Laparoscopic Heller myotomy with Toupet fundoplication: revisiting GERD in treated achalasia.

INTRODUCTION: With the advent of the laparoscopic era in the 1990s, laparoscopic Heller myotomy replaced pneumatic dilation as the first-line treatment for achalasia. An advantage of this approach was the addition of a fundoplication to reduce gastroesophageal reflux disease (GERD). More recently, Peroral Endoscopic Myotomy has competed for first-line therapy, but the postoperative GERD may be a weakness. This study leverages our experience to characterize GERD following LHM with Toupet fundoplication (LHM+T ) so that other treatments can be appropriately compared. METHODS: A single-institution retrospective review of adult patients with achalasia who underwent LHM+T from January 2012 to April 2022 was performed. We obtained routine 6-month postoperative pH studies and patient symptom questionnaires. Differences in questionnaires and reflux symptoms in relation to pH study were explored via Kruskal-Wallis test or chi-square tests. RESULTS: Of 170 patients who underwent LHM+T , 51 (30%) had postoperative pH testing and clinical symptoms evaluation. Eleven (22%) had an abnormal pH study; however, upon manual review, 5 of these (45.5%) demonstrated low-frequency, long-duration reflux events, suggesting poor esophageal clearance of gastric refluxate and 6/11 (54.5%) had typical reflux episodes. Of the cohort, 7 (15.6%) patients reported GERD symptoms. The median [IQR] severity was 1/10 [0, 3] and median [IQR] frequency was 0.5/4 [0, 1]. Patients with abnormal pH reported more GERD symptoms than patients with a normal pH study (3/6, 50% vs 5/39, 12.8%, p = 0.033). Those with a poor esophageal clearance pattern (n = 5) reported no concurrent GERD symptoms. CONCLUSION: The incidence of GERD burden after LHM+T is relatively low; however, the nuances relevant to accurate diagnosis in treated achalasia patients must be considered. Symptom correlation to abnormal pH study is unreliable making objective postoperative testing important. Furthermore, manual review of abnormal pH studies is necessary to distinguish GERD from poor esophageal clearance.

Telemedicine Use Decreases the Carbon Footprint of the Bariatric Surgery Preoperative Evaluation.

BACKGROUND: Healthcare-associated activity accounts for 10% of the United States' carbon dioxide (CO2) emissions. Using telemedicine for bariatric surgery evaluations decreases emissions and reduces patient burden during the multiple required interdisciplinary visits. After adopting telemedicine during COVID, our clinic continues to utilize telemedicine for preoperative bariatric evaluations. We evaluated the reduced environmental impact associated with this practice. METHODS: A retrospective review of all new evaluations for vertical sleeve gastrectomy (SG) or Roux-en Y gastric bypass (RYGB) from 2019 and 2021 was conducted. The 2019 year represents pre-pandemic, in-person evaluations and 2021 represents telemedicine evaluations during the COVID pandemic. Carbon emissions were calculated using the Environmental Protection Agency's (EPA's) validated formula of 404g CO2 per car-mile. Preoperative evaluation time was calculated from the initial clinic visit to the operation date. RESULTS: There were 51 patients in the 2019 cohort and 55 patients in the 2021 cohort. In the 2019 in-person cohort, there was significantly more kg of estimated CO2 emitted (10,225 vs. 2011.4, p<.001) compared to the 2021 cohort. For time required to complete the preoperative workup, there was no statistically significant difference between the two groups (162 days vs. 193 days, p=.226). The attrition rate was lower in the 2021 cohort (22.22% v. 35.9%, p<.001). CONCLUSIONS: Implementation of telemedicine for bariatric preoperative evaluations reduced patient travel, carbon emissions, and improved attrition rate. We encourage bariatric providers to use telemedicine as we believe this eases patient burdens and, with wider adoption, could significantly reduce our carbon footprint.

Preoperative esophageal testing predicts postoperative reflux status in sleeve gastrectomy patients.

BACKGROUND: Patients who undergo vertical sleeve gastrectomy (VSG) are at risk of postoperative GERD. The reasons are multifactorial, but half of conversions to Roux-en Y gastric bypass are for intractable GERD. Our institution routinely performs preoperative pH and high-resolution manometry studies to aid in operative decision making. We hypothesize that abnormal pH studies in concert with ineffective esophageal motility would lead to higher rates of postoperative reflux after VSG. METHODS: A single institution retrospective review was conducted of adult patients who underwent preoperative pH and manometry testing and VSG between 2015 and 2021. Patients filled out a symptom questionnaire at the time of testing. Postoperative reflux was defined by patient-reported symptoms at 1-year follow-up. Univariate logistic regression was used to examine the relationship between esophageal tests and postoperative reflux. The Lui method was used to determine the cutpoint for pH and manometric variables maximizing sensitivity and specificity for postoperative reflux. RESULTS: Of 291 patients who underwent VSG, 66 (22.7%) had a named motility disorder and 67 (23%) had an abnormal DeMeester score. Preoperatively, reflux was reported by 122 patients (41.9%), of those, 69 (56.6%) had resolution. Preoperative pH and manometric abnormalities, and BMI reduction did not predict postoperative reflux status (p = ns). In a subgroup analysis of patients with an abnormal preoperative pH study, the Lui cutpoint to predict postoperative reflux was a DeMeester greater than 24.8. Postoperative reflux symptoms rates above and below this point were 41.9% versus 17.1%, respectively (p = 0.03). CONCLUSION: While manometry abnormalities did not predict postoperative reflux symptoms, GERD burden did. Patients with a mildly elevated DeMeester score had a low risk of postoperative reflux compared to patients with a more abnormal DeMeester score. A preoperative pH study may help guide operative decision-making and lead to better counseling of patients of their risk for reflux after VSG.

Predictors of repeat transarterial chemoembolization in the treatment of hepatocellular carcinoma.

OBJECTIVES: Repeat transarterial chemoembolization (TACE) is a common intervention performed for hepatocellular carcinoma (HCC). The aim of this study was to identify predictors of the need for repeat TACE. METHODS: Between 2008 and 2012, data on patient and tumour variables were collected for 262 patients treated with a first TACE procedure for HCC. The decision to perform repeat TACE procedures was made at the completion of the first TACE or after follow-up imaging demonstrated the subtotal treatment of HCC tumours. RESULTS: Repeat TACE was performed in 67 of 262 (25.6%) patients. Necrosis of HCC, measured after the first TACE, was lower in patients who subsequently received repeat TACE (P = 0.042). On multivariable analysis, total tumour diameter of >5 cm [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.45-5.25; P = 0.002] and increasing age (OR 1.04/year, 95% CI 1.00-1.07; P = 0.030) were predictive of the need for repeat TACE. Measures of liver function and TACE approach (selective versus non-selective) were not predictive of repeat TACE. Median survival did not differ significantly between patients who did (median survival: 21.1 months) and did not (median survival: 26.1 months) receive a repeat TACE procedure (P = 0.574). CONCLUSIONS: The requirement for repeat TACE is associated with older age, increased HCC tumour burden and subtotal TACE-induced HCC necrosis. Importantly, repeat TACE was not associated with reduced survival.