GERD after Bariatric Surgery: A Review of the Underlying Causes and Recommendations for Management.

PURPOSE OF REVIEW: GERD after bariatric surgery is an ongoing concern for bariatric surgeons and their patients. This paper reviews the association of persistent or de novo GERD after multiple types of bariatric surgery, and focuses on the work up and management of GERD after SG. RECENT FINDINGS: Two recent large, multicenter randomized clinical trials have shown stronger associations between SG and GERD compared to RYGB. A large group of internationally recognized bariatric surgeons collaborated on 72 consensus statements to help guide the bariatric community on the subject of redo surgeries after SG, including as it pertains to GERD. We present an algorithm that consolidates the best-practices recommendations of the work-up and management of GERD after sleeve gastrectomy, and mention areas of persistent controversy where future research is warranted.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD).

BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. METHODS: Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS: The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. CONCLUSION: Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Reflux Surgery in Lung Transplantation: A Multicenter Retrospective Study.

BACKGROUND: Aspiration has been associated with graft dysfunction after lung transplantation, leading some to advocate for selective use of fundoplication despite minimal data supporting this practice. METHODS: We performed a multicenter retrospective study at 4 academic lung transplant centers to determine the association of gastroesophageal reflux disease and fundoplication with bronchiolitis obliterans syndrome and survival using Cox multivariable regression. RESULTS: Of 542 patients, 136 (25.1%) underwent fundoplication; 99 (18%) were found to have reflux disease without undergoing fundoplication. Blanking the first year after transplantation, fundoplication was not associated with a benefit regarding freedom from bronchiolitis obliterans syndrome (hazard ratio [HR], 0.93; 95% CI, 0.58-1.49) or death (HR, 0.97; 95% CI, 0.47-1.99) compared with reflux disease without fundoplication. However, a time-dependent adjusted analysis found a slight decrease in mortality (HR, 0.59; 95% CI, 0.28-1.23; P = .157), bronchiolitis obliterans syndrome (HR, 0.68; 95% CI, 0.42-1.11; P = .126), and combined bronchiolitis obliterans syndrome or death (HR, 0.66; 95% CI, 0.42-1.04; P = .073) in the fundoplication group compared with the gastroesophageal reflux disease group. CONCLUSIONS: Although a statistically significant benefit from fundoplication was not determined because of limited sample size, follow-up, and potential for selection bias, a randomized, prospective study is still warranted.

Recurrent dysphagia after myotomy for achalasia: pneumatic dilation or POEM? : Which modality offers superior outcomes?

INTRODUCTION: Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy. METHODS: We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3. RESULTS: 103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72 min, p < 0.01) as was mean length of stay (1.56 vs 0.3 days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD. CONCLUSION: Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures.

Gender disparities in gastrointestinal surgery fellowship programs.

BACKGROUND: Gender disparities in surgical leadership have come under increased scrutiny, and in order to better understand why these disparities exist, it is important to study the disparities across surgical fellowship programs. METHODS: Data derived from the Fellowship Council (FC) database for fellows completing training from academic years 2015-2019 were analyzed. Available information included institution, fellowship type, program director (PD), associate program director (APD), faculty, and fellow names for all FC Fellowships. Faculty and fellow gender were determined from personal knowledge or publicly available online biographical information. RESULTS: A total of 1023 fellows and 221 programs were analyzed. The advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs included 321 fellows, with a small increase in the percentage of female fellows from 28 to 31% over 5 years. Advanced GI/MIS/bariatric fellowship programs had a total of 262 fellows, also with a small increase in the percent of female fellows, from 29 to 38% in the study period. The gender of program directors, assistant program directors, and faculty for the fellowship programs studied were analyzed as well. Of the 221 programs in the Fellowship Council data, 13.6% of program directors, 18.3% of associate program directors, and 19.9% of faculty were female. Advanced GI/MIS fellowship programs had the lowest percentage of female PDs, with only 9.3% of the program directors being female. Colorectal surgery fellowships had the highest percentage of female PDs, with 33% being female. CONCLUSIONS: In conclusion, women are underrepresented in gastrointestinal surgery fellowships among both trainees and educators. It is likely that a significant contributing factor to this underrepresentation of female fellows is the underrepresentation of female program directors and faculty; although neither our study nor any previously published study has proven that statistically.

