The continued financial effect of COVID: Increasing costs for non-elective major lower extremity amputations.

Background: The COVID-19 pandemic necessitated changes in processes of care, which significantly impacted surgical care. This study evaluated the impact of these changes on patient outcomes and costs for non-elective major lower extremity amputations (LEA). Methods: The 2019-2021 Florida Agency for Health Care Administration database was queried for adult patients who underwent non-elective major LEA. Per-patient inflation-adjusted costs were collected. Patient cohorts were established based on Florida COVID-19 mortality rates: COVID-heavy (CH) included nine months with the highest mortality, COVID-light (CL) included nine months with the lowest mortality, and pre-COVID (PC) included nine months before COVID (2019). Outcomes included in-hospital patient outcomes and hospitalization cost. Results: 6132 patients were included (1957 PC, 2104 CH, and 2071 CL). Compared to PC, there was increased patient acuity at presentation, but morbidity (31%), mortality (4%), and length of stay (median 12 [8-17] days) were unchanged during CH and CL. Additionally, costs significantly increased during the pandemic; median total cost rose 9%, room costs increased by 16%, ICU costs rose by 15%, and operating room costs rose by 15%. When COVID-positive patients were excluded, cost of care was still significantly higher during CH and CL. Conclusions: Despite maintaining pre-pandemic standards, as evidenced by unchanged outcomes, the pandemic led to increased costs for patients undergoing non-elective major LEA. This was likely due to increased patient acuity, resource strain, and supply chain shortages during the pandemic. Key message: While patient outcomes for non-elective major lower extremity amputations remained consistent during the COVID-19 pandemic, healthcare costs significantly increased, likely due to increased patient acuity and heightened pressures on resources and supply chains. These findings underscore the need for informed policy changes to mitigate the financial impact on patients and healthcare systems for future public health emergencies.

Transition to Permitless Open Carry and Association with Firearm-Related Suicide.

BACKGROUND: Firearm-related death rates continue to rise in the US. As some states enact more permissive firearm laws, we sought to assess the relationship between a change to permitless open carry (PLOC) and subsequent firearm-related death rates, a currently understudied topic. STUDY DESIGN: Using state-level data from 2013 to 2021, we performed a linear panel analysis using a state fixed-effects model. We examined total firearm-related death, suicide, and homicide rates separately. If a significant association between OC law and death rate was found, we then performed a difference-in-difference (DID) analysis to assess for a causal relationship between changing to PLOC and increased death rate. For significant DID results, we performed confirmatory DID separating firearm and nonfirearm death rates. RESULTS: Nineteen states maintained a no OC or permit-required law, whereas 5 changed to permitless and 26 had a PLOC before 2013. The fixed-effects model indicated more permissive OC law that was associated with increased total firearm-related deaths and suicides. In DID, changing law to PLOC had a significant average treatment effect on the treated of 1.57 (95% CI 1.05 to 2.09) for total suicide rate but no significant average treatment effect for the total firearm-related death rate. Confirmatory DID results found a significant average treatment effect on the treated of 1.18 (95% CI 0.90 to 1.46) for firearm suicide rate. CONCLUSIONS: OC law is associated with total firearm-related death and suicide rates. Based on our DID results, changing to PLOC is indeed strongly associated with increased suicides by firearm.

Is nonoperative management of appendicitis inferior in the COVID-19 era?

