Machine learning prediction of major adverse cardiac events after elective bariatric surgery.

BACKGROUND: Machine learning (ML) is an emerging technology with the potential to predict and improve clinical outcomes including adverse events, based on complex pattern recognition. Major adverse cardiac events (MACE) after bariatric surgery have an incidence of 0.1% but carry significant morbidity and mortality. Prior studies have investigated these events using traditional statistical methods, however, studies reporting ML for MACE prediction in bariatric surgery remain limited. As such, the objective of this study was to evaluate and compare MACE prediction models in bariatric surgery using traditional statistical methods and ML. METHODS: Cross-sectional study of the MBSAQIP database, from 2015 to 2019. A binary-outcome MACE prediction model was generated using three different modeling methods: (1) main-effects-only logistic regression, (2) neural network with a single hidden layer, and (3) XGBoost model with a max depth of 3. The same set of predictor variables and random split of the total data (50/50) were used to train and validate each model. Overall performance was compared based on the area under the receiver operating curve (AUC). RESULTS: A total of 755,506 patients were included, of which 0.1% experienced MACE. Of the total sample, 79.6% were female, 47.8% had hypertension, 26.2% had diabetes, 23.7% had hyperlipidemia, 8.4% used tobacco within 1 year, 1.9% had previous percutaneous cardiac intervention, 1.2% had a history of myocardial infarction, 1.1% had previous cardiac surgery, and 0.6% had renal insufficiency. The AUC for the three different MACE prediction models was: 0.790 for logistic regression, 0.798 for neural network and 0.787 for XGBoost. While the AUC implies similar discriminant function, the risk prediction histogram for the neural network shifted in a smoother fashion. CONCLUSION: The ML models developed achieved good discriminant function in predicting MACE. ML can help clinicians with patient selection and identify individuals who may be at elevated risk for MACE after bariatric surgery.

Response to botulinum toxin may predict response to peroral pyloromyotomy in patients with gastroparesis.

BACKGROUND : Patients with gastroparesis who have undergone prior intrapyloric botulinum toxin injection (BTI) may seek an opinion regarding peroral pyloromyotomy (POP). There are only two small reports assessing the role of BTI as a predictor for successful treatment with POP. METHODS: We performed a retrospective cohort study to assess whether symptomatic improvement after BTI predicts a response to POP. We included 119 patients who had undergone both BTI and POP at Cleveland Clinic Ohio or Cleveland Clinic Florida from January 2016 to September 2019. RESULTS: 65.5 % of patients had symptomatic improvement after BTI. Gastroparesis Cardinal Symptom Index (GCSI) scores were available for 74 patients, with 64 % achieving a response to POP, defined as a decrease in mean GCSI ≥ 1. In multivariable analysis, response to BTI (odds ratio [OR] 7.7 [95 %CI 2.2-26.1]) and higher pre-POP GCSI score (OR 2.3 [95 %CI 1.2-4.6]) were independent predictors of response to POP. CONCLUSIONS: Clinical improvement after BTI is a predictor of response to POP in patients with gastroparesis. This information may aid in improving patient selection for POP.

A nationwide analysis of median arcuate ligament release between 2010 and 2020: a NSQIP Study.

BACKGROUND: Median arcuate ligament syndrome is a rare disease with overlapping symptoms of broad foregut pathology. Appropriately selected patients can benefit from a laparoscopic or open median arcuate ligament release. Institutional series have reported the outcomes of open and laparoscopic techniques but there are no nationwide analysis comparing both techniques and overall trends in treatment. METHODS: Cross-sectional study using the American College of Surgeons-National Surgical Quality Improvement Project from 2010 to 2020. Celiac artery compression syndrome cases were identified by International Classification of Diseases (ICD) codes and categorized as open or laparoscopic. Trends in the use of each technique and 30-day complications were compared between the groups. RESULTS: A total of 578 open cases (76%) and 185 laparoscopic cases (24%) were identified. There was an increase adoption of the laparoscopic approach, with 22% of the cases employing this technique at the end of the study period, compared to 7% at the beginning of the study period. The open group had a higher prevalence of hypertension (26% vs 18%, p = 0.04) and bleeding disorders (5% vs 2%, p 0.03). Laparoscopic approach had a shorter length of stay (2.3 days vs 5.2 days, p < 0.0001), lower major complication rates (0.5% vs 4.0%, p = 0.02) and lower reoperation rates (0% vs 2.6%, p = 0.03). Overall mortality was 0.1%. CONCLUSION: Overall numbers of surgical intervention for treatment of median arcuate ligament increased during this timeframe, as well as increased utilization of the laparoscopic approach. It appears to be an overall safe procedure, offering lower rates of complications and shorter length of stay.

Primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) versus sleeve gastrectomy to SADI conversions: a comparison study of prevalence and safety.

BACKGROUND: Conversion from sleeve gastrectomy (SG) to single anastomosis duodeno-ileal bypass (SADI) is becoming increasingly common, but data regarding safety is of these conversions is scarce. As such, the objective of this study was to compare the 30-day rate of serious complications and mortality of primary SADI (p-SADI-S) with SG to SADI (SG-SADI) conversions. METHODS: This retrospective cohort study analyzed the MBSAQIP database. Patients undergoing p-SADI-S and SG-SADI were included. Data collection was limited to 2020 and 2021. A multivariable logistic regression analysis was performed between groups to determine if SG-SADI was an independent predictor of 30-day serious complications or mortality. RESULTS: A total of 783 patients were included in this study, 488 (62.3%) underwent p-SADI-S and 295 (37.6%) underwent SG-SADI. The mean body mass index (BMI) at the time of surgery was lower in the SG-SADI cohort (45.1 vs 51.4 kg/m2, p < 0.001). Indications for revision in the SG-SADI cohort included weight recurrence (50.8%), inadequate weight loss (41.0%), other (3.0%), GERD (2.7%), and persistent comorbidities (2.5%). SG-SADI had longer operative times (156.7 vs 142.1 min, p < 0.001) and was not associated with a higher rate of serious complications (5.7 vs 6.9%, p = 0.508) compared to p-SADI-S. p-SADI-S was associated with a higher rate of pneumonia (1.2 vs 0.0%, p < 0.001), and SG-SADI was not correlated with higher rates of reoperation (3.0 vs 3.2%, p = 0.861), readmission (5.4 vs 5.5%, p = 0.948) and death (0.0 vs 0.2%, p = 0.437). On multivariable analysis, SG-SADI was not independently predictive of serious complications (OR 0.81, 95% CI 0.43 to 1.52, p = 0.514) when adjusting for age, sex, BMI, comorbidities, and operative time. CONCLUSIONS: The prevalence of SG-SADI is high, representing 37.6% of SADI-S procedures. Conversion from sleeve to SADI, is safe, and as opposed to other studies of revisional bariatric surgery, has similar 30-day complication rates to primary SADI-S.

Real-time intraoperative functioning lumen imaging probe during endoscopic per-oral pyloromyotomy (pop).

BACKGROUND: Endoscopic per-oral pyloromyotomy (POP) has emerged as a safe and effective first line option in medically refractory gastroparesis. Determining the appropriate extent of the pyloromyotomy continues to present a challenge as there are no standardized tools for measuring changes in pyloric distensibility during the procedure. The objective of this study was to evaluate the utility of using impedance planimetry with endoscopic functional luminal imaging probe (FLIP) to measure changes in pyloric distensibility after POP, and to compare these changes with improvement in symptoms and objective gastric emptying. METHODS: Patients with medically refractory gastroparesis underwent POP with FLIP measurements of the pylorus (EndoFLIP®, Medtronic, Fridley MN). FLIP measurements, as well as changes in symptoms measured by the validated gastroparesis cardinal symptom index (GCSI) and scintigraphic gastric emptying studies (GES), were evaluated before and after POP. RESULTS: A total of 14 patients underwent measurement with FLIP during POP, 12 of whom had pre- and post-POP measurements. Mean pyloric diameter increased by 1.4 mm, from 13.9 mm to 15.3 mm (p = 0.0012). Mean distensibility index increased from 6.2 mm2/mmHg to 9.1 mm2/mmHg (p = 0.0074). Successful division of the pylorus was achieved in 100% of patients with a mean operative time of 36 min and no perioperative complications. The mean length of stay was 0.7 days (0-3 days). Post-POP mean GCSI score improved from 2.97 to 2.28 at a mean follow-up time of 27 days (p < 0.001). Objective improvement in gastric emptying was observed in 80% of patients with scintigraphic GES, with mean four-hour retention decreasing from 46.3% to 32.4% (p < 0.007). CONCLUSIONS: FLIP is a safe and feasible tool to provide objective measurements during POP. Larger cohorts with longer follow-up are required to determine if measured improvements in pyloric diameter and distensibility are predictive of sustained improvements in GCSI and GES.

Robotic versus laparoscopic median arcuate ligament (MAL) release: a retrospective comparative study.