Antireflux surgery leads to durable improvement in laryngopharyngeal reflux symptoms.

BACKGROUND: Laryngopharyngeal reflux (LPR) symptoms are often present in patients with Gastroesophageal reflux disease (GERD). Whereas antireflux surgery (ARS) provides predictably excellent results in patients with typical GERD, those with atypical symptoms have variable outcomes. The goal of this study was to characterize the response of LPR symptoms to antireflux surgery. METHODS: Patients who underwent ARS between January 2009 and May 2020 were prospectively identified from a single institutional database. Patient-reported information on LPR symptoms was collected at standardized time points (preoperative and 2 weeks, 8 weeks, and 1 year postoperatively) using a validated Reflux Symptom Index (RSI) questionnaire. Patients were grouped by preoperative RSI score: ≤ 13 (normal) and > 13 (abnormal). Baseline characteristics were compared between groups using chi-square test or t-test. A mixed effects model was used to evaluate improvement in RSI scores. RESULTS: One hundred and seventy-six patients fulfilled inclusion criteria (mean age 57.8 years, 70% female, mean BMI 29.4). Patients with a preoperative RSI ≤ 13 (n = 61) and RSI > 13 (n = 115) were similar in age, BMI, primary reason for evaluation, DeMeester score, presence of esophagitis, and hiatal hernia (p > 0.05). The RSI > 13 group had more female patients (80 vs 52%, p = < 0.001), higher mean GERD-HRQL score, lower rates of PPI use, and normal esophageal motility. The RSI of all patients improved from a mean preoperative value of 19.2 to 7.8 (2 weeks), 6.1 (8 weeks), and 10.9 (1 year). Those with the highest preoperative scores (RSI > 30) had the best response to ARS. When analyzing individual symptoms, the most likely to improve included heartburn, hoarseness, and choking. CONCLUSIONS: In our study population, patients with LPR symptoms achieved a rapid and durable response to antireflux surgery. Those with higher preoperative RSI scores experienced the greatest improvement. Our data suggest that antireflux surgery is a viable treatment option for this patient population.

Endoscopic and Surgical Management of Gastroesophageal Reflux Disease.

Approximately, 10% to 15% of patients in the United States experience gastroesophageal reflux symptoms on a weekly basis, negatively affecting the quality of life and increasing the risk of reflux-related complications. For patients with symptoms recalcitrant to proton pump inhibitor (PPI) therapy or those who cannot take PPIs, surgical fundoplication is the gold standard. The preoperative workup is complex but vital for operative planning and ensuring good postoperative outcomes. Most patients are highly satisfied after fundoplication, though transient dysphagia, gas bloating, and resumption of PPI use are common postoperatively. Multiple newer technologies offer safe alternatives to fundoplication with similar outcomes.

Perioperative Cost Differences Between Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass: A Single Institutional Review.

Background: Minimizing bariatric surgery care costs is important since more than 250,000 patients undergo bariatric surgery annually in the United States. The study objective was to compare perioperative costs for the two most common bariatric procedures: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). In addition, we sought to identify predictors of high-cost perioperative care. Methods: Adult patients who underwent LSG or LRYGB from 2012 to 2017 were identified using our institutional bariatric surgery database. Perioperative costs, defined as costs incurred from the time of entering the preoperative unit until exiting the postanesthesia care unit, were obtained through billing data. Median perioperative cost components of LSG and LRYGB were compared using Mann-Whitney tests. Multivariable logistic regression was performed to investigate patient-level predictors of high-cost care, defined as the top tercile of perioperative costs. Results: We included 546 bariatric surgery patients with a mean age and body mass index (BMI) of 49.7 years and 45.9 kg/m2, respectively. There were no significant differences in median perioperative costs between LSG and LRYGB ($14,942 versus $15,016; P = .80). Stapler use was the largest cost contributor for both procedures, accounting for 27.7% and 29.2% of costs for LSG and LRYGB, respectively. In multivariable analyses, preoperative patient characteristics, including BMI, were not associated with high-cost perioperative care. Conclusions: Perioperative costs for LSG and LRYGB were similar in our single institution study. Reducing costs outside of the operating room, including those related to ED visits and complications, may be more impactful than focusing on cost reduction directly related to perioperative care.