BACKGROUND: Previous studies on nonoperative management (NOM) of acute appendicitis (AA) indicated comparable outcomes to surgery, but the effect of COVID-19 infection on appendicitis outcomes remains unknown. Thus, we evaluate appendicitis outcomes during the COVID-19 pandemic to determine the effect of COVID-19 infection status and treatment modality. We hypothesized that active COVID-19 patients would have worse outcomes than COVID-negative patients, but that outcomes would not differ between recovered COVID-19 and COVID-negative patients. Moreover, we hypothesized that outcomes would not differ between nonoperative and operative management groups, regardless of COVID-19 status. METHODS: We queried the National COVID Cohort Collaborative from 2020 to 2023 to identify adults with AA who underwent operative or NOM. COVID-19 status was denoted as follows: COVID-negative, COVID-active, or COVID-recovered. Intention to treat was used for NOM. Propensity score-balanced analysis was performed to compare outcomes within COVID groups, as well as within treatment modalities. RESULTS: A total of 37,868 patients were included: 34,866 COVID-negative, 2,540 COVID-active, and 460 COVID-recovered. COVID-active and recovered less often underwent operative management. Unadjusted, there was no difference in mortality between COVID groups for operative management. There was no difference in rate of failure of NOM between COVID groups. Adjusted analysis indicated, compared with operative, NOM carried higher odds of mortality and readmission for COVID-negative and COVID-active patients. CONCLUSION: This study demonstrates higher odds of mortality among NOM of appendicitis and near equivalent outcomes for operative management regardless of COVID-19 status. We conclude that NOM of appendicitis is associated with worse outcomes for COVID-active and COVID-negative patients. In addition, we conclude that a positive COVID test or recent COVID-19 illness alone should not preclude a patient from appendectomy for AA. Surgeon clinical judgment of a patient's physiology and surgical risk should, of course, inform the decision to proceed to the operating room. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Analysis of Germin-like protein genes family in Vitis vinifera (VvGLPs) using various in silico approaches

Abstract Germin-like proteins (GLPs) play an important role against various stresses. Vitis vinifera L. genome contains 7 GLPs; many of them are functionally unexplored. However, the computational analysis may provide important new insight into their function. Currently, physicochemical properties, subcellular localization, domain architectures, 3D structures, N-glycosylation & phosphorylation sites, and phylogeney of the VvGLPs were investigated using the latest computational tools. Their functions were predicted using the Search tool for the retrieval of interacting genes/proteins (STRING) and Blast2Go servers. Most of the VvGLPs were extracellular (43%) in nature but also showed periplasmic (29%), plasma membrane (14%), and mitochondrial- or chloroplast-specific (14%) expression. The functional analysis predicted unique enzymatic activities for these proteins including terpene synthase, isoprenoid synthase, lipoxygenase, phosphate permease, receptor kinase, and hydrolases generally mediated by Mn+ cation. VvGLPs showed similarity in the overall structure, shape, and position of the cupin domain. Functionally, VvGLPs control and regulate the production of secondary metabolites to cope with various stresses. Phylogenetically VvGLP1, -3, -4, -5, and VvGLP7 showed greater similarity due to duplication while VvGLP2 and VvGLP6 revealed a distant relationship. Promoter analysis revealed the presence of diverse cis-regulatory elements among which CAAT box, MYB, MYC, unnamed-4 were common to all of them. The analysis will help to utilize VvGLPs and their promoters in future food programs by developing resistant cultivars against various biotic (Erysiphe necator and in Powdery Mildew etc.) and abiotic (Salt, drought, heat, dehydration, etc.) stresses.