BACKGROUND: Multiple retrospective studies have demonstrated the safety and feasibility of laparoscopic median arcuate ligament division with celiac neurolysis for the definitive management of median arcuate ligament syndrome (MALS). This study queries the clinical equipoise of robotic (RMALR) versus laparoscopic MAL release (LMALR) at a high-volume center. METHODS: A retrospective analysis of consecutive 26 RMALR and 24 LMALR between March 2018 and August 2019 by a single surgeon at a quaternary academic institution was completed. Primary endpoint was postoperative decrease in celiac trunk expiratory peak systolic velocities (PSVs) measured by mesenteric duplex ultrasonography. Secondary outcomes included reported improvement in MALS-related clinical symptoms, distribution of first assistant seniority level, and involvement of second assistants in RMALR versus LMALR. RESULTS: Mean operative times for LMALR and RMALR were 86 and 134 min, respectively (p < 0.0001). There were no open conversions and mean length of hospital stay was 1 day for both cohorts. Both groups provided an equally effective decrease in postoperative peak systolic velocities (PSVs) (LMALR p = 0.0011; RMALR p = 0.0022; LMALR vs. RMALR p = 0.7772). While RMALR had significantly higher reduction of chronic abdominal pain postoperatively, there were no significant differences in other postoperative symptom relief between groups. However, RMALR patients reported significant relief of postprandial abdominal pain (p < 0.0001) and chronic nausea (p = 0.0002). RMALR had significantly more junior first assistants (p = 0.0001) and less frequently required second assistants compared to LMALR (p = 0.0381). CONCLUSIONS: In this study comparing RMALR to LMALR, postoperative chronic abdominal pain relief was significantly less in the former while other outcomes were equivalent. In comparison with LMALR, RMALR cases were associated with more junior first assistants, fewer second assistants, and longer operative times. Both approaches are safe and feasible for well-selected patients in experienced centers.

Thirty-Day Readmission After Bariatric Surgery: Causes, Effects on Outcomes, and Predictors.

BACKGROUND: Bariatric surgery (BSx) is one of the most common surgical procedures in North America. Readmissions may be associated with a high burden to the healthcare system. METHODS: Retrospective study of the 2016 National Readmission Database of adult patients readmitted within 30 days after an index admission for BSx. Outcomes were: 30-day readmission rate, mortality, healthcare-related utilization resources, and independent predictors of readmission. Comparison groups were index admission, readmitted, and non-readmitted patients. RESULTS: A total of 161,141 patients underwent BSx. The 30-day readmission rate was 3.3%. Main causes for readmission were dehydration, acute kidney injury, venous thromboembolism events, and sepsis. Readmitted patients were more likely to develop shock (0.5% vs. 0.1%; P < 0.01) with no differences in mechanical ventilation (1.9% vs. 2.0%; P = 0.83) during index admission compared to non-readmitted patients. Readmission was associated with higher in-hospital mortality rate (1.5% vs. 0.1%; P < 0.01) and prolonged length of stay (4.6 vs. 2.4 days; P < 0.01). The total in-hospital economic burden of readmission was $234 million in total charges and $58.7 million in total costs. Independent predictors of readmission were: Charlson comorbidity index of ≥ 3, longer length of stay, admission to larger bed size hospitals, discharge to nursing home, and acute kidney injury. Medicaid, private insurance, BMI of 30-39 kg/m2, and 40-44 kg/m2 were associated with lower odds for readmission. CONCLUSION: Readmissions after BSx are associated with higher in-hospital mortality rate and pose a high healthcare burden. We identified risk factors that can be targeted to decrease readmissions after BSx, healthcare burden, and patient morbidity and mortality.

Endoscopic mucosal incision and muscle interruption (MIMI) for the treatment of Zenker's diverticulum.

