The utility of self-expanding metal stents in benign biliary strictures- a retrospective case series.

BACKGROUND: Benign biliary strictures can have a significant negative impact on patient quality of life. There are several modalities which can be utilized with the goal of stricture resolution. These techniques include balloon dilatation, placement of multiple plastic stents and more recently, the use of metal stents. The aim of this study was to evaluate the local success of self-expanding metal stents in successfully resolving benign biliary strictures. METHODS: This was a single institution, retrospective case series. Patients included in our study were patients who underwent endoscopic retrograde cholangiopancreatography with placement of self expanding metal stents for benign biliary strictures at our institution between 2016-2022. Patients were excluded for the following: malignant stricture, and inability to successfully place metal stent. Data was evaluated using two-sided t-test with 95% confidence interval. RESULTS: A total of 31 patients underwent placement of 43 self-expanding metal stents and met inclusion criteria. Mean age of patients was 59 ± 10 years, and were largely male (74.2% vs. 25.8%). Most strictures were anastomotic stricture post liver transplant (87.1%), while the remainder were secondary to chronic pancreatitis (12.9%). Complications of stent placement included cholangitis (18.6%), pancreatitis (2.3%), stent migration (20.9%), and inability to retrieve stent (4.7%). There was successful stricture resolution in 73.5% of patients with anastomotic stricture and 33.3% of patients with stricture secondary to pancreatitis. Resolution was more likely if stent duration was > / = 180 days (73.3% vs. 44.4%, p < 0.05). There was no demonstrated added benefit when stent duration was > / = 365 days (75% vs. 60.9%, p = 0.64). CONCLUSIONS: This study demonstrates that self expanding metal stents are a safe and effective treatment for benign biliary strictures, with outcomes comparable to plastic stents with fewer interventions. This study indicates that the optimal duration to allow for stricture resolution is 180-365 days.

Extent of Lymph Node Harvest: A Retrospective Cohort Comparison of Intracorporeal Versus Extracorporeal Anastomosis in Right Hemicolectomy.

Background: Minimally invasive surgery has been demonstrated to have clear advantages in colon cancer management, with a decrease in the morbidity and mortality associated with surgery. With the introduction of intracorporeal anastomosis (ICA), the entire mesenteric dissection and division is performed under vision laparoscopically and may lead to superior lymph node harvest. The aim of our study is to evaluate lymph node harvest in patients undergoing totally laparoscopic right hemicolectomy with ICA compared to laparoscopic-assisted right hemicolectomy with extracorporeal anastomosis (ECA). Methods: This is a single institution retrospective cohort study. Eligible patients underwent laparoscopic right hemicolectomy at our institution between 2012 and 2022. Patients were identified using a hospital database, and surgeon office databases. Patients included underwent laparoscopic right hemicolectomy for neoplastic lesions (colon cancer/unresectable polyps), or benign etiologies. We excluded patients who underwent laparotomy (intra-operative conversion), resection without anastomosis, resection for IBD, or lack of documented lymph node number. Data were compared using two-sided t-test evaluation with a 95% confidence interval. Results: A total of 679 patients were included, 493 ECA (72.6%) and 186 ICA (27.4%). Patient demographics (age, biologic sex, American Society of Anesthesiologists and body mass index) were not significantly different. Lymph node harvest was significantly higher in those with ICA (24 ± 14 versus 21 ± 1, P < .05). In subgroup analysis, this difference was maintained in patients with malignant processes (27 ± 14 versus 23 ± 10, P < .05). Conclusions: In our experience, ICA has higher lymph node harvest in comparison to ECA. This may improve outcomes and options for adjuvant therapies in malignant indications.

Laparoscopic Right Hemicolectomy for Inflammatory Bowel Disease: Is Intracorporeal Anastomosis Feasible? A Retrospective Cohort Comparison Study.

