Predictability of magnetic sphincter augmentation device explantation: a nomogram-based scoring tool from an experienced quaternary center.

BACKGROUND: Magnetic sphincter augmentation (MSA) explantation is an uncommon occurrence, and there are limited studies characterizing factors predictive of MSA explantation. This study aimed to create a nomogram to aid in determining the probability of explantation in patients before MSA implantation. METHODS: An institutional review board-approved, prospectively maintained database was retrospectively reviewed for all patients undergoing antireflux surgery between February 2015 and May 2023. All patients who underwent MSA-related procedures were included. Patients were divided into 2 groups, explant group and nonexplant group, and differences were analyzed. A multivariable logistic regression model was fitted to identify independent risk factors for predicting MSA explantation, and a nomogram-based scoring tool was developed. RESULTS: There were 227 patients (134 females and 93 males) with a mean age of 51.4 years. The explant group included 28 patients (12.3%), whereas the nonexplant group included 199 patients (87.7%). Patient sociodemographic characteristics, medical comorbidities, preoperative testing results, and surgical history were included in the analysis. The multivariable regression model resulted in 4 significant variables that were included in the nomogram. These included preoperative DeMeester score, preoperative gastroesophageal reflux disease health-related quality of life score, preoperative distal contractile integral value on manometry, and body mass index. Based on these variables, a scoring nomogram was developed with values ranging from 0 to 18. CONCLUSION: Our data were used to develop a scoring calculator capable of predicting the probability of MSA explantation. This scoring tool can guide preoperative patient selection and treatment decisions.

The impact of COVID-19 on surgical cases at a large quaternary referral hospital.

Introduction: Coronavirus-19 (COVID) stressed healthcare systems by increasing hospital admissions and in-hospital mortality. The impact of COVID on surgical patients is unknown. The purpose of this study was to evaluate how the COVID pandemic affected surgical patients at a large quaternary referral hospital. Methods: A retrospective review of patients undergoing surgical procedures was performed to evaluate patients undergoing surgery. The impact of COVID on surgical patients was divided into four timeframes based on government regulations: pre-COVID (January 1, 2020 to March 15, 2020), suspended (March 16, 2020 to May 4, 2020), backlogged cases (May 5, 2020 to June 14, 2020), and restoration (June 15, 2020 to September 30, 2020). Differences between patient characteristics and outcomes during these timeframes were evaluated. Results: A total of 21,424 surgical cases were performed between January 1, 2020 and September 30, 2020. During the suspended timeframe (when all elective cases were cancelled), the percentage of surgeries increased in men (53.8% compared to 49.2% pre-COVID; P < 0.01), in Black and Hispanic patients (23.1% and 15.3%, respectively; P < 0.05), and in Medicaid and self-pay patients (16.3% compared to 9.9% pre-COVID; P < 0.01). All service lines experienced similar trends in overall case volume except obstetrics (constant), trauma, vascular, and thoracic (which increased during the suspended timeframe). Conclusions: COVID-19 induced stresses in surgical patients, altering payor mix and impacting minority groups at a large quaternary referral hospital.

The use of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh in ventral hernia repair: a systematic review and meta-analysis.

PURPOSE/BACKGROUND: Despite the growing use of bioabsorbable mesh in ventral hernia repairs (VHR), the evidence of its impact on patient outcomes remains limited. This study aims to investigate the efficacy and safety profile of poly-4-hydroxybutyrate (P4HB) mesh for ventral hernia repair through a systematic review and meta-analysis. METHODS: A literature search of five databases (PubMed, Embase, Ovid, Medline, and Google Scholar) produced a list of publications that analyzed the use of P4HB mesh in ventral hernia repair in both clean and contaminated cases. The primary postoperative outcomes of hernia recurrence, surgical site infections (SSI), and any complications were analyzed through a pooled meta-analysis. RESULTS: In our systematic review, 21 studies met the inclusion criteria with a total of 1858 patients (933 males and 925 females) and an average age of 56.8 years. The median follow-up ranged from 1.6 to 62.3 months. In our meta-analysis, the use of P4HB mesh in VHR in proportion of events demonstrated a recurrence rate of 9% [6%; 15%], SSI of 10% [6%; 16%] and 35% [9%; 42%] for rate of any complications. Sub-meta-analysis restricted to studies with follow up > 18 months continues to show low rates of recurrence of 9% (95%CI, 4-17%), SSI of 9% (95%CI, 4-16%), and 31% (95%CI, 23-41%) for any complications. CONCLUSION: Our study demonstrates that the use of P4HB mesh is both safe and effective in ventral hernia repairs. When further analyzed past 18 months, the time where P4HB mesh fully resorbs, the rates of hernia recurrence, SSI, and any complications remain low of upwards of 5 years and comparable to the rates seen in synthetic and biologics in similar patient populations.