Resumo As proteínas do tipo germin (GLPs) desempenham um papel importante contra vários estresses. O genoma de Vitis vinifera L. contém 7 GLPs; muitos deles são funcionalmente inexplorados. No entanto, a análise computacional pode fornecer informações importantes sobre sua função. Atualmente, as propriedades físico-químicas, localização subcelular, arquitetura de domínio, estruturas 3D, sítios de N-glicosilação e fosforilação e estudos filogenéticos dos VvGLPs foram conduzidos usando as ferramentas computacionais mais recentes. Suas funções foram previstas usando a ferramenta Search para recuperação de genes/proteínas em interação (STRING) e servidores Blast2Go. A maioria dos VvGLPs são extracelulares (43%) na natureza, mas também mostraram expressão periplasmática (29%), na membrana plasmática (14%) e específica para mitocôndrias ou cloroplastos (14%). A análise funcional previu atividades enzimáticas únicas para essas proteínas, incluindo terpeno sintase, isoprenoide sintase, lipoxigenase, fosfato permease, receptor quinase e hidrolases geralmente mediadas por cátion Mn +. VvGLPs mostraram similaridade na estrutura geral, forma e posição do domínio cupin. Funcionalmente, os VvGLPs controlam e regulam a produção de metabólitos secundários para lidar com vários estresses. Filogeneticamente, VvGLP1, -3, -4, -5 e VvGLP7 mostraram maior similaridade devido à duplicação, enquanto VvGLP2 e VvGLP6 revelaram uma relação distante. A análise do promotor revelou a presença de diversos elementos cis-reguladores, entre os quais CAAT box, MYB, MYC, sem nome-4, sendo comum a todos eles. A análise ajudará a utilizar VvGLPs e seus promotores em programas alimentares futuros, desenvolvendo cultivares resistentes contra vários estresses bióticos (Erysiphe necator e no oídio, etc.) e abióticos (sal, seca, calor, estresse hídrico, etc.).

Analysis of Germin-like protein genes family in Vitis vinifera (VvGLPs) using various in silico approaches / Análise da família de genes de proteínas semelhantes a germin em Vitis vinifera (VvGLPs) usando várias abordagens in silico

Germin-like proteins (GLPs) play an important role against various stresses. Vitis vinifera L. genome contains 7 GLPs; many of them are functionally unexplored. However, the computational analysis may provide important new insight into their function. Currently, physicochemical properties, subcellular localization, domain architectures, 3D structures, N-glycosylation & phosphorylation sites, and phylogeney of the VvGLPs were investigated using the latest computational tools. Their functions were predicted using the Search tool for the retrieval of interacting genes/proteins (STRING) and Blast2Go servers. Most of the VvGLPs were extracellular (43%) in nature but also showed periplasmic (29%), plasma membrane (14%), and mitochondrial- or chloroplast-specific (14%) expression. The functional analysis predicted unique enzymatic activities for these proteins including terpene synthase, isoprenoid synthase, lipoxygenase, phosphate permease, receptor kinase, and hydrolases generally mediated by Mn+ cation. VvGLPs showed similarity in the overall structure, shape, and position of the cupin domain. Functionally, VvGLPs control and regulate the production of secondary metabolites to cope with various stresses. Phylogenetically VvGLP1, -3, -4, -5, and VvGLP7 showed greater similarity due to duplication while VvGLP2 and VvGLP6 revealed a distant relationship. Promoter analysis revealed the presence of diverse cis-regulatory elements among which CAAT box, MYB, MYC, unnamed-4 were common to all of them. The analysis will help to utilize VvGLPs and their promoters in future food programs by developing resistant cultivars against various biotic (Erysiphe necator and in Powdery Mildew etc.) and abiotic (Salt, drought, heat, dehydration, etc.) stresses.

As proteínas do tipo germin (GLPs) desempenham um papel importante contra vários estresses. O genoma de Vitis vinifera L. contém 7 GLPs; muitos deles são funcionalmente inexplorados. No entanto, a análise computacional pode fornecer informações importantes sobre sua função. Atualmente, as propriedades físico-químicas, localização subcelular, arquitetura de domínio, estruturas 3D, sítios de N-glicosilação e fosforilação e estudos filogenéticos dos VvGLPs foram conduzidos usando as ferramentas computacionais mais recentes. Suas funções foram previstas usando a ferramenta Search para recuperação de genes/proteínas em interação (STRING) e servidores Blast2Go. A maioria dos VvGLPs são extracelulares (43%) na natureza, mas também mostraram expressão periplasmática (29%), na membrana plasmática (14%) e específica para mitocôndrias ou cloroplastos (14%). A análise funcional previu atividades enzimáticas únicas para essas proteínas, incluindo terpeno sintase, isoprenoide sintase, lipoxigenase, fosfato permease, receptor quinase e hidrolases geralmente mediadas por cátion Mn +. VvGLPs mostraram similaridade na estrutura geral, forma e posição do domínio cupin. Funcionalmente, os VvGLPs controlam e regulam a produção de metabólitos secundários para lidar com vários estresses. Filogeneticamente, VvGLP1, -3, -4, -5 e VvGLP7 mostraram maior similaridade devido à duplicação, enquanto VvGLP2 e VvGLP6 revelaram uma relação distante. A análise do promotor revelou a presença de diversos elementos cis-reguladores, entre os quais CAAT box, MYB, MYC, sem nome-4, sendo comum a todos eles. A análise ajudará a utilizar VvGLPs e seus promotores em programas alimentares futuros, desenvolvendo cultivares resistentes contra vários estresses bióticos (Erysiphe necator e no oídio, etc.) e abióticos (sal, seca, calor, estresse hídrico, etc.).