Background: Inflammatory bowel disease (IBD) affects all ages and backgrounds, and many individuals require surgical intervention during their disease course. The adoption of laparoscopic techniques in this patient population has been slow, including intracorporeal anastomosis (ICA). The aim of our study was to determine if ICA was feasible and safe in patients with IBD undergoing laparoscopic right hemicolectomy (LRHC). Methods: This is a retrospective, single institution cohort study of elective and emergent cases of LRHC at a single academic center. Patients included underwent LRHC or ileocolic resection for IBD. Exclusion criteria: conversion to laparotomy, resection without anastomosis, or unconfirmed diagnosis of IBD. Main outcomes studied were anastomotic leak rate, surgical site infection (SSI), postoperative length of stay, 30-day readmission/reoperation, and operative time. Secondary outcomes were incisional hernia rates and rates of disease recurrence. Results: A total of 70 patients were included, 12 underwent ICA and 58 extracorporeal anastomosis. Anastomotic leak rate (intracorporeal 8.3% [n = 1], extracorporeal 8.6% [n = 5], P = .97), and SSI rates (intracorporeal 0%, extracorporeal 6.9% [n = 4], P = .36) were similar. Mean postoperative length of stay, rates of 30-day readmission/reoperation and diagnosis of hernia at 1 year were not significantly different. Rates of IBD recurrence and location of recurrence at 1 year were similar. However, operative time was significantly longer in those undergoing ICA (intracorporeal 187 minutes versus extracorporeal 139 minutes, P = < .05). Conclusions: ICA is a safe option in patients with IBD undergoing LRHC.

Laparoscopic right colectomies with intracorporeal compared to extracorporeal anastomotic techniques are associated with reduced post-operative incisional hernias.

BACKGROUND: Owing to important differences in surgical technique, laparoscopic right colectomy with intracorporeal (ICA) compared to extracorporeal (ECA) anastomotic technique may result in improved patient outcomes. We aimed to compare both techniques according to incisional hernias and other pertinent perioperative characteristics, post-operative complications, and oncologic quality markers. METHODS: All adult patients undergoing laparoscopic right colectomies between 2015 and 2020 at a single institution were included. ICA and ECA techniques were compared based on selected outcomes using univariable and multivariable statistical analyses, as appropriate. Subgroup analyses were restricted to patients with neoplastic indications for surgery and non-urgent operations. RESULTS: A total of 517 patients met inclusion criteria, of which 139 (26.9%) underwent ICA and 378 (73.1%) underwent ECA. ICA and ECA patients had similar baseline characteristics. At two years of follow-up, a lower proportion of ICA patients developed a hernia at the extraction incision (1.5% vs. 7.1%, p = 0.02) and ICA was associated with an 80% reduction in extraction incision hernias (aHR 0.20, p = 0.03). These results were stable through subgroup and sensitivity analyses. Median operative time was longer in the ICA group (186 min vs. 135 min, p < 0.001), but the gap in operative time narrowed during the study period. Median length of stay was one calendar day shorter in the ICA group (3 days vs. 4 days, p = 0.007) and ICA was associated with a 13% decrease in the length of stay (aRR 0.87, p = 0.02). The incidence of superficial wound infections, anastomotic leaks and re-interventions was lower in ICA patients, but this difference was not statistically significant. 90-day unscheduled visits, readmissions, and mortalities were similar across both groups, as were oncologic outcomes. CONCLUSION: Laparoscopic right colectomies with intracorporeal anastomoses are associated with a reduction in incisional hernias and shorter hospital lengths of stay without compromising on patient safety or oncologic principles.

Bariatric Center Designation and Outcomes Following Repeat Abdominal Surgery in Bariatric Patients.