BACKGROUND: In peroral endoscopic myotomy for Zenker's diverticulum (Z-POEM), the cricopharyngeus muscle is divided within a submucosal tunnel started in the hypopharynx. We aimed to evaluate the safety and preliminary outcomes in patients who underwent a modified version of the Z-POEM where the tunnel is made directly overlying the cricopharyngeus, the mucosal incision and muscular interruption (MIMI) approach, and to compare these with patients who underwent a non-tunneled flexible endoscopic approach. METHODS: All patients with ZD who were treated by flexible endoscopy at our institution between January 2015 and February 2020 were identified by a retrospective chart review. Dysphagia symptoms were assessed using a validated scoring system. RESULTS: Nineteen patients with ZD underwent MIMI (mean age 76.1 years, 68.1% male) and seven patients underwent non-tunneled flexible endoscopic approach (mean age 64.4 years, 85.7% male) during the study period. Mean ZD size was 2.8 cm in the MIMI group and 1.9 cm in the non-tunneled group (p = 0.03). Clinical success was achieved in 17/19(89.5%) MIMI patients and 7/7(100%) of non-tunneled flexible endoscopic patients (p = 0.101). Dysphagia scores improved in both groups, although this difference was only significant in the MIMI group (p ≤ 0.001). Recurrence occurred in 2/17(11.7%) MIMI patients and 3/7(42.9%) non-tunneled flexible endoscopic patients (p = 0.096). There were 4 complications, including one pharyngeal perforation requiring open surgical repair in a patient with a small ZD with an associated cricopharyngeal bar in the MIMI group. Median length of follow-up was 290 [142; 465] days in the MIMI group and 1056 [258; 1206] days in the non-tunneled group (p = 0.094). CONCLUSIONS: MIMI is a technically feasible and effective treatment for ZD. Care should be taken in patients with a cricopharyngeal bar and small ZD, as this may increase the risk of perforation. Larger studies with long-term follow-up are needed to determine if MIMI reduces the risk of symptom recurrence when compared to non-tunneled flexible endoscopic approaches.

Gastrectomy versus stomach left in situ with Roux-en-Y reconstruction for the treatment of gastroparesis.

BACKGROUND: Gastroparesis is a debilitating functional disorder of the stomach marked by delayed gastric emptying in the absence of mechanical obstruction. Patients with severe, refractory symptoms may ultimately be managed with Roux-en-Y reconstruction; however, it is unclear whether the stomach should be left in situ, similar to a conventional gastric bypass, or resected as in gastrectomy. METHODS: All patients undergoing Roux-en-Y for the treatment of gastroparesis (GP) at our institution from September 2010 through March 2018 were retrospectively reviewed. Patients with prior gastric resection or whose primary operative indication was not gastroparesis were excluded from analysis. RESULTS: Twenty-six patients underwent Roux-en-Y with stomach left in situ (RY-SIS) and twenty-seven patients underwent gastrectomy with Roux-en-Y reconstruction during the study period. The mean age was 49.7 years in the RY-SIS cohort and 48.5 years in the gastrectomy cohort. Etiology of GP was similar between the two cohorts. Patients undergoing gastrectomy were more likely to have previous interventions for GP (63.0% vs. 26.9%). RY-SIS was associated with a shorter operative time (155 vs. 223 min), less blood loss (24 vs. 130 mL), and shorter length of stay (4.0 vs. 7.2 days). Twelve patients (44.4%) had complications within 30 days following gastrectomy compared to two patients (7.7%) following RY-SIS (p = 0.001). Patients in the RY-SIS cohort were more likely to require further subsequent surgical intervention for GP (23.1% vs. 3.7%, p = 0.04). At last follow-up, there were no differences in reported GP symptoms or symptom scoring. CONCLUSIONS: Gastrectomy was associated with greater perioperative morbidity compared to leaving the stomach in situ. Symptomatic improvement at intermediate follow-up was equivalent following either procedure. However, patients undergoing RY-SIS were more likely to require subsequent surgical intervention, suggesting that gastrectomy may be a more definitive operation for the management of medically refractory gastroparesis.

Minimally invasive Roux-en-Y reconstruction as a salvage operation after failed nissen fundoplication.

BACKGROUND: Conversion of Nissen fundoplication to Roux-en-Y (RnY) anatomy may be indicated in patients with post-surgical complications or who fail to achieve durable control of their disease. Herein we describe the largest series of patients at a single institution who underwent minimally invasive conversion of Nissen fundoplication to RnY reconstruction. METHODS: All patients with prior Nissen fundoplication which were converted to RnY anatomy at our institution from March 2009 through November 2017 were retrospectively reviewed and analyzed. Patients were identified based on CPT codes and the description of the operation performed. All cases with attempted minimally invasive approach were included for analysis. RESULTS: Fifty patients underwent conversion from prior Nissen fundoplication to RnY anatomy during the study period. The cohort was 84.0% female with a mean age of 53.5 years and a median body mass index of 36.7 kg/m2. Thirteen patients (26.0%) had multiple prior foregut operations. Complications from fundoplication that warranted revision included recurrent hiatal hernia (n = 16), post-surgical gastroparesis (n = 10), and mechanical complications from the wrap (n = 8). An additional fourteen patients underwent conversion to RnY for metabolic disease. The mean operative time and estimated blood loss were 266 min and 132 mL, respectively, with all but one (98.0%) completed with a minimally invasive approach. The median length of stay was 5 days. Complications included marginal ulcer (n = 2), superficial surgical site infection (n = 2), anastomotic leak (n = 2), and one case each of pulmonary embolism, small bowel obstruction, and gastrointestinal bleeding. There were no mortalities at a median follow-up of 12.4 months. CONCLUSIONS: Conversion of prior Nissen fundoplication to RnY anatomy is technically challenging, although it is safe and feasible even in the setting of multiple prior foregut operations. A minimally invasive approach should be offered to patients by surgeons with experience in revisional foregut and bariatric surgery.