Healthcare Resource Utilization in Inguinal Hernia Repair: A Three-Year Cost Evaluation of Truven Health Marketscan Research Databases.

BACKGROUND: Inguinal hernia repair is the most commonly performed elective operation in the United States, with over 800,000 cases annually. While clinical outcomes comparing laparoscopic versus open techniques have been well documented, there is little data comparing costs associated with these techniques. This study evaluates the cost of healthcare resources during the 90-d postoperative period following inguinal hernia repair. METHODS: We analyzed data from the Truven Health MarketScan Research Databases. Adult patients with an ICD-9 or CPT code for inguinal hernia repair from 2012 to 2014 were included. Patients with continuous enrollment for 6 mo prior to surgery and 6 mo after surgery were analyzed. Related healthcare service costs (readmission and/or ER visit and/or outpatient visit) were calculated by clinical classification software and generalized linear modeling was used to compare healthcare utilization between groups. RESULTS: 124,582 cases were identified (open = 84,535; lap = 40,047). Index surgery cost was 41% higher in laparoscopic cases. The cost for readmission was close to $25,000 and similar between both groups, but the laparoscopic group were 12% less likely to be readmitted for surgical complications within 90-d when compared to the open group. Cost of bilateral laparoscopic repair is less than that of serial unilateral open repairs. CONCLUSION: Laparoscopic inguinal hernia repair carries a higher index surgery cost than open repair. However, open repair has an increased rate of readmission. To maximize value, efforts should be directed at minimizing readmissions and improving identification of bilateral hernias at the time of initial presentation.

Both gastric electrical stimulation and pyloric surgery offer long-term symptom improvement in patients with gastroparesis.

BACKGROUND: Gastroparesis (GP) is hallmarked by nausea, vomiting, and early satiety. While dietary and medical therapy are the mainstay of treatment, surgery has been used to palliate symptoms. Two established first-line surgical options are gastric electrostimulation (GES) and pyloric procedures (PP) including pyloroplasty or pyloromyotomy. We sought to compare these modalities' improvement in Gastroparesis cardinal symptom index (GCSI) subscores and potential predictors of therapy failure. METHODS: All patients undergoing surgery at a single institution were prospectively identified and separated by surgery: GES, PP, or combined GESPP. GCSI was collected preoperatively, at 6 weeks and 1 year. Postoperative GCSI score over 2.5 or receipt of another gastroparesis operation were considered treatment failures. Groups were compared using Pearson's chi-squared and Kruskal-Wallis one-way ANOVA. RESULTS: Eighty-two patients were included: 18 GES, 51 PP, and 13 GESPP. Mean age was 44, BMI was 26.7, and 80% were female. Preoperative GCSI was 3.7. The PP group was older with more postsurgical gastroparesis. More patients with diabetes underwent GESPP. Preoperative symptom scores and gastric emptying were similar among all groups. All surgical therapies resulted in a significantly improved GCSI and nausea/vomiting subscore at 6 weeks and 1 year. Bloating improved initially, but relapsed in the GES and GESPP group. Satiety improved initially, but relapsed in the PP group. Fifty-nine (72%) had surgical success. Ten underwent additional surgery (7 crossed into the GESPP group, 3 underwent gastric resection). Treatment failures had higher preoperative GCSI, bloating, and satiety scores. Treatment failures and successes had similar preoperative gastric emptying. CONCLUSIONS: Both gastric electrical stimulation and pyloric surgery are successful gastroparesis treatments, with durable improvement in nausea and vomiting. Choice of operation should be guided by patient characteristics and discussion of surgical risks and benefits. Combination GESPP does not appear to confer an advantage over GES or PP alone.

Unnecessary use of radiology studies in the diagnosis of inguinal hernias: a retrospective cohort study.

