy) had a longer median overall survival (15.6 months vs 8.1 months) compared to those who received chemotherapy alone (P < .001). CONCLUSION: This study suggests that pancreatic resection in patients with liver metastases, in combination with chemotherapy and/or chemoradiation, may be associated with improved survival in well-selected patients. However, attempts at an aggressive surgical approach for patients with liver-only stage IV pancreatic adenocarcinoma patients should only be performed only under a well-designed prospective clinical trial.