Enhanced recovery outcomes following per-oral pyloromyotomy (POP): a comparison of safety and cost with same-day discharge versus inpatient recovery.

BACKGROUND: While per-oral pyloromyotomy (POP) has shown promise as a novel endoscopic procedure to treat medically refractory gastroparesis, standardized care pathways are not well-defined. We aimed to compare the safety and cost of same-day discharge (SDD) after POP with inpatient stay overnight or longer. METHODS: All patients with SDD after POP between January 2016 and May 2018 were retrospectively identified from a prospectively maintained registry. Propensity scores considering gender, age, gastroparesis etiology, and American Society of Anesthesiologists (ASA) class were used to match a comparison group which stayed overnight or longer. Statistical tests included two-sample t tests for continuous variables, Fisher's exact test for categorical variables, and paired sample t tests for within-group comparisons with repeated measures. RESULTS: Fifty-four patients who underwent POP with SDD during the study period were propensity-matched with 54 patients with inpatient recovery. The SDD cohort was 85.2% female with a mean age of 44.8 years and median ASA class 3. The etiology of gastroparesis was idiopathic in 53.7% (n = 29), diabetic in 29.6% (n = 16), and post-surgical in 11.1% (n = 6). Operative time was shorter in the SDD cohort (25.4 vs. 31.3 min, p = 0.02). The mean post-procedure recovery time was 4 h in patients with SDD and 29.3 h in the inpatient cohort (p < 0.001). There was a trend towards less readmissions with SDD (7.4% vs. 18.5%, p = 0.08). There was no increased risk of complications with SDD (1.9% vs. 3.7%, p = 0.57). Compared to inpatient recovery, the average total cost for the procedure, recovery, and all subsequent care within 30 days was 26.0% less with SDD (p < 0.001). CONCLUSIONS: Following POP, patients can be safely discharged the same day with low risk of both complications and readmission. Total costs in the complete perioperative period are significantly less with SDD compared to inpatient recovery.

An exploratory study to evaluate visual function endpoints in non-advanced age-related macular degeneration.

BACKGROUND: To prevent irreversible vision loss in age-related macular degeneration (AMD), it is critical to detect retinal dysfunction before permanent structural loss occurs. In the current study we evaluated a series of visual function tests to identify potential endpoints to detect visual dysfunction in non-advanced AMD. METHODS: A series of visual function tests were performed on 23 non-advanced AMD subjects (AREDS grade 1-4 on simplified scale) and 34 age-matched normals (AREDS grade 0). Tests included some commonly used endpoints such as ETDRS visual acuity (VA), low luminance (LL) 2.0ND ETDRS VA, MNREAD as well as newly developed tests such as the Ora-VCF™ test, Ora-tablet reading test, color sensitivity etc. Differences between the two groups were compared for each test. Test-retest repeatability and reproducibility was assessed on a subset of subjects and percent agreement was calculated. RESULTS: There was no difference in standard ETDRS VA between non-advanced AMD (0.06 ± 0.02 logMAR) and normal groups (0.04 ± 0.02 logMAR) (p = 0.57). LL 2.0 ETDRS VA and MNREAD showed no difference between the groups (p > 0.05). Ora-VCF™ test was significantly worse in the non-advanced AMD group compared to normals (0.67 ± 0.07 in AMD; 0.45 ± 0.04 in normals, p = 0.005). Non-advanced AMD subjects also had significantly worse reading performance using the Ora-tablet with LL 2.0ND (114.55 ± 11.22 wpm in AMD; 145.17 ± 9.55 wpm in normals p = 0.049). No significant difference between the groups was noted using other tests. Repeatability was 82% for Ora-VCF™ test and 92% for Ora-tablet LL 2.0ND reading. Reproducibility was 89% for both Ora-VCF™ test and Ora-tablet LL 2.0ND reading. CONCLUSION: While there was no significant difference between non-advanced AMD and normal groups using some current common endpoints such as ETDRS VA, LL 2.0 ETDRS VA or MNREAD, Ora-VCF™ test and Ora-tablet LL 2.0ND reading tests were able to identify significant visual dysfunction in non-advanced AMD subjects. These tests show promise as endpoints for AMD studies.