Achieving fascial closure with preoperative botulinum toxin injections in abdominal wall reconstruction: outcomes from a high-volume center.

Preoperative injection of Botulinum Toxin A (Botox) has been described as an adjunctive therapy to facilitate fascial closure of large hernia defects in abdominal wall reconstruction (AWR). The purpose of this study was to evaluate the impact of Botox injections on fascial closure and overall outcomes to further validate its role in AWR. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2014 and March 2022. Patients who did and did not receive preoperative Botox injections were analyzed and compared. A total of 426 patients were included (Botox 76, NBotox 350). The Botox group had significantly larger hernia defects (90 cm2 vs 9 cm2, p < 0.01) and a higher rate of component separations performed (60.5% vs 14.4%, p < 0.01). Despite this large difference in hernia defect size, primary fascial closure rates were similar between the groups (p = 0.49). Notably, the Botox group had higher rates of surgical-site infections (SSIs)/surgical-site occurrences (SSOs) (p < 0.01). Following propensity score matching to control for multiple patient factors including age, sex, diabetes, chronic obstructive pulmonary disease (COPD), and hernia size, the Botox group still had a higher rate of component separations (50% vs 26.3%, p = 0.03) and higher incidence of SSIs/SSOs (39.5% vs 13.5%, p = 0.01). Multimodal therapy with Botox injections and component separations can help achieve fascial closure of large defects during AWR. However, adding these combined therapies may increase the occurrence of postoperative SSIs/SSOs.

Gastric per-oral endoscopic myotomy versus pyloric injection of botulinum toxin for the treatment of gastroparesis: our institutional experience and a systematic review of the literature.

INTRODUCTION: Gastric Per-Oral Endoscopic Myotomy (GPOEM) has been developed as an effective treatment option for patients with medically refractory gastroparesis. Other endoscopic options, such as pyloric injection of botulinum toxin (Botox), is often performed with limited efficacy. The purpose of this study was to evaluate GPOEM for the treatment of gastroparesis and compare its efficacy to Botox injection results reported in the literature. METHODS: A retrospective review was conducted to identify all patients who underwent a GPOEM for the treatment of gastroparesis between September 2018 and June 2022. Changes in Gastric Emptying Scintigraphy (GES) studies and Gastroparesis Cardinal Symptom (GCSI) scores from the preoperative to postoperative period were analyzed. In addition, a systematic review was conducted to identify all publications reporting the outcomes of Botox injections for the treatment of gastroparesis. RESULTS: A total of 65 patients (51 female, 14 male) underwent a GPOEM during the study period. Twenty-eight patients (22 female, 6 male) had both preoperative and postoperative GES studies in addition to GCSI scores. The etiologies of gastroparesis were diabetic (n = 4), idiopathic (n = 18), and postsurgical (n = 6). Fifty percent of these patients had undergone previous failed interventions including Botox injections (n = 6), gastric stimulator placement (n = 2), and endoscopic pyloric dilation (n = 6). Outcomes showed a significant decrease in GES percentages (mean difference = - 23.5%, p < 0.001) and GCSI scores (mean difference = - 9.6, p = 0.02) postoperatively. In the systematic review for Botox, transient mean improvements in postoperative GES percentages and GCSI scores were reported at 10.1% and 4.0, respectively. CONCLUSION: GPOEM leads to significant improvement in GES percentages and GCSI scores postoperatively and is superior to Botox injection results reported in the literature.

