Postobesity Surgery Esophageal Dysfunction: A Combined Cross-Sectional Prevalence Study and Retrospective Analysis.

INTRODUCTION: Esophageal dysmotility including features of achalasia may develop because of bariatric surgery. However, the prevalence of these complications is unknown. We sought to define the prevalence of dysphagia and major esophageal motility disorders including achalasia after bariatric surgery through a large retrospective database review. METHODS: Patients with a history of laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass who underwent a diagnostic high-resolution impedance manometry (HRIM) either before or after bariatric surgery across 3 large tertiary referral sites from June 2012 through February 2019 were identified from a procedural database. HRIM studies were interpreted per the Chicago classification v3.0 by a blinded investigator (K.R.). Demographic/clinical features were collected. In addition, patients who underwent bariatric surgery from January 2014 to April 2015 were contacted and administered a validated symptom assessment survey to gauge the overall prevalence of dysphagia in a postbariatric population. RESULTS: A total of 137 patients were identified, including 97 who underwent HRIM after bariatric surgery (laparoscopic sleeve gastrectomy [n = 39, 40.1%]; Roux-en-Y gastric bypass [n = 58, 59.8%]) at a median of 5.84 years (interquartile range 2.1-12.5) postoperatively and 40 preoperative bariatric surgery candidates with medically complicated obesity. A manometric pattern consistent with achalasia was identified in 7 (7.2%) postsurgical patients compared with none in the preoperative group (P = 0.08). We further identified a separate achalasia-like pattern defined by aperistalsis and increased intragastric pressure (postobesity surgery esophageal dysfunction [POSED]) in 5 (5.2%) postsurgical patients vs none found preoperatively (P = 0.14). Achalasia or POSED was associated with postbariatric surgery (12.4% vs 0%, P = 0.02). Increasing time since surgery was independently associated with the development of achalasia (median 12.5 vs 5.8 years, P = 0.02), POSED (median 15.0 vs 5.8 years, P = 0.02) and major motility disorders (6.6 vs 4.9 years, P = 0.01). Furthermore, among 271 postbariatric surgery patients contacted for symptom assessment via survey, the prevalence of dysphagia was 13.7% at a mean 3.9 years after surgery. DISCUSSION: Postoperative dysphagia is a common long-term complication of bariatric surgery. This is potentially the consequence of a time-dependent association with the development of postoperative esophageal dysmotility, particularly achalasia and POSED. Consequently, esophageal dysmotility may be an important under-recognized complication of bariatric surgery.

Competency in esophagogastroduodenoscopy: a validated tool for assessment and generalizable benchmarks for gastroenterology fellows.

BACKGROUND AND AIMS: The Assessment of Competency in Endoscopy (ACE) tools for colonoscopy and EGD were both put forth by the Training Committee of the American Society for Gastrointestinal Endoscopy (ASGE), with the intent of providing teachers and programs a means to continuously assess fellow skills in these procedures throughout their years of training. Despite the availability of the tools, there are no data that define when competency in EGD has been reached. The goal of this study is to validate the EGD ACE tool (ACE-E) and for the first time describe learning curves and competency benchmarks for EGD by examining a large national cohort of trainees. METHODS: In a prospective, multicenter trial, gastroenterology fellows at all stages of training had their core cognitive and motor skills in EGDs assessed by staff using the ACE-E tool. Evaluations occurred at set intervals of every 50 procedures over an academic year. Like the previously reported and validated ACE tool for colonoscopy, the ACE-E tool uses a 4-point grading scale to define a skills continuum from novice to competent. At each assessment interval, average scores for each skill were computed and overall competency benchmarks for each skill were established using the contrasting groups method. RESULTS: Ninety-six GI fellows at 10 U.S. academic institutions had 1002 EGDs assessed using the ACE-E tool. Average ACE-E scores of 3.5 were found to be inclusive of all minimal competency thresholds identified for each core skill. In addition, independent intubation of the second part of the duodenum (D2) at rates of ≥95% as well as D2 intubation times of ≤4.75 minutes and average total procedure times of ≤12.5 minutes were identified as the points separating competent from non-competent groups. Although the average fellow achieves the D2 intubation rates and time criteria by 100 and 150 procedures, respectively, achieving ACE-E threshold scores on the remaining metrics was typically not achieved until 200 to 250 procedures. CONCLUSIONS: Nationally generalizable learning curves for EGD skills in GI fellows are described. Average ACE-E scores of 3.5, independent D2 intubation rates of 95%, and D2 intubation times of ≤4.75 minutes are recommended as minimum competency criteria. On average, it takes GI fellows only 150 procedures to simply drive the scope adequately but 250 procedures to achieve minimum competence in the remaining cognitive and motor skills. The D2 intubation rate threshold and learning curve found in this multicenter cohort using the ACE-E tool are similar to those recently described by researchers in the United Kingdom; however, development of cognitive and overall competence requires a higher procedure threshold than previously described.