BioMuta and BioXpress: mutation and expression knowledgebases for cancer biomarker discovery.

Single-nucleotide variation and gene expression of disease samples represent important resources for biomarker discovery. Many databases have been built to host and make available such data to the community, but these databases are frequently limited in scope and/or content. BioMuta, a database of cancer-associated single-nucleotide variations, and BioXpress, a database of cancer-associated differentially expressed genes and microRNAs, differ from other disease-associated variation and expression databases primarily through the aggregation of data across many studies into a single source with a unified representation and annotation of functional attributes. Early versions of these resources were initiated by pilot funding for specific research applications, but newly awarded funds have enabled hardening of these databases to production-level quality and will allow for sustained development of these resources for the next few years. Because both resources were developed using a similar methodology of integration, curation, unification, and annotation, we present BioMuta and BioXpress as allied databases that will facilitate a more comprehensive view of gene associations in cancer. BioMuta and BioXpress are hosted on the High-performance Integrated Virtual Environment (HIVE) server at the George Washington University at https://hive.biochemistry.gwu.edu/biomuta and https://hive.biochemistry.gwu.edu/bioxpress, respectively.

Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis.

BACKGROUND: Gastroparesis is a debilitating functional disorder of the stomach characterized by delayed gastric emptying absent an obstructive etiology. Surgical or endoscopic disruption of the pylorus has been utilized to treat this disease, but there is little evidence comparing laparoscopic pyloroplasty (LP) with endoscopic per-oral pyloromyotomy (POP). Herein we describe our experience at our institution using a propensity-matched cohort study to compare outcomes between these procedures. METHODS: All patients who underwent LP for the treatment of gastroparesis from October 2014 through September 2017 at our institution were retrospectively reviewed. Propensity scoring was used to match these patients 1:1 to patients undergoing POP during this time period based on gender, age, and etiology of gastroparesis. Symptom scores using the Gastroparesis Cardinal Symptom Index (GCSI), scintigraphic gastric emptying studies (GES), and perioperative outcomes were compared between matched cohorts. Thirty patients underwent LP for gastroparesis during the study period which were matched 1:1 with patients undergoing POP. The etiology of gastroparesis was 63.3% idiopathic (n = 19), 20.0% post-surgical (n = 6), and 16.7% diabetic (n = 5) in both cohorts. RESULTS: Patients who underwent LP had a longer average length of stay (4.6 vs. 1.4 days, p = 0.003), operative time (99.3 vs. 33.9 min, p < 0.001), and estimated blood loss (12.9 vs. 0.4 mL, p < 0.001). There were more complications in the LP cohort (16.7 vs. 3.3%, p = 0.086), which included surgical site infection (6.7 vs. 0%, p = 0.153), pneumonia (6.7 vs. 0.0%, p = 0.153), and unplanned ICU admission (10.0 vs. 0.0%, p = 0.078). LP and POP both resulted in similar, significant improvements in both in GCSI scores and objective gastric emptying. CONCLUSIONS: Per-oral endoscopic pyloromyotomy (POP) is safe and effective for the treatment of medical refractory gastroparesis. POP has less perioperative morbidity compared to LP with comparative functional outcomes.

Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis: Short Term Results From the First 100 Patients at a High Volume Center.

OBJECTIVE: For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center. METHODS: The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0 ±â€Š14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82 ±â€Š0.86 to 2.54 ±â€Š1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP. CONCLUSION: For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.

Multi- and Extensively Drug Resistant Mycobacterium tuberculosis in South Africa: a Molecular Analysis of Historical Isolates.