Corrigendum to "Association of state-level factors with rate of firearm-related deaths" [Surg. Open Sci. vol. 14 (2023) 114-119].

[This corrects the article DOI: 10.1016/j.sopen.2023.07.011.].

Artificial Intelligence in Surgical Research: Accomplishments and Future Directions.

MINI-ABSTRACT: The study introduces various methods of performing conventional ML and their implementation in surgical areas, and the need to move beyond these traditional approaches given the advent of big data. OBJECTIVE: Investigate current understanding and future directions of machine learning applications, such as risk stratification, clinical data analytics, and decision support, in surgical practice. SUMMARY BACKGROUND DATA: The advent of the electronic health record, near unlimited computing, and open-source computational packages have created an environment for applying artificial intelligence, machine learning, and predictive analytic techniques to healthcare. The "hype" phase has passed, and algorithmic approaches are being developed for surgery patients through all stages of care, involving preoperative, intraoperative, and postoperative components. Surgeons must understand and critically evaluate the strengths and weaknesses of these methodologies. METHODS: The current body of AI literature was reviewed, emphasizing on contemporary approaches important in the surgical realm. RESULTS AND CONCLUSIONS: The unrealized impacts of AI on clinical surgery and its subspecialties are immense. As this technology continues to pervade surgical literature and clinical applications, knowledge of its inner workings and shortcomings is paramount in determining its appropriate implementation.

A new acyl derivative of sulfadimethoxine inhibits phagocyte oxidative burst and ameliorates inflammation in a mice model of zymosan-induced generalised inflammation.

Chronic inflammation and oxidative stress play a pivotal role in the pathophysiology of most challenging illnesses, including cancer, Alzheimer's, cardiovascular and autoimmune diseases. The present study aimed to investigate the anti-inflammatory potential of a new sulfadimethoxine derivative N-(4-(N-(2,6-dimethoxypyrimidin-4-yl) sulfamoyl) phenyl) dodecanamide (MHH-II-32). The compound was characterised by applying 1H-, 13C-NMR, EI-MS and HRFAB-MS spectroscopic techniques. The compound inhibited zymosan-induced oxidative bursts from whole blood phagocytes and isolated polymorphonuclear cells with an IC50 value of (2.5 ± 0.4 and 3.4 ± 0.3 µg/mL), respectively. Furthermore, the inhibition of nitric oxide with an IC50 (3.6 ± 2.2 µg/mL) from lipopolysaccharide-induced J774.2 macrophages indicates its in vitro anti-inflammatory efficacy. The compound did not show toxicity towards normal fibroblast cells. The observational findings, gross anatomical analysis of visceral organs and serological tests revealed the non-toxicity of the compound at the highest tested intraperitoneal (IP) dose of 100 mg/kg in acute toxicological studies in Balb/c mice. The compound treatment (100 mg/kg) (SC) significantly (P < 0.001) downregulated the mRNA expression of inflammatory markers TNF-α, IL-1ß, IL-2, IL-13, and NF-κB, which were elevated in zymosan-induced generalised inflammation (IP) in Balb/c mice while upregulated the expression of anti-inflammatory cytokine IL-10, which was reduced in zymosan-treated mice. No suppressive effect was observed at the dose of 25 mg/kg. Ibuprofen was taken as a standard drug. The results revealed that the new acyl derivative of sulfadimethoxine has an immunomodulatory effect against generalised inflammatory response with non-toxicity both in vitro and in vivo, and has therapeutic potential for various chronic inflammatory illnesses.