Per-oral endoscopic myotomy is a safe and effective treatment for Zenker's diverticulum: a retrospective multicenter study.

Zenker per-oral endoscopic myotomy (ZPOEM) has become a promising technique for Zenker's diverticulum (ZD). The aim of this study was to add to the limited body of literature evaluating the safety and efficacy of ZPOEM. A prospectively maintained database was retrospectively reviewed to identify patients who underwent ZPOEM at two separate institutions between January 2020 and January 2022. Demographics, preoperative and postoperative clinical data, intraoperative data, adverse events, and length of stay were analyzed. A total of 40 patients (mean age 72.5 years, 62.5% male) were included. Average operative time was 54.7 minutes and average length of stay was 1.1 days. There were three adverse events, and only one was related to the technical aspects of the procedure. Patients showed improvement in the Functional Oral Intake Scale (FOIS) scores at 1 month (5 vs 7, p < 0.0001). The median FOIS scores remained 7 at both 6 and 12 months, although this improvement was not statistically significant at these time intervals (p = 0.46 and 0.37, respectively). Median dysphagia scores were decreased at 1 (2.5 vs 0, p < 0.0001), 6 (2.5 vs 0, p < 0.0001), and 12 months (2.5 vs 0, p = 0.016). The number of patients reporting ≥1 symptom was also decreased at 1 (40 vs 9, p < 0.0001) and 6 months (40 vs 1, p = 0.041). Although the number of patients reporting ≥1 symptom remained consistent at 12 months, this was not statistically significant (40 vs 1, p = 0.13). ZPOEM is a safe and highly effective treatment for the management of ZD. .

Enhanced Recovery After Surgery Protocol in Bariatric Surgery Leads to Decreased Complications and Shorter Length of Stay.

PURPOSE: Enhanced recovery after surgery (ERAS) programs have been shown in some specialties to improve short-term outcomes following surgical procedures. There is no consensus regarding the optimal perioperative care for bariatric surgical patients. The purpose of this study was to develop a bariatric ERAS protocol and determine whether it improved outcomes following surgery. MATERIALS AND METHODS: An IRB-approved prospectively maintained database was retrospectively reviewed for all patients undergoing bariatric surgery from October 2018 to January 2020. Propensity matching was used to compare post-ERAS implementation patients to pre-ERAS implementation. RESULTS: There were 319 patients (87 ERAS, 232 pre-ERAS) who underwent bariatric operations between October 2018 and January 2020. Seventy-nine patients were kept on the ERAS protocol whereas 8 deviated. Patients who deviated from the ERAS protocol had a longer length of stay when compared to patients who completed the protocol. The use of any ERAS protocol (completed or deviated) reduced the odds of complications by 54% and decreased length of stay by 15%. Furthermore, patients who completed the ERAS protocol had an 83% reduction in odds of complications and 31% decrease in length of stay. Similar trends were observed in the matched cohort with 74% reduction in odds of complications and 26% reduction in length of stay when ERAS was used. CONCLUSIONS: ERAS protocol decreases complications and reduces length of stay in bariatric patients.

Probability of additional intervention and long-term follow-up of esophagomyotomy.

INTRODUCTION: Two common surgical procedures used to treat esophageal motility disorders are laparoscopic Heller myotomy (LHM) with partial fundoplication and per-oral endoscopic myotomy (POEM). The difference in frequency of follow-up interventions following these procedures is unknown. This study was designed to report differences in post-surgical interventions as one of the major long-term follow-up expectations. METHODS: An IRB approved registry was used to identify all patients undergoing surgery with LHM or POEM. Following surgery, patients requiring additional interventions with esophageal non-pneumatic dilation, botox injection, or repeat myotomy, as well as persistent proton pump inhibitor (PPI) use were recorded. Multivariable logistic regression analysis was performed to estimate risk factors associated with return for additional post-operative intervention. RESULTS: A total of 203 patients were identified, 139 met inclusion criteria (33 LHM and 106 POEM). There was a higher rate of non-pneumatic EGD dilation (33% vs 15%, p = 0.04), repeat myotomy (18% vs 2%, p < 0.01), and higher rate of overall post-operative intervention in LHM than POEM. With POEM, there was a higher rate of post-operative PPI use (63 vs 29%, p < 0.01). There was no difference in time to post-operative intervention for either group, but if intervention were to occur the median time was within the first year. Patients with a change in pre- to post-operative Eckardt score of 4 or greater decreased their chance of having a post-operative intervention. CONCLUSION: Our results for both LHM and POEM emphasize the importance of long-term follow-up in patients with an esophageal motility disorder. We have found that patients undergoing LHM are more likely to have a post-operative intervention as well as a higher rate of repeat myotomy than POEM. With both interventions, a greater change in Eckardt score decreased the likelihood of reintervention.

Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs provide a framework for optimal perioperative care to improve post-operative outcomes following surgical procedures. However, there is no consensus regarding an ERAS protocol following foregut surgery. The purpose of this study was to develop an ERAS protocol for these patients and determine whether they improved outcomes. METHODS: An IRB approved prospectively maintained database was retrospectively reviewed for all patients undergoing benign minimally invasive foregut surgery from October 2018 to January 2020. All patients were entered into the ACS risk calculator to determine their predicted rate of complications and length of stay for comparison between the ERAS and control groups. Propensity matching was used to compare post-ERAS implementation to pre-ERAS implementation patients. Firth logistic and Poisson regression analysis were used to assess the rate of complications and length of stay among the different groups of patients. RESULTS: There were 255 patients (60 Post-ERAS, 195 Pre-ERAS) who underwent foregut operations and met inclusion criteria. ERAS was implemented, and patients were then subdivided based on those who completed ERAS (44) and those who deviated from the protocol (16). Propensity matching analysis was performed to compare the different cohorts and showed ERAS patients had 41% decreased odds of complications and 33% reduction in length of stay compared to pre-ERAS patients. Completion of the ERAS protocol resulted in even further reductions in odds of complication and length of stay compared to patients who deviated from the protocol. CONCLUSIONS: ERAS has shown to improve perioperative outcomes, but there is limited literature supporting the use of ERAS in foregut surgery. Usage of an ERAS protocol can decrease complications and reduce the length of stay in patients.

Predictability of Endoscopic Success for Foregut and Bariatric Leak in an Experienced Quaternary Center.

BACKGROUND: Leaks of the esophagus and stomach are difficult to manage and associated with significant morbidity and mortality. Endoscopic therapy can manage these leaks without surgical intervention. Our goal is to create a scoring tool to aid in predicting the success of endoscopic therapy in these patients. STUDY DESIGN: An IRB-approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to January 2021, including patients treated for esophageal and stomach leaks. Endpoints include success of leak closure for patients treated solely by endoscopic therapy (ET) compared with surgical therapy as failed endoscopic therapy (FET). A multivariable logistic regression model was fitted to identify independent risk factors for predicting success of endoscopic therapy, and a scoring calculator was developed. RESULTS: There were 80 patients (60 females) with a mean age of 50 years. The ET group included 59 patients (74%), whereas the FET group included 21 patients (26%). Patient demographics, comorbidities, surgical history, and timing of leak diagnosis were used. Multivariable analysis resulted in 4 variables associated with higher probability of successful endoscopic leak management without need for additional surgery. These included increased age, lower BMI, lack of previous bariatric surgery, and quicker identification of the leak. Consequently, a scoring nomogram was developed with values from 0 to 22. CONCLUSION: Our data show the development of a scoring calculator capable of quantifying the likelihood of success treating foregut and bariatric leaks with endoscopic therapies. This can be used clinically to guide treatment decisions.

Overall Complications Following Robotic Heller Myotomy Are Lower Compared With Laparoscopy.