Modern advances in genomics provide an opportunity to reinterpret historical bacterial culture collections. In this study, genotypic antibiotic resistance profiles of Mycobacterium tuberculosis isolates from a historical 20-year-old multidrug-resistant tuberculosis (MDR-TB) culture collection in South Africa are described. DNA samples extracted from the phenotypically MDR-TB isolates (n = 240) were assayed by Hain line probe assay (LPA) for the confirmation of MDR-TB and by Illumina Miseq whole-genome sequencing (WGS) for the characterization of mutations in eight genes (rpoB, katG, inhA, rpsL, pncA, embB, gyrA, and rrs) that are known to code for resistance to commonly used anti-TB agents. LPA identified 71.3% of the TB isolates as MDR-TB, 18.3% as rifampin (RIF) monoresistant, 2% as isoniazid (INH) monoresistant, and 8.3% as susceptible to both RIF and INH (RIF+INH). In a subset of 42 randomly selected isolates designated as RIF+INH resistant by Löwenstein-Jensen (LJ) culture in 1993, LPA and WGS results confirmed MDR-TB. In all five INH-monoresistant isolates by LPA and in all but one (the wild type) of the 34 successfully sequenced RIF-monoresistant isolates, WGS revealed matching mutations. Only 26% of isolates designated as susceptible by LPA, however, were found to be wild type by WGS. Novel mutations were found in the rpoB (Thr480Ala, Gln253Arg, Val249Met, Val251Tyr, Val251Phe), katG (Trp477STOP, Gln88STOP, Trp198STOP, Trp412STOP), embB (Thr11Xaa, Gln59Pro), and pncA (Thr100Ile, Thr159Ala, Ala134Arg, Val163Ala, Thr153Ile, DelGpos7, Phe106Ser) genes. Three MDR-TB isolates showed mutations in both the gyrA and rrs genes, suggesting that extensively drug-resistant tuberculosis existed in South Africa well before its formal recognition in 2006.

An Odyssey of complications from band, to sleeve, to bypass; definitive laparoscopic completion gastrectomy with distal esophagectomy and esophagojejunostomy for persistent leak.

INTRODUCTION: Anastomotic leaks are uncommon yet potentially devastating complications after bariatric surgery. While the initial management includes resuscitation and sepsis control, the definitive management often requires endoscopic or surgical interventions. Surgical revision of the initial surgery may be necessary for chronic non-healing fistula. PATIENTS AND METHODS: The patient is a 45-year-old female with history of laparoscopic adjustable gastric banding who underwent band removal and conversion to a sleeve gastrectomy (SG) due to her failed weight loss, which resulted in a leak at gastroesophageal junction. She underwent multiple attempted endoluminal treatments without success and then SG was converted to Roux-en-Y gastric bypass (RYGB). However, this failed and the persistent leak led to a gastro-pleural fistula requiring left chest decortication. After addressing nutritional deficiencies, she underwent laparoscopic completion gastrectomy and Roux-en-Y esophagojejunostomy reconstruction. RESULTS: Five ports and a liver retractor were placed. Dissection was carried down posteriorly to free up the Roux limb and then to the right crus. There was an abscess cavity around the left crus. The esophagus was circumferentially mobilized and the abscess cavity was debrided. The proximal Roux limb was disconnected with a linear stapler. Upper endoscopy was used to identify the leak. The healthy tissue was confirmed above the leak and the distal esophagus was transected. Esophageal stump was mobilized up into the middle mediastinum. Esophagojejunostomy was completed with 25 mm circular stapler. A linear stapler was used to close the candy cane. The procedure took 2 h and 40 min. Estimated blood loss was 100 ml. Her postoperative course was uncomplicated. CONCLUSION: We present a video of the complex surgical revision of a leak after through the gamut of bariatric surgery: band to sleeve, failed endoluminal therapy and conversion of SG to RYGB. Durable success was achieved by a completion gastrectomy, distal esophagectomy with Roux-en-Y esophagojejunostomy.

Surgical management of gastroesophageal reflux disease in patients with systemic sclerosis.

BACKGROUND: Systemic sclerosis (scleroderma) is frequently associated with both gastroesophageal reflux disease (GERD) and simultaneous esophageal dysmotility. Anti-reflux procedures in this patient population must account for the existing physiology of each patient and likely disease progression. We aim to compare perioperative and intermediate outcomes of fundoplication versus gastric bypass for the treatment of GERD. METHODS: After IRB approval, patients with systemic sclerosis undergoing fundoplication or gastric bypass for the treatment of GERD from 2004 to 2016 were identified. Demographics, perioperative data, immediate complications, and symptom improvement were retrieved and analyzed. RESULTS: Fourteen patients with systemic sclerosis underwent surgical treatment of GERD during the defined study period. Average body mass index was 26 kg/m2. Seven fundoplications (2 Nissens, 4 Toupets, and 1 Dor) and 7 Roux-en-Y gastric bypasses (RYGB) were performed. No 30-day mortality was observed in either group. Median follow-up was 97 months for the fundoplication group (range 28-204 months), and 19 months for the RYGB group (range 1-164 months). Preoperatively, dysphagia, heartburn, and regurgitation were present in 71% (n = 10), 86% (n = 12), and 64% (n = 9) of patients, respectively. Eleven patients had pH study prior to surgical intervention, and 91% of them had abnormal acid exposure. Esophagitis was evident in 85% (n = 11) of patients during preoperative upper endoscopy, and two patients had Barrett's esophagus. Impaired esophageal motility was present in all RYGB patients and 71% of fundoplication patients. Of the patients who had assessment of their GERD symptoms at follow-up, all five patients in the RYGB group and only 3 (50%) patients in the fundoplication group reported symptom improvement or resolution. CONCLUSIONS: Laparoscopic RYGB as an anti-reflux procedure is safe and may provide an alternative to fundoplication in the treatment of GERD for systemic sclerosis patients with esophageal dysmotility.