BACKGROUND: The diagnosis of inguinal hernias is predominantly based on physical exam, although imaging may be used in select cases. The objective of this study was to determine the frequency of unnecessary imaging used in the diagnosis of inguinal hernias. METHODS: Patients who underwent elective inguinal hernia repair at a large academic health system in the U.S. from 2010 to 2017 were included. Within this cohort, we identified patients who received imaging 6 months prior to surgery. Through chart review of physical exam findings and imaging indications, we categorized patients into four imaging categories: unrelated, necessary, unnecessary, and borderline. Multivariable logistic regression analysis was used to identify factors associated with receipt of unnecessary imaging. RESULTS: Of 2162 patients who underwent inguinal hernia surgery, 249 patients had related imaging studies 6 months prior to surgery. 47.0% of patients received unnecessary imaging. 66.9% and 33.1% of unnecessary studies were ultrasounds and CT scans, respectively. 24.5% of patients had necessary studies, while 28.5% had studies with borderline indications. On multivariable analysis, having a BMI between 25.0 and 29.9 kg/m2 was associated with receipt of unnecessary studies. Primary care providers and ED physicians were more likely to order unnecessary imaging. CONCLUSIONS: Nearly 50% of all patients who receive any related imaging prior to surgery had potentially unnecessary diagnostic radiology studies. This not only exposes patients to avoidable risks, but also places a significant economic burden on patients and our already-strained health system.

Phone follow-up after inguinal hernia repair.

BACKGROUND: Typically, in-person follow-up in clinic is utilized after outpatient inguinal hernia repair. Studies have shown that phone follow-up may be successfully used for the detection of postoperative hernia recurrences. However, no studies have evaluated the detection rates of other postoperative complications, such as emergency department visits and readmissions, with the utilization of phone follow-up after inguinal hernia repair. The objective of our study was to investigate the safety of a phone follow-up care pathway following elective, outpatient inguinal hernia repair. METHODS: In this retrospective cohort study, adult patients who underwent elective, outpatient inguinal hernia repair between 2013 and 2019 at a large academic health system in the Midwest United States were identified from the electronic health record. Patients were categorized by type of postoperative follow-up: in-person or phone follow-up. Baseline demographics, operative, and postoperative data were compared between follow-up groups. Multivariable logistic regression was performed to investigate predictors of having any related emergency department (ED) visit/readmission/reoperation within 90 days. RESULTS: We included 2009 patients who underwent elective inguinal hernia repair during the study period. 321 patients had in-person follow-up only, while 1,688 patients had phone follow-up. There was a higher rate of laparoscopic repair in the phone follow-up group (85.4% vs. 53.0% for in-person follow-up). There were no differences in rates of related 90-day ED visits, readmissions, and reoperations between the phone and in-person follow-up groups. On multivariable logistic regression, receipt of phone follow-up was not a predictor of having 90-day ED visits, readmissions, or reoperations (OR 1.30, 95% CI [0.83, 2.05]). CONCLUSIONS: Patients who underwent phone follow-up had similarly low rates of adverse outcomes to those with in-person follow-up. Phone follow-up protocols may be implemented as an alternative for patients and provide a means to decrease healthcare utilization following inguinal hernia repair.

pH Impedance Parameters Associated with Improvement in GERD Health-Related Quality of Life Following Anti-reflux Surgery.

INTRODUCTION: pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery. METHODS: Data from a single-institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014 and 2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid-blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome. RESULTS: We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of 1 year. GERD-HRQL scores improved from 22.4 (SD ± 10.1) preoperatively to 4.2 (± 6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (p = 0.01) and Toupet fundoplication (vs. Nissen; p = 0.03) were independently associated with greater improvement in GERD-HRQL. CONCLUSIONS: Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.

Long-term dysphagia resolution following POEM versus Heller myotomy for achalasia patients.