BACKGROUND: The use of robotics in foregut surgery has become more prevalent in the United States over the last 10 years. We sought to find the differences in the clinical outcomes of robotic surgery compared with traditional laparoscopy in patients undergoing Heller myotomy. MATERIALS AND METHODS: A retrospective population-based analysis was performed using the National Inpatient Sample (NIS) database for the span of 2010 to 2015. All patients who underwent laparoscopic or robotic Heller myotomy were included. Weighted multivariable random intercept linear and logistic regression models were used to assess the impact of robotic surgery on patient outcomes compared with laparoscopy. RESULTS: There was a total of 11,562 patients with a median age of 54.2 years. Robotic Heller myotomy has a significantly decreased risk of overall complications for all centers (odds ratio=0.46; 95% confidence interval=0.29, 0.74). A subset analysis was performed looking specifically at high-volume centers (>20 operations per year), and overall complications remained lower in the robotic group. However, in high-volume centers, the robotic cohort did have a higher rate of esophageal perforation (2.7% vs. 0.8%, P<0.001). There was a higher length of stay in the laparoscopic Heller cohort (3.0 vs. 2.6 d, P=0.06) but higher overall charges in the robotic Heller cohort ($42,900 vs. $34,300, P=0.03). CONCLUSIONS: Robotic Heller myotomy is associated with lower overall complications and improved outcomes compared with laparoscopic Heller myotomy, even in high-volume centers. Robotic Heller myotomy is associated with a higher rate of esophageal perforations in high-volume centers despite the reduction in overall complications.

Nutritional Support and Duration of Drainage Recommendations for Endoscopic Internal Drainage: Review of the Literature and Initial Experience.

INTRODUCTION: Anastomotic leaks following foregut surgery pose a difficult scenario for surgeons. While definitive surgical options are more invasive and may result in diversion requiring subsequent surgeries, endoscopic management of these leaks has been shown to work as an alternative platform for management. An evolving option is endoscopic internal drainage. We have reviewed our experience using endoscopic internal drainage and report our outcomes. MATERIALS AND METHODS: An institution review board approved prospectively gathered database was used to identify all patients undergoing endoscopic internal drainage following esophageal and gastric leaks. Patient demographics, sentinel operation causing the leak, and outcomes of therapy were collected. The rate of healing and complications with the drainage catheter in place were the primary endpoints. RESULTS: Sixteen patients were identified (5 male, 11 female) that underwent endoscopic internal drainage with a mean age of 48 and mean BMI of 30.8. Overall success rate was 69% (11/16), where 4 patients required a definitive surgery, and one healed with endoluminal vacuum therapy. Of the 4 failures, 1 patient required esophagojejunostomy, 2 patients required a fistulojejunostomy, and one required a partial gastrectomy. A total of 12 patients (75%) had a prior endoscopic procedure that was unsuccessful. The mean duration of drainage catheter in place was 48 days. While the catheter was in place, 4 patients were allowed minimal PO intake in conjunction with total parenteral nutrition or tube feeds. The rest of the patients were strict NPO with other means of nutrition. There were no complications with the drainage catheters and no deaths. CONCLUSION: Leaks following esophagogastric surgery are difficult to manage; however, endoscopic internal drainage has been shown to be effective. Duration of the technique should be around 6 to 8 weeks with nutritional support guided by the comfort of the managing clinician.

Can subjective symptoms predict objective findings in gastroesophageal reflux disease patients?

INTRODUCTION: Medical therapy is the first-line treatment for gastroesophageal reflux disease, but surgical options are available and shown to be effective when medical management fails. There is no consensus for when a surgical evaluation is indicated. We set out to determine if the GERD-HRQL questionnaire scores correlate to objective findings found in patients undergoing anti-reflux surgery to predict when surgical consultation could be warranted. METHODS: A prospectively gathered database was used for patients undergoing anti-reflux surgery from January 2014 to September 2020. Inclusion criteria required a diagnosis of GERD and comprehensive esophageal workup with the GERD-HRQL questionnaire, EGD, esophageal manometry, and ambulatory pH monitoring. Analysis of the GERD-HRQL scores was compared to objective endpoints to see correlation and predictability. Logistic regression analysis was used to assess relationship between the presence of objective findings and GERD-HRQL questionnaire scores. RESULTS: There were 246 patients meeting inclusion criteria. There was no significant correlation between GERD-HRQL score and DeMeester score (correlation coefficient = 0.23), or presence of a hiatal hernia, regardless of size (p = 0.89). Patients with esophagitis had significantly higher average GERD-HRQL scores compared to those without esophagitis (40.1 ± 18.9 vs 30.4 ± 19.1, p < 0.0001). Patients with a score of 40 or greater had a 42% to 65% probability of having esophagitis versus a score of 30 or less, lowering the chances of having esophagitis to less than 35%. CONCLUSION: Usage of a GERD-HRQL questionnaire score can potentially show the correlation between subjective and objective findings in the workup of a patient for anti-reflux surgery. Specifically, patients with a GERD-HRQL score of 40 or greater have an increased probability of esophagitis compared to those with a score of 30 or less. Using these scores can help referring clinicians identify those patients failing medical therapy and allow for prompt referral for surgical evaluation.