Patient outcomes and cost in robotic emergency general surgery.

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

Antibacterial activity of thymoquinone derivative.

Natural products such as terpenoidal compounds have been extremely tested against pathogenic bacteria. Researches are frequently carried out to find out new natural, semisynthetic and synthetic antibacterial agents due to problems of resistance. Thymoquinone derivative was obtained in our previous study and the current research is a continuation. The antibacterial activity of a monoterpenoid; thymoquinone derivative, 5-isopropyl-2-methyloxepine-1-one (1) has been evaluated for the first time by following the Agar cup bioassay method employed. The bacterial strains used in this study were Escherichia coli and Bacillus subtilis. Compound 1 showed moderate activity against Gram-positive organism; B. subtilis and good activity against Gram-negative species; E. coli with zones of inhibition (ZOI) 10.0 ± 0.2 mm and 11.0 ± 0.2 mm against E. coli and B. subtilis, respectively, and in comparison with antibiotic, imipenem. The zones of inhibition were calculated as the mean of the triplicate. The antibacterial activity of thymoquinone derivative 1 could be explained by the presence of unsaturated lactone.

EUS-guided Gastroenterostomy: A Multicenter International Study Comparing Benign and Malignant Diseases.

BACKGROUND: Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is a minimally invasive therapy for patients with gastric outlet obstruction without the risks of surgical bypass and the limited long-term efficacy of enteral self-expanding metal stent placement. However, due to its novelty, there is a lack of significant data comparing long-term outcomes of patients with EUS-GE, based on the underlying disease. In this study, we compare outcomes of EUS-GE on benign versus malignant indications. METHODS: Consecutive patients from 12 international, tertiary care centers who underwent EUS-GE over 3 years were extracted in a retrospective registry. Demographic characteristics, procedure-related information and follow-up data was collected. Primary outcome was the rate of adverse events associated with EUS-GE and the comparison of the rate of adverse events in benign versus malignant diseases. Secondary outcomes included technical and clinical success as well as hospitalization admission. RESULTS: A total of 103 patients were included: 72 malignant and 31 benign. The characteristics of the patients undergoing EUS-GE is shown in Table 1. The mean age of the cohort was 68 years and 58 years for malignant and benign etiology. Gender distribution was 57% and 39% being females in malignant and benign etiology group, respectively. Clinical success, technical success, average procedure time, and hospital length of stay were similar in both groups. Patients with benign underlying etiology had significantly higher number of surgically altered midgut anatomy (P=0.0379). CONCLUSION: EUS-GE is equally efficient regardless of the underlying etiology (malignant vs. benign), and the adverse events both groups were comparable.

Association of state-level factors with rate of firearm-related deaths.