Magnetic surgery: first U.S. experience with a novel device.

INTRODUCTION: Magnet-assisted surgery is a new platform within minimally invasive surgery. The Levita™ Magnetic Surgical System, the first magnetic surgical system to receive Food and Drug Administration (FDA) approval, includes a deployable, magnetic grasper and an external magnet that is used to manipulate the grasper within the peritoneal cavity. This system is currently approved for patients undergoing laparoscopic cholecystectomy with a body mass index (BMI) between 21 and 34 kg/m2. Herein, we detail the first United States experience with the Levita™ Magnetic Surgical System during laparoscopic cholecystectomy. METHODS: The Levita™ Magnetic Surgical System was used on consecutive patients undergoing laparoscopic cholecystectomy at our institution from June 2016 through November 2016. Only patients undergoing elective surgery and those with a body mass index (BMI) between 21 and 34 kg/m2 were included. Baseline patient characteristics, operative time, and perioperative details were collected. RESULTS: A total of ten patients underwent laparoscopic cholecystectomy with the Levita™ Magnetic Surgical System during the defined study period. The mean age at the time of surgery was 49.0 years and the average BMI of the cohort was 27.6 kg/m2. The average operative time was 64.4 min. There were no perioperative complications. Seven (70.0%) patients were discharged to home on the day of surgery, while the remaining three (30.0%) patients were discharged to home on postoperative day number one. Surgeons reported that the magnetic grasper was easy to use and provided adequate tissue retraction and exposure. CONCLUSIONS: The Levita™ Magnetic Surgical System is safe and feasible to use in patients undergoing laparoscopic cholecystectomy. Routine use of this system may facilitate a reduction in the total number of laparoscopic trocars used, leading to less tissue trauma and improved cosmesis. Additional studies are needed to determine the applicability and utility of this system for other general surgery cases.

Comparison of laparoscopic jejunostomy tube to percutaneous endoscopic gastrostomy tube with jejunal extension: long-term durability and nutritional outcomes.

INTRODUCTION: Enteral access through the jejunum is indicated when patients cannot tolerate oral intake or gastric feeding. While multiple approaches for feeding jejunal access exist, few studies have compared the efficacy of these techniques. The purpose of this study was to investigate the long-term durability, re-intervention rates, and nutritional outcomes following percutaneous endoscopic gastrostomy tubes with jejunal extension tubes (PEG-JET) versus laparoscopic jejunostomy tubes (j-tubes). METHODS: Retrospective chart review was performed on all patients who underwent PEG-JET or laparoscopic jejunostomy tube placement from January 2005 through December 2015 at our institution. Thirty-day and long-term outcomes were compared between the two groups. RESULTS: A total of 105 patients underwent PEG-JET and 307 patients underwent laparoscopic j-tube placement during the defined study period. In terms of 30-day outcomes, patients who underwent PEG-JET placement were significantly more likely to experience a tube dislodgement event (p = 0.005) and undergo a re-intervention (p < 0.001). Patients who had a laparoscopic j-tube placed were significantly more likely to meet their enteral feeding goals (p = 0.002) and less likely to require nutritional supplementation with total parenteral nutrition (TPN) (p < 0.001). With regard to long-term outcomes, patients who underwent PEG-JET placement were significantly more likely to experience tube occlusion (p < 0.001) and require an endoscopic or surgical tube re-intervention (p < 0.001). Patients who underwent laparoscopic j-tube placement were significantly more likely to experience a tube site leak (p = 0.015) but were less likely to require nutritional supplementation with TPN (p = 0.001). CONCLUSION: Laparoscopic jejunostomy tubes provide more durable long-term enteral access compared to PEG-JET. Consideration should be given to laparoscopic jejunostomy tube placement in eligible patients who cannot tolerate oral intake or gastric enteral feeding.