Laparoscopic repair of large diaphragmatic hernia after left ventricular assist device implantation followed by orthotopic heart transplantation.

In patients with advanced heart failure and deteriorating clinical status, a left ventricular assist device (LVAD) can be used as a bridge to transplantation or as an alternative to transplantation. An uncommon complication of orthotopic heart transplant or LVADs is diaphragmatic hernia during implantation or explantation of the device. We describe a patient with a diaphragmatic hernia with incarcerated colon and small bowel treated previously with a HeartMate 3 LVAD and subsequent transplantation. This case highlights the need to consider the diagnosis of diaphragmatic hernia based on symptoms after HeartMate 3 implantation and/or subsequent transplantation, as well as the ability to manage these hernias with a minimally invasive laparoscopic approach to minimize postoperative morbidity and mortality.

Complications Following Robotic Hiatal Hernia Repair Are Higher Compared to Laparoscopy.

BACKGROUND: The use of robotic platforms in surgery is becoming increasingly common in both practice and residency training. In this study, we compared the perioperative outcomes between robotic platforms and traditional laparoscopy in paraesophageal hernia repair. METHODS: A retrospective population-based analysis was performed using the National Inpatient Sample for the period of 2010-2015. Adult patients (≥18 years old) who underwent laparoscopic or robotic paraesophageal hernia repairs were included. Weighted multivariable random intercept linear and logistic regression models were used to assess the effects of robotic surgery on patient outcomes. RESULTS: A total of 168,329 patients were included in the study. The overall adjusted rate of complications was significantly higher in patients who underwent robotic paraesophageal hernia (PEH) repair compared to laparoscopic PEH OR (95% CI) = 1.17 (1.07, 1.27). Specifically, respiratory failure OR (95% CI) = 1.68 (1.37, 2.05) and esophageal perforation OR (95% CI) = 2.19 (1.42, 3.93) were higher in robotic PEH patients. A subset analysis was performed looking at high-volume centers (>20 operations per year), and, although the risk of complications was lower in the high volume centers compared to intermediate volume centers, complication rates were still significantly higher in the robotic surgery group compared to laparoscopic. Overall charges per surgery were significantly higher in the robotic group. CONCLUSION: Robotic PEH repair is associated with significantly more complications compared to laparoscopic paraesophageal hernia repair even in high-volume centers.

Factors that promote successful endoscopic management of laparoscopic sleeve gastrectomy leaks.

INTRODUCTION: Staple line leaks following laparoscopic sleeve gastrectomy (LSG) are associated with significant morbidity and mortality. Endoluminal techniques, including stent placement and endoluminal vacuum therapy (EVAC), have become viable options to treat these patients without the need for additional surgery. The purpose of this study was to define the conditions where certain endoscopic therapies are most likely to succeed compared to surgery. METHODS: An IRB approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to March 2019. All patients who were treated for gastrointestinal leaks following LSG were included. Endpoints include success of leak closure and hospital-related morbidity for the patients treated solely by endoscopic only methods (EP) compared to the additional surgery group (SP). RESULTS: There were 39 patients (33 females; 6 males) with a median age of 45.9 years. The EP group included 23 patients (59%), whereas SP included 16 patients (31%). On average, the SP had longer days from sentinel surgery to our hospital admission (70 vs 41), a higher percentage of previous bariatric surgery prior to sentinel LSG (50% vs 17%), and a higher readmission rates following discharge (50% vs 39%). Total length of stay was also higher in the SP compared to the EP (45.4 vs 11). Using this data, a treatment algorithm was developed to optimally treat future patients who suffer from gastrointestinal leaks following LSG. CONCLUSIONS: Endoscopic therapies, such as EVAC, stent placement, internal drainage, and over-the-scope clips, have a higher chance of success if performed earlier to their sentinel surgery and if patients have had no prior bariatric surgeries. Patients who require additional surgery tend to have longer hospital stays and readmission rates. Using the treatment algorithm provided can help determine when endoscopic therapies are likely to succeed.