Background: Over 48,000 people died by firearm in the United States in 2021. Firearm violence has many inciting factors, but the full breadth of associations has not been characterized. We explored several state-level factors including factors not previously studied or insufficiently studied, to determine their association with state firearm-related death rates. Methods: Several state-level factors, including firearm open carry (OC) and concealed carry (CC) laws, state rank, partisan lean, urbanization, poverty rate, anger index, and proportion of college-educated adults, were assessed for association with total firearm-related death rates (TFDR). Secondary outcomes were firearm homicide (FHR) and firearm suicide rates (FSR). Exploratory data analysis with correlation plots and ANOVA was performed. Univariable and multivariable linear regression on the rate of firearm-related deaths was also performed. Results: All 50 states were included. TFDR and FSR were higher in permitless OC and permitless CC states. FHR did not differ based on OC or CC category. Open carry and CC were eliminated in all three regression models due to a lack of significance. Significant factors for each model were: 1) TFDR - partisan lean, urbanization, poverty rate, and state ranking; 2) FHR - poverty rate; 3) FSR - partisan lean and urbanization. Conclusions: Neither open nor concealed carry is associated with firearm-related death rates when socioeconomic factors are concurrently considered. Factors associated with firearm homicide and suicide differ and will likely require separate interventions to reduce firearm-related deaths. Key message: Neither open carry nor concealed carry law are associated with total firearm-related death rate, but poverty rate, urbanization, partisan lean, and state ranking are associated. When analyzing firearm homicide and suicide rates separately, poverty rate is strongly associated with firearm homicide rate, while urbanization and partisan lean are associated with firearm suicide rate.

Predicting Severe Complications from Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Data-Driven, Machine Learning Approach to Augment Clinical Judgment.

BACKGROUND: CRS-HIPEC provides oncologic benefit in well-selected patients with peritoneal carcinomatosis; however, it is a morbid procedure. Decision tools for preoperative patient selection are limited. We developed a risk score to predict severity of 90 day complications for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). PATIENTS AND METHODS: Adults who underwent CRS-HIPEC at the University of Pittsburgh Medical Center (March 2001-April 2020) were analyzed as part of this study. Primary endpoint was severe complications within 90 days following CRS-HIPEC, defined using Comprehensive Complication Index (CCI) scores as a dichotomous (determined using restricted cubic splines) and continuous variable. Data were divided into training and test sets. Several machine learning and traditional algorithms were considered. RESULTS: For the 1959 CRS-HIPEC procedures included, CCI ranged from 0 to 100 (median 32.0). Adjusted restricted cubic splines model defined severe complications as CCI > 61. A minimum of 20 variables achieved optimal performance of any of the models. Linear regression achieved the highest area under the receiving operator characteristic curve (AUC, 0.74) and outperformed the NSQIP Surgical Risk calculator (AUC 0.80 vs. 0.66). Factors most positively associated with severe complications included peritoneal carcinomatosis index score, symptomatic status, and undergoing pancreatectomy, while American Society of Anesthesiologists 2 class, appendiceal diagnosis, and preoperative albumin were most negatively associated with severe complications. CONCLUSIONS: This study refines our ability to predict severe complications within 90 days of discharge from a hospitalization in which CRS-HIPEC was performed. This advancement is timely and relevant given the growing interest in this procedure and may have implications for patient selection, patient and referring provider comfort, and survival.

COVID-Induced Alterations in Surgical Care and Outcomes in Perforated Diverticulitis.

BACKGROUND: COVID-19 caused healthcare systems to significantly alter processes of care. Literature on the pandemic's effect on healthcare processes and resulting surgical outcomes is lacking. This study aims to determine outcomes of open colectomy in patients with perforated diverticulitis during the pandemic. METHODS: Using CDC data, the highest and lowest COVID mortality rates were calculated and used to establish 9-month COVID-heavy (CH) and COVID-light (CL) timeframes, respectively. Nine-months of 2019 were assigned as pre-COVID (PC) control. Florida AHCA database was utilized for patient-level data. Primary outcomes were length of stay (LOS), morbidity, and in-hospital mortality. Stepwise regression with 10-fold cross-validation determined factors most impacting outcomes. A parallel analysis excluding COVID-positive patients was performed to differentiate COVID-infection from processes of care. RESULTS: There were 3862 patients in total. COVID-positive patients had longer LOS, more intensive care unit admissions, and higher morbidity and mortality. After excluding 105 COVID-positive patients, individual outcomes were not different per timeframe. Regression showed timeframe did not affect primary outcomes. DISCUSSION: Outcomes following colectomy for perforated diverticulitis were worse for COVID-positive patients. Despite increased stress on the healthcare system during the pandemic, major outcomes were unchanged for COVID-negative patients. Our results indicate that despite COVID-associated changes in processes of care, acute care surgery can still be performed in COVID-negative patients without increased mortality and minimal change in morbidity.

