Revision paraesophageal hernia repair outcomes in patients with typical and atypical reflux.

BACKGROUND: Revision laparoscopic anti-reflux surgery (RLARS) is effective in alleviating the typical symptoms of gastroesophageal reflux disease (GERD). RLARS outcomes in patients with atypical GERD symptoms has not been well established. A composite Reflux Symptom Index (RSI) score greater than 13 indicates extraesophageal manifestation of pathological reflux. In this study, we analyzed the differences in quality-of-life (QOL) and perioperative outcomes between patients with atypical versus typical GERD who underwent RLARS. METHODS: A retrospective review was conducted of a prospectively maintained database of patients with pathologic reflux who underwent RLARS from February 2003 to October 2019. The cohort was divided into two groups, those with typical versus atypical manifestations of GERD, as defined by their RSI score. Patients with a RSI score of  > 13 were assigned to the Atypical group and those ≤ 13 were assigned to the Typical group. Patient QOL outcomes were prospectively followed using the RSI survey. Significance was defined by p-value less than 0.05. RESULTS: A total of 133 patients (Typical 61, Atypical 72) were included in the final analysis. The two groups were similar (p > 0.05) in mean age (58.1 ± 13.3 vs. 55.3 ± 15.5 years), body mass index (29.6 ± 5.0 vs. 30.3 ± 5.4), female sex distribution (60.7% vs. 59.7%) and age adjusted Charlson score (1.76 ± 1.58 vs. 1.98 ± 1.94). The Typical group had a higher frequency of type III hiatal hernia (62.3% vs. 29.2%) and Collis gastroplasty (29.5% vs. 5.6%). The groups had similar rates of partial and complete fundoplication with similar median length of stay (Typical: 3.0 ± 3.4 days vs. Atypical: 2.4 ± 1.7 days). After a mean follow-up of 30.2 ± 33.6 months, both groups reported similar rates of improvement in RSI outcome from baseline (58.1% vs 43.3%, p = .149). However, the RSI outcome at the latest follow-up for the Typical group was significantly better than the Atypical group after RLARS (2.8 ± 5.3 vs. 15.9 ± 11.1, respectively). CONCLUSION: Patients who undergo revision paraesophageal hernia repair with objective findings of GERD and subjective complaints of atypical reflux symptoms may show long-term improvement in QOL outcomes. However, these results are contingent on proper patient selection and a thorough work-up for pathological reflux in this population. Further research is needed to determine universal diagnostic criteria to assist in the early detection and surgical treatment of patients with atypical GERD.

Relationship Between Gender, Training Level and Goal Orientation Achievement Motivation: Implications for Learners and Faculty.

PURPOSE: Achievement goal orientation (GO) theory describes Mastery (M), one's intrinsic drive for competency for the sake of competency, and performance approach (PAP), a drive for competency by displaying competency, which are both adaptive. In learners motivated by performance avoid (PAV), showing competency by avoiding appearing incompetent dominates (maladaptive). The aim of this study was to determine differences in GO by gender and training (PGY) level. METHODS: A prospective, multi-institutional cohort of general surgery trainees participated in a cross-sectional study (2020-2021). Participants completed a 10-item instrument (the Goal Orientation in Surgical Trainees, GO-ST) measured on a 5-pointLikert scale (1 = never,3 = weekly,5 = daily). Student's t-tests and ANOVA F-test were used as appropriate. RESULTS: A total of 144/164 trainees participated (87.8%). The sample was 40.0%(n = 56) female and 57.9%(n = 81) male; 21.3%(n = 30) were PGY1, 22.0%(n = 31) PGY2, 24.8%(n = 35) PGY3, 18.4%(n = 26) PGY4, 13.5%(n = 19) PGY5. There were no significant differences in mean scale scores by gender for Mastery (3.3 vs 3.5; p = 0.17), or PAP (3.7 vs 3.5; p = 0.10), but mean PAV scores were significantly higher for females (3.6 vs 3.3; p = 0.04). While there were no significant differences in mean Mastery and PAP scale scores by training level (p = 0.44; p = 0.31), there was a significant difference in PAV scores (p < 0.01). The frequency of PAV feelings decreased over 5 years. CONCLUSIONS: Only PAV motivation differed by gender and training level. Understanding the psychology of motivation with this framework can aid both residents and programs in re-focusing on more adaptive learning strategies and supporting trainees in their transition to master surgeons.