Fever, Rash, and Shortness of Breath in a 69-Year-Old.

A 69-year-old had fever, fatigue, rash, right periorbital swelling, and shortness of breath. Chest computed tomography revealed numerous small, bilateral pulmonary nodules; laboratory testing revealed mean corpuscular volume, 96.1 fL; hemoglobin level, 12.4 mg/dL; and leukopenia. What is the diagnosis and what would you do next?

Procedural and anthropometric factors associated with musculoskeletal injuries among gastroenterology endoscopists.

BACKGROUND AND AIMS: Musculoskeletal (MSK) injuries among gastroenterologists are common. Our study describes risk factors and consequences of injury by comparing provider-specific anthropometric and objective procedural data to self-reported injury patterns. METHODS: A validated MSK symptom survey was sent to gastroenterologists to gauge prevalence, distribution, and severity of active injury. Respondents' procedural activities over 7 years were collected via an endoscopic database. RESULTS: 64 surveys were completed. 54 respondents had active pain; 53.1% reported activity-limiting injury. Activity-limiting injuries lead to longer colonoscopy times (25.3 vs. 22.1 min, P = 0.03) and lower procedural volumes (532 vs. 807, P = 0.01). Hand/wrist injuries yielded longer colonoscopy insertion times (9.35 vs. 8.21 min, P = 0.03) and less hands-on scope hours (81.2 vs. 111.7 h, P = 0.04). Higher esophagogastroduodenoscopy volume corelated with shoulder injury (336.5 vs. 243.1 EGDs/year, P = 0.04). Females had more foot injuries (P = 0.04). CONCLUSION: Activity-limiting MSK symptoms/injuries affect over 50% of endoscopists with negative impact on procedural volume and efficiency.

Hearing loss as a risk factor for dementia: A systematic review.

OBJECTIVES: To review evidence of hearing loss as a risk factor for dementia. Data Sources: PubMed Review methods: A systematic review was conducted using the PubMed database using the search terms (hearing loss OR presbycusis) AND (dementia OR cognitive decline). Initially, 488 articles were obtained. Only those studies evaluating an association between hearing loss and incident dementia or cognitive decline were included in the analysis. This resulted in 17 articles which were thoroughly evaluated with consideration for study design, method for determining hearing loss and cognitive status, relevant covariates and confounding factors, and key findings. RESULTS: All of the 17 articles meeting inclusion criteria indicate that hearing loss is associated with dementia or cognitive decline. The methods used among the studies for ascertaining hearing loss and dementia were notably varied. For hearing loss, peripheral auditory function was tested far more than central auditory function. For peripheral audition, pure tone audiometry was the most commonly reported method for defining hearing loss. Only a few studies measured central auditory function by using the Synthetic Sentence Identification with Ipsilateral Competing Message test (SSI-ICM) and the Staggered Spondaic Word Test (SSW). Dementia was most often defined using the Mini Mental State Exam (MMSE). However, many studies used extensive batteries of tests to define cognitive status, often including a neuropsychologist. Confounding variables such as cardiovascular risk factors were measured in 17 studies and family history of dementia was only evaluated in 1 study. Overall, the methods used by studies to ascertain hearing loss, cognitive status and other variables are valid, making their evaluation appear reliable. CONCLUSION: While each of the studies included in this study utilized slightly different methods for evaluating participants, each of them demonstrated that hearing loss is associated with higher incidence of dementia in older adults. LEVEL OF EVIDENCE: Level V, systematic review.