Endoscopic Ultrasound-Guided Gallbladder Drainage Versus Percutaneous Drainage in Patients With Acute Cholecystitis Undergoing Elective Cholecystectomy.

INTRODUCTION: Cholecystectomy (CCY) is the gold standard treatment of acute cholecystitis (AC). Nonsurgical management of AC includes percutaneous transhepatic gallbladder drainage (PT-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). This study aims to compare outcomes of patients who undergo CCY after having received EUS-GBD vs PT-GBD. METHODS: A multicenter international study was conducted in patients with AC who underwent EUS-GBD or PT-GBD, followed by an attempted CCY, between January 2018 and October 2021. Demographics, clinical characteristics, procedural details, postprocedure outcomes, and surgical details and outcomes were compared. RESULTS: One hundred thirty-nine patients were included: EUS-GBD in 46 patients (27% male, mean age 74 years) and PT-GBD in 93 patients (50% male, mean age 72 years). Surgical technical success was not significantly different between the 2 groups. In the EUS-GBD group, there was decreased operative time (84.2 vs 165.4 minutes, P < 0.00001), time to symptom resolution (4.2 vs 6.3 days, P = 0.005), and length of stay (5.4 vs 12.3 days, P = 0.001) compared with the PT-GBD group. There was no difference in the rate of conversion from laparoscopic to open CCY: 5 of 46 (11%) in the EUS-GBD arm and 18 of 93 (19%) in the PT-GBD group ( P value 0.2324). DISCUSSION: Patients who received EUS-GBD had a significantly shorter interval between gallbladder drainage and CCY, shorter surgical procedure times, and shorter length of stay for the CCY compared with those who received PT-GBD. EUS-GBD should be considered an acceptable modality for gallbladder drainage and should not preclude patients from eventual CCY.

Invasive CO 2 monitoring with arterial line compared to end tidal CO 2 during peroral endoscopic myotomy.

Background and study aims Peroral endoscopic myotomy (POEM) has become a recognized treatment for achalasia. The technique requires CO 2 insufflation. It is estimated that the partial pressure of CO 2 (PaCO 2 ) is 2 to 5 mm Hg higher than the end tidal CO 2 (etCO 2 ), and etCO 2 is used as a surrogate for PaCO 2 because PaCO 2 requires an arterial line. However, no study has compared invasive and noninvasive CO 2 monitoring during POEM. Patients and methods Seventy-one patients who underwent POEM were included in a prospective comparative study. PaCO 2 plus etCO 2 was measured in 32 patients (invasive group) and etCO 2 only in 39 matched patients (noninvasive group). Pearson correlation coefficient (PCC) and Spearman's Rho were used to calculate the correlation between PaCO 2 and ETCO 2 . Results PaCO 2 and ETCO 2 were strongly correlated: PCC R value: 0.8787 P  ≤ 0.00001, Spearman's Rho R value: 0.8775, P  ≤ 0.00001. Within the invasive group, the average difference between PaCO 2 and ETCO 2 was 3.39 mm Hg (median 3, standard deviation 3.5), within the 2- to 5-mm Hg range. The average procedure time (scope in to scope out) was increased 17.7 minutes ( P  = 0.044) and anesthesia duration was 46.3 minutes. Adverse events (AEs) included three hematomas and one nerve injury in the invasive group and one pneumothorax in the noninvasive group. There were no differences in AE rates between the groups (13 % vs 3 % P  = 0.24). Conclusions Universal PaCO 2 monitoring contributes to increased procedure and anesthesia times without any decrease in AEs in patients undergoing POEM. CO 2 monitoring with an arterial line should only be performed in patients with major cardiovascular comorbidities; in all other patients, ETCO 2 is an appropriate tool.