Safety of magnetic sphincter augmentation in patients with prior bariatric and anti-reflux surgery.

BACKGROUND: Magnetic sphincter augmentation (MSA) has been recognized as an effective treatment option for patients with gastroesophageal reflux disease. The feasibility of MSA in patients with prior gastric surgery has not been well established. This study aims to evaluate the safety and efficacy of MSA in patients with prior gastric surgery including bariatric and other anti-reflux operations. METHODS: A prospectively gathered registry approved by the institutional review board for patients undergoing anti-reflux surgery was retrospectively reviewed. All patients who underwent MSA were included. The patients were divided into two groups based on the presence of prior gastric surgeries compared to those without. Endpoints collected include differences between the two groups in their preoperative evaluation, perioperative course, and postoperative effectiveness. RESULTS: A total of 103 patients underwent MSA where 82 patients (80%) had no prior gastric surgery and 21 patients (20%) had prior gastric surgery. The prior gastric surgery group included 10 patients with prior anti-reflux surgery, 11 patients with prior bariatric surgery. Perioperative factors were higher in the prior gastric surgery group including operating room time (135 min vs. 93 min, p = < 0.001), number of beads used (16 vs. 14, p = < 0.001), and percent of patients staying overnight (47% vs. 5%, p = < 0.001). There was no difference in several factors of their preoperative evaluation including preoperative GERD-HRQL and RSI scores, hiatal hernia presence, or DeMeester score. Post-operative GERD-HRQL and RSI scores were not different as well as patient satisfaction, patients resuming PPI use, and device explant rate. CONCLUSIONS: This study demonstrates equivalent outcomes with integration of MSA in patients with prior gastric surgery in comparison to patients without prior gastric surgery. However, these surgeries are longer, require larger devices, and patients are more likely to stay overnight.

Comparison of Objective Intermediate-Term Outcomes Between per-Oral Endoscopic Myotomy and Laparoscopic Heller Myotomy Show Equivalence.

INTRODUCTION: The surgical gold standard for esophageal motility disorders is laparoscopic Heller myotomy (LHM). Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their intermediate-term outcomes. METHODS: Data were collected on consecutive LHM and POEM patients treated for esophageal motility disorders from January 2015 to December 2019. All patients were invited for a comprehensive workup between 6 and 12 months post-myotomy including symptom evaluation, pH testing off medications, manometry, and esophagogastroduodenoscopy (EGD). Primary outcomes include swallowing function and development of postoperative gastroesophageal reflux disease (GERD). RESULTS: There were 100 patients (46 LHM and 54 POEM). Patient demographics and presenting symptoms were comparable. Follow-up data were obtained from 49% of patients. Average length of follow-up for all patients was 10 months. Mean Eckardt scores for LHM decreased from 6.6 to 2.4 (P < .05) and from 7.06 to 2.2 for POEM (P < .05). Mean integrated relaxation pressure decreased from 22.8 preoperatively to 11 postoperatively in LHM patients and from 24.6 to 11.5 in POEM patients. POEM patients had a lower incidence of objective postoperative GERD with lower average DeMeester scores (20 vs 29.4) and a higher percentage of patients with a normal DeMeester score (47% vs 31%) compared to LHM patients. However, postoperative GERD health related quality of life scores (11.7 vs 14.1), the percent of patients on proton pump inhibitors (PPIs) (40% vs 53%), and frequency of grade C/D esophagitis (4.3% vs 5.6%) were lower in LHM patients. CONCLUSIONS: Intermediate-term symptom resolution and esophageal physiology are improved equally with both procedures. The development of postoperative GERD is equivalent.

Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication.

BACKGROUND: Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation. MATERIALS AND METHODS: A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control. RESULTS: Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH. CONCLUSIONS: Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.