BACKGROUND: Heller myotomy (HM) has historically been considered the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM) is a less-invasive procedure and offers a quicker recovery. Although some studies have compared short-term outcomes of HM and POEM, predictors of long-term dysphagia resolution remain unclear. The objective of this study was to evaluate patient-reported outcomes for achalasia patients who underwent either POEM or HM over a 9-year period. METHODS: Data from our single academic institutional foregut database were used to identify achalasia patients who underwent HM or POEM from 2009 to 2018. Electronic health record data were reviewed to obtain patient characteristics and operative data. Achalasia severity stages were established for each patient using esophagram findings from an attending radiologist blinded to the procedure type. Postoperative outcomes were assessed via telephone for patients with at least 9 months of follow-up using Eckardt dysphagia scores. Patient age, sex, type of operation, and duration of follow-up were included in a multivariable linear regression model with Eckardt score as the outcome. RESULTS: Our cohort included 141 patients (97 HM and 44 POEM). Eighty-two patients completed a phone survey at the 9 months or greater time interval (response rate = 58%). Mean Eckardt scores were 2.98 and 2.53 at a median follow-up of 3 years and 1 year for HM and POEM patients, respectively (an Eckardt score ≤ 3 is considered a successful myotomy). Lower stages of achalasia on esophagram (e.g., Stage 0 vs. Stage 4) were associated with greater dysphagia improvement. On multivariable analysis, operative approach was not associated with a statistically significant difference in dysphagia outcomes. CONCLUSIONS: POEM and HM were associated with similar rates of dysphagia resolution for achalasia patients at a median of 2 years of follow-up. Both procedures appear to be durable options for achalasia treatment.

Healthcare spending and utilization following antireflux surgery: examining costs and reasons for readmission.

BACKGROUND: While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair. METHODS: Data were analyzed from the Truven Health MarketScan® Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012-2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code. RESULTS: A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175). CONCLUSION: The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.

Looking Ahead: the SSAT Strategic Plan Version 2.0 for the Next Decade.

The Society for Surgery of the Alimentary Tract is a robust clinical society with over 2500 members. As a society that is focused on the entire alimentary tract, we overlap with other more organ-centric societies. This has led to a constant struggle of knowing how the Society for Surgery of the Alimentary Tract can best serve the surgical community. The board of directors held its second strategic retreat in 10 years to develop aspirational goals in hopes to define the direction of the society for the next 5 years. The output of this meeting is presented in this document.

National Underutilization of Neoadjuvant Chemotherapy for Gastric Cancer.

BACKGROUND: Since the publication of the landmark MAGIC trial in 2006, neoadjuvant chemotherapy has become the standard of care for stage II/III gastric cancer. Nevertheless, many patients still do not begin their treatment with neoadjuvant chemotherapy. The objective of our study was to identify factors associated with underutilization of neoadjuvant chemotherapy for stage II/III gastric cancer. METHODS: Patients with pathological stage II and III primary gastric cancer between 2004 and 2015 were identified from the American College of Surgeons National Cancer Database. Patients who received neoadjuvant chemotherapy were compared with those who underwent surgery only or surgery followed by chemotherapy. Predictors of receipt of neoadjuvant chemotherapy were identified using multivariable logistic regression model. Median survival was calculated for each treatment strategy. RESULTS: We included 15,947 patients with pathological stage II/III gastric cancer. The proportion of patients receiving neoadjuvant chemotherapy increased from less than 5% before 2006 to 27.5% in 2015. On multivariable analysis, factors associated with no receipt of neoadjuvant therapy included treatment year before 2006 and age greater than 80. Treatment at high-volume centers, academic research programs, or integrated network cancer programs and undergoing total/subtotal or en bloc gastrectomy predicted receipt of neoadjuvant chemotherapy. CONCLUSIONS: Ten years after the publication of the MAGIC trial, fewer than 1/3 of patients with stage II/III gastric cancer are receiving neoadjuvant chemotherapy, which has been shown to improve disease-specific survival. Further studies are needed to understand these disparities and ensure both patients and providers are having evidence-based discussions about multimodal therapy for gastric cancer.

Complications After Esophagectomy.

Esophagectomy is the mainstay for treating esophageal cancers and other pathology. Even with refinements in surgical techniques and the introduction of minimally invasive approaches, the overall morbidity remains formidable. Complications, if not quickly recognized, can lead to significant long-term sequelae and even death. Vigilance with a high degree of suspicion remains the surgeon's greatest ally when caring for a patient who has recently undergone an esophagectomy. In this review, we highlight different approaches in dealing with anastomotic leaks, chyle leaks, cardiopulmonary complications, and later functional issues after esophagectomy.

30-Day Outcomes After Intraoperative Leak Testing for Bariatric Surgery Patients.

BACKGROUND: Intraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB). METHODS: This is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using χ2 test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes. RESULTS: We included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission. CONCLUSIONS: Use of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact.