Barrett's esophagus before and after Roux-en-Y gastric bypass for severe obesity.

INTRODUCTION: Barrett's esophagus (BE) has been associated with obesity and metabolic syndrome. Laparoscopic Roux-en-Y gastric bypass (LRYGB) may represent a surgical approach which addresses both severe obesity and BE. LRYGB diverts bile away from the gastric pouch and esophagus due to the long Roux limb, and very little acid is produced in the cardia-based gastric pouch. Furthermore, surgically induced weight loss may diminish systemic inflammation, which may contribute to metaplastic changes in the esophagus. Moreover, improved compliance with proton-pump inhibitor therapy, as a consequence of enrolling in a bariatric program, will decrease acid production further. Decreased duodeno-gastro-esophageal reflux should lead to decreased BE. In this study we examine the effect of LRYGB on regression of BE. METHODS AND PROCEDURES: We performed a review of all patients with biopsy proven BE, who underwent LRYGB at our institution. A total of 19 patients were identified. A subset of those patients was identified who had at least 1 year of clinical, endoscopic, or histological data, comprising a total of 14 patients. Seven of these patients had symptoms of gastroesophageal reflux. All 19 patients had short-segment BE. One patient had low-grade dysplasia. RESULTS: Post-LRYGB, 6 of 14 (42.9%) patients had histologic regression of BE to normal esophageal mucosa, with no evidence of ongoing BE. 13 of 14 patients (92.8%) reported compliance with continuing PPI therapy for at least the first year after surgery. Body mass index for the group of 14 patients improved from 46.6 to 30.3 kg/m2. CONCLUSIONS: We recommend LRYGB as an effective combined bariatric and anti-reflux surgical procedure for patients with severe obesity and BE. In short-term follow-up, LRYGB achieved endoscopic and histologic regression to normal mucosa in a substantial number of the patients in our series. Long-term follow-up for patients with BE according to standard surveillance protocols is still recommended.

Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures, remains associated with significant major morbidity including bile leak and bile duct injury (BDI). The effect of changes in practice over time, and of interventions to improve patient safety, on morbidity rates is not well understood. The aim of this review was to describe current incidence rates and trends for BDI and other complications during and after LC, and to identify risk factors and preventative measures associated with morbidity and BDI. METHODS: PubMed, MEDLINE, and Web of Science database searches and data extraction were conducted for studies which reported individual complications and complication rates following laparoscopic cholecystectomy in a representative population. Outcomes data were pooled. Meta-regression analysis was performed to assess factors associated with conversion, morbidity, and BDI rates. RESULTS: One hundred and fifty-one studies reporting outcomes for 505,292 patients were included in the final quantitative synthesis. Overall morbidity, BDI, and mortality rates were 1.6-5.3%, 0.32-0.52%, and 0.08-0.14%, respectively. Reported BDI rates reduced over time (1994-1999: 0.69(0.52-0.84)% versus 2010-2015 0.22(0.02-0.40)%, p = 0.011). Meta-regression analysis suggested higher conversion rates in developed versus developing countries (4.7 vs. 3.4%), though a greater degree of reporting bias was present in these studies, with no other significant associations identified. CONCLUSIONS: Overall, trends suggest a reduction in BDI over time with unchanged morbidity and mortality rates. However, data and reporting are heterogenous. Establishment of international outcomes registries should be considered.

Evaluation of crowd-sourced assessment of the critical view of safety in laparoscopic cholecystectomy.

BACKGROUND: Faculty experts (FE) and crowd workers (CW) can assess technical skill, but assessment of operative technique has not been explored. We sought to evaluate if CW could be taught to assess completion of the critical view of safety (CVS) in laparoscopic cholecystectomy. METHODS: We prepared 160 blinded, surgical videos of laparoscopic cholecystectomy from public domain websites. Videos were edited to ≤60 s, ending when a structure was cut/clipped. CW analyzed videos using Global Objective Assessment of Laparoscopic Skills (GOALS) and CVS criteria assessment tools after watching an instructional tutorial. Ten videos were randomly selected from each performance quartile based on GOALS. Five FE rated the 40 videos using GOALS and CVS. Linear mixed effects models derived average CW and FE ratings for GOALS and CVS for each video. Spearman correlation coefficients (SCC) were used to assess the degree of correlation between performance measures. Satisfactory completion of the CVS was defined as scoring an average CVS ≥ 5. Videos with an average GOALS ≥ 15 were considered top technical performers. RESULTS: A high degree of correlation was seen between all performance measures: CVS ratings between CW and FE, SCC 0.89 (p < 0.001); GOALS and CVS ratings SCC 0.77 (p < 0.001) for CW, and SCC 0.71 (p < 0.001) for FE. Sixteen videos were assigned top technical performer ratings by both CW and FE but the average CVS was inadequate (3.8 and 3.6, respectively), and the percentage of satisfactory CVS ≥ 5 was 12.5%. CONCLUSIONS: A high degree of correlation was found between CW and FE in assessment of the CVS. However, in this video analysis, high technical performers did not achieve a complete CVS in most cases. Educating CW to assess operative technique for the identification of low or average performers is feasible and may broaden the application of this assessment and feedback tool.

Is Endoluminal Bariatric Therapy a New Paradigm of Treatment for Obesity?

The prevalence of obesity has steadily increased throughout recent decades, and along with it, the costs of caring for the associated comorbid conditions has increased as well. Traditional bariatric surgical procedures generally are safe and effective, but patient acceptance, the risk of minor and sometimes serious complications, costs, and insurance coverage have limited the application of these techniques to the treatment of a minority of patients. Endoluminal techniques represent newer approaches to weight loss that can be used independently or in concert with traditional medical and surgical treatments for obesity, with varying degrees of success. It is anticipated that less invasiveness will increase the appeal across a broader representation of patients, perhaps increasing the number of obese patients who choose an intervention over medical management and possibly resulting in a greater total loss of excess body weight across a population; this may reduce costs involved in treating the complications of weight-related comorbidities. Acceptance of endoluminal bariatric procedures and devices will hinge on proving safety, efficacy, and value.

The role of endoscopy in the management of GERD.

We recommend that uncomplicated GERD be diagnosed on the basis of typical symptoms without the use of diagnostic testing, including EGD. We recommend EGD for patients who have symptoms suggesting complicated GERD or alarm symptoms. We recommend that EGD not be routinely performed solely for the assessment of extraesophageal GERD symptoms. We recommend that endoscopic findings of reflux esophagitis be classified according to an accepted grading scale or described in detail. We suggest that repeat EGD be performed in patients with severe erosive esophagitis after at least an 8-week course of PPI therapy to exclude underlying BE or dysplasia. 44BB We recommend against obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude BE in adults. We suggest that endoscopy be considered in patients with multiple risk factors for Barrett's esophagus. We recommend that tissue samples be obtained to confirm endoscopically suspected Barrett's esophagus. We suggest that endoscopic antireflux therapy be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options.

SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy.

BACKGROUND: Although it has been 25 years since the introduction of laparoscopy to cholecystectomy, outcomes remain largely unchanged, with rates of bile duct injury higher in the modern age than in the era of open surgery. The SAGES Safe Cholecystectomy Task Force (SCTF) initiative seeks to encourage a culture of safety in laparoscopic cholecystectomy (LC) and reduce biliary injury. An expert consensus study was conducted to identify interventions thought to be most effective in pursuit of this goal. METHODS: An initial list of items for safer practice in LC was identified by the SCTF through a nominal group technique (NGT) process. These were put forward to 407 SAGES committee members in two-stage electronically distributed Delphi surveys. Consensus was achieved if at least 80 % of respondents ranked an item as 4 or 5 on a Likert scale of importance (1-5). Additionally, respondents ranked five top areas of importance for the following domains: training, assessment, and research. RESULTS: Thirty-nine initial items were identified through NGT. Response rates for each Delphi round were 40.2 and 34 %, respectively. Final consensus was achieved on 15 items, the majority of which related to non-technical factors in LC. Key domains for training, assessment, and research were identified. Critical view of safety was deemed most important for overall safety, as well as training and assessment of LC. Intraoperative cholangiography was identified as an additional priority area for future research. CONCLUSIONS: Consensus items to progress surgical practice, training, assessment, and research have been identified, to promote safe practice and improve patient outcomes in LC.

Modifications in endoscopic practice for pediatric patients.

We recommend that endoscopy in children be performed by pediatric-trained endoscopists whenever possible. We recommend that adult-trained endoscopists coordinate their services with pediatricians and pediatric specialists when they are needed to perform endoscopic procedures in children. We recommend that endoscopy be performed within 24 hours in symptomatic pediatric patients with known or suspected ingestion of caustic substances. We recommend emergent foreign-body removal of esophageal button batteries, as well as 2 or more rare-earth neodymium magnets. We recommend that procedural and resuscitative equipment appropriate for pediatric use should be readily available during endoscopic procedures. We recommend that personnel trained specifically in pediatric life support and airway management be readily available during sedated procedures in children. We recommend the use of endoscopes smaller than 6 mm in diameter in infants and children weighing less than 10 kg. We recommend the use of standard adult duodenoscopes for performing ERCP in children who weigh at least 10 kg. We recommend the placement of 12F or 16F percutaneous endoscopic gastrostomy tubes in children who weigh less than 50 kg.

How do SAGES members rate its guidelines?

BACKGROUND: The development of practice guidelines should take into consideration the opinions of end users. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has implemented several changes in its guideline development and dissemination process based on previous end-user input. METHODS: An anonymous electronic survey was conducted via e-mail solicitation in September 2011. Respondents were asked to submit their feedback on the 26 guidelines produced by our society using a 32-item questionnaire and to suggest topics for new guideline development and areas of improvement. RESULTS: Responses from the survey were received by 494 people, of whom 474 (96 %) were clinicians; 373 (75 %) were general, laparoscopic, or bariatric surgeons; and 324 (65 %) held leadership roles within their institution. Most respondents were 35-44 years old (36 %), male (83 %), and had been in practice for over 10 years (54 %). A total of 383 (81 %) had used our guidelines, and, of those, 96 % agreed with their content. Guideline quality was rated 4.34; value 4.27; and ease of access 3.97 on a five-point Likert scale. The most commonly referenced guideline in the survey regarded surgical treatment of reflux (67 %), followed by laparoscopy during pregnancy (51 %). The three most common reasons guidelines were accessed were to update knowledge (68 %), to maximize patient care through evidence-based treatment (51 %), and to obtain a critical literature review. CONCLUSIONS: The majority of respondents indicated they greatly value and agree with our guidelines. These results indicate that recent efforts to improve our guidelines have succeeded.

Fundamentals of Endoscopic Surgery cognitive examination: development and validity evidence.

BACKGROUND: Flexible endoscopy is an integral part of surgical care. Exposure to endoscopic procedures varies greatly in surgical training. The Society of American Gastrointestinal and Endoscopic Surgeons has developed the Fundamentals of Endoscopic Surgery (FES), which serves to teach and assess the fundamental knowledge and skills required to practice flexible endoscopy of the gastrointestinal tract. This report describes the validity evidence in the development of the FES cognitive examination. METHODS: Core areas in the practice of gastrointestinal endoscopy were identified through facilitated expert focus groups to establish validity evidence for the test content. Test items then were developed based on the content areas. Prospective enrollment of participants at various levels of training and experience was used for beta testing. Two FES cognitive test versions then were developed based on beta testing data. The Angoff and contrasting group methods were used to determine the passing score. Validity evidence was established through correlation of experience level with examination score. RESULTS: A total of 220 test items were developed in accordance with the defined test blueprint and formulated into two versions of 120 questions each. The versions were administered randomly to 363 participants. The correlation between test scores and training level was high (r = 0.69), with similar results noted for contrasting groups based on endoscopic rotation and endoscopic procedural experience. Items then were selected for two test forms of 75 items each, and a passing score was established. CONCLUSIONS: The FES cognitive examination is the first test with validity evidence to assess the basic knowledge needed to perform flexible endoscopy. Combined with the hands-on skills examination, this assessment tool is a key component for FES certification.

Endoscopic Treatment of Gastroesophageal Reflux Disease.

There have been many devices and ideas to treat reflux disease endoscopically. Several devices have been tried and even FDA approved but now are no longer used. The push for these therapies is to find effective reflux control with lower risk and faster recovery. In this article we describe an endoscopic suturing device (TIF), radiofrequency device (Stretta) and a newer technique that has a lot of promise called antireflux mucosectomy. All these procedures seem to help control reflux at a minimum of morbidity given current information. As reflux is so prevalent a shift to these techniques for appropriate patients is likely to improve patient care.

Cholecystokinin-cholescintigraphy in adults: consensus recommendations of an interdisciplinary panel.

BACKGROUND & AIMS: Cholecystokinin-cholescintigraphy (CCK-CS) provides a physiologic, noninvasive, and quantitative method for assessing gallbladder contraction and calculation of a gallbladder ejection fraction (GBEF). At present, it is used most commonly to identify patients with suspected functional gallbladder disorder. However, the methodology of CCK infusion and normal values differ markedly among imaging centers. METHODS: This document represents the consensus opinion of an interdisciplinary panel that gathered to assess the current optimal method for performing CCK-CS in adults, potential uses and limitations of CCK-CS, and questions that require further investigation. RESULTS: The panel recommended the use of a single, standardized, recently described CCK-CS protocol that involves infusion of 0.02 µg/kg of sincalide over 60 minutes with a normal gallbladder ejection fraction defined as ≥38%. The panel emphasized the need for a large, multicenter, prospective clinical trial to establish the utility of CCK-CS in the diagnosis of functional gallbladder disease. Although not without controversy regarding its clinical utility, the primary indication for CCK-CS at present is the well-selected patient with suspected functional gallbladder disorder. CONCLUSIONS: Agreement was reached that the adoption of this standardized protocol is critical to improve how CCK-CS is used to direct patient care and will represent an improvement over the diverse methods currently in use by eliminating the current lack of uniformity and adding both reliability and credibility to the results.

Minimum staffing requirements for the performance of GI endoscopy.

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.