INTRODUCTION: Repeat abdominal surgery in the bariatric surgery patient population may be challenging for non-bariatric-accredited institutions. The impact of regionalized bariatric care on clinical outcomes for bariatric surgery patients requiring repeat abdominal surgery is currently unknown. This study aims to investigate the association between bariatric center designation and clinical outcomes following hepatobiliary, hernia, and upper and lower gastrointestinal operations among patients with prior bariatric surgery. METHODS: This is a cohort study of a large sample of Ontario residents who underwent primary bariatric surgery between 2010 and 2017. A comprehensive list of eligible abdominal operations was captured using administrative data. The primary outcome was 30-d complications. Secondary outcomes included 30-d mortality, readmission, and length of stay. RESULTS: Among the 3301 study patients, 1305 (40%) received their first abdominal reoperation following bariatric surgery at a designated bariatric center. Nonbariatric center designation was not associated with significantly higher rates of 30-d complications (5.73% versus 5.72%), mortality (0.80% versus 0.77%), readmissions (1.11% versus 1.85%), or median postoperative length of stay (4 versus 4 d). After grouping the category of reoperations, upper gastrointestinal (odds ratio [OR] 0.66, confidence interval [CI] 0.39-1.11) and abdominal wall hernia surgery (OR 0.52, CI 0.27-0.99) showed a lower adjusted OR for complications among bariatric centers. CONCLUSIONS: Our study demonstrates that after adjustment for case-mix and patient characteristics, bariatric surgery patients undergoing repeat abdominal surgery at nonbariatric centers is not associated with higher proportion of complications or mortality. Complex hernia surgery may be considered the most appropriate for referral.

Pilot Evaluation of a Novel, Low-Cost, Simulation Model for Training and Assessment of Laparoscopic Intracorporeal Continuous Suturing.

Background: Laparoscopic intracorporeal continuous suturing is being employed in a growing number of minimally invasive procedures. However, there is a lack of adequate bench models for gaining proficiency in this complex task. The purpose of this study was to assess a novel simulation model for running suture. Methods: Participants were grouped as novice (LSN) or expert (LSE) at laparoscopic suturing based on prior experience and training level. A novel low-cost bench model was developed to simulate laparoscopic intracorporeal continuous closure of a defect. The primary outcome measured was time taken to complete the task. Videos were scored by independent raters for Global Operative Assessment of Laparoscopic Skills (GOALS). Results: Sixteen subjects (7 LSE and 9 LSN) participated in this study. LSE completed the task significantly faster than LSN (430 ± 107 vs 637 ± 164 seconds, P ≤ .05). LSN scored higher on accuracy penalties than LSE (Median 30 vs 0, P ≤ .05). Mean GOALS score was significantly different between the 2 groups (LSE 20.64 ± 2.64 vs LSN 14.28 ± 1.94, P < .001) with good inter-rater reliability (ICC ≥ .823). An aggregate score using the formula: Performance Score = 1200-time(sec)-(accuracy penalties x 10) was significantly different between groups with a mean score of 741 ± 141 for LSE vs 285 ± 167 for LSN (P < .001). Conclusion A novel bench model for laparoscopic continuous suturing was able to significantly discriminate between laparoscopic experts and novices. This low-cost model may be useful for both training and assessment of laparoscopic continuous suturing proficiency.

Cost analysis of indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery.

BACKGROUND: Indocyanine green, near infrared, fluorescence angiography (ICG-FA) is increasingly adopted in colorectal surgery for intraoperative tissue perfusion assessment to reduce anastomotic leakage rates. However, the economic impact of this intervention has not been investigated. This study is a cost analysis of the routine use of ICG-FA in colorectal surgery from the hospital payer perspective. METHODS: A decision analysis model was developed for colorectal resections considering two scenarios: resection without using ICG-FA and resection with intraoperative ICG-FA for anastomotic perfusion assessment. Incorporated into the model were the costs of ICG agent, fluorescence angiography equipment, surgery, anastomotic leak, and the leak rates with and without ICG-FA. All input data were derived from recent publications. RESULTS: The routine use of ICG-FA for colorectal anastomosis is cost saving when cost analysis is performed using the following base case assumptions: 8.6% leak rate without ICG-FA, odds ratio of 0.46 for reduction of leakage with ICG-FA (4.8% leak rate relative to 8.6% base case), cost of ICG-FA of $250, and incremental cost of leak, not requiring reoperation, of $9,934.50. In one-way sensitivity analyses, routine use of ICG-FA was cost saving if the cost of an anastomotic leak is more than $5616.29, the cost of ICG-FA is less than $634.44, the leak rate (without ICG-FA) is higher than 4.9%, or the odds ratio for reduction of leak with ICG-FA is less than 0.69. There is a per-case saving of $192.22 with the use of ICG-FA. CONCLUSION: Using the best available evidence and most conservative base case values, routine use of ICG-FA in colorectal surgery was found to be cost saving. Since the evidence suggests there is a reduction in leak rate, the routine use of ICG-FA is a dominating strategy. However, the overall quality of evidence is low and there is a clear need for prospective, randomized controlled trials.

Video Context Improves Performance in Identifying Operative Planes on Static Surgical Images.

BACKGROUND: Correct identification of the surgical tissue planes of dissection is paramount at the operating room, and the needed skills seem to be improved with realistic dynamic models rather than mere still images. The objective is to assess the role of adding video prequels to still images taken from operations on the precision and accuracy of tissue plane identification using a validated simulation model, considering various levels of surgeons' experience. METHODS: A prospective observational study was conducted involving 15 surgeons distributed to three equal groups, including a consultant group [C], a senior group [S], and a junior group [J]. Subjects were asked to identify and draw ideal tissue planes in 20 images selected at suitable operative moments of identification before and after showing a 10- second videoclip preceding the still image. A validated comparative metric (using a modified Hausdorff distance [%Hdu] for object matching) was used to measure the distance between lines. A precision analysis was carried out based on the difference in %Hdu between lines drawn before and after watching the videos, and between-group comparisons were analyzed using a one-way analysis of variance (ANOVA). The analysis of accuracy was done on the difference in %Hdu between lines drawn by the subjects and the ideal lines provided by an expert panel. The impact of videos on accuracy was assessed using a repeated-measures ANOVA. RESULTS: The C group showed the highest preciseness as compared to the S and J groups (mean Hdu 9.17±11.86 versus 12.1±15.5 and 20.0±18.32, respectively, p <0.001) and significant differences between groups were found in 14 images (70%). Considering the expert panel as a reference, the interaction between time and experience level was significant ( F (2, 597) = 4.52, p <0.001). Although the subjects of the J group were significantly less accurate than other surgeons, only this group showed significant improvements in mean %Hdu values after watching the lead-in videos ( F (1, 597) = 6.04, p = 0.014). CONCLUSIONS: Adding video context improved the ability of junior trainees to identify tissue planes of dissection. A realistic model is recommended considering experience-based differences in precision in training programs.

Colonic displacement as a marker of endoscopic skill: development of a novel tool for endoscopy training.

BACKGROUND: Colonoscopy is a technically challenging procedure. The colonoscope is prone to forming loops in the colon, which can lead patient discomfort and even perforation. We hypothesized that expert endoscopists use techniques to avoid loop formation, identify and straighten loops earlier, and thus exert less force. METHODS: Using a commercially available physical colon simulator model (Kyoto Kagaku), electromagnetic tracking markers (NDI Medical) were placed along the mobile segments of the colon (sigmoid, transverse) to measure the degree of displacement of the colon as the scope was advanced to the cecum. The colon model was set for each participant to simulate a redundant alpha loop in the sigmoid colon. Gastroenterology and surgical trainees and attendings were assessed. Demographic data were collected for each participant. RESULTS: Seventy-five participants were enrolled in the study. There were 17 (22.7%) attending physicians, and 58 (77.3%) trainees. Attending physicians advanced the scope to the cecum faster. The mean time required for procedure completion was 360.5 s compared to 178.4 s for the trainee and attending groups respectively (mean difference: 182.1 s, 95% CI: 93.0, 269.7; p = 0.0002). Attending physicians exerted significantly lower mean colonic displacement than trainees. The mean colonic displacement was 79.8 mm for the trainee group and 57.9 mm for the attending group (mean difference: 21.9 mm, 95% CI: 2.6, 41.2; p = 0.04). Those who used torque steering caused lower maximum colonic displacement than those who used knob steering. CONCLUSION: Attending physicians advance the scope during colonoscopy in a manner that results in significantly less colonic displacement than resident trainees. Although prior studies have shown a difference in force application between endoscopists and inexperienced students, ours is the first to differentiate across varying degrees of endoscopic skill. Future studies will define metrics for incorporation into endoscopic training curricula, focusing on techniques that encourage safety and comfort for patients.

Safety of Same-day Discharge in High-risk Patients Undergoing Ambulatory General Surgery.

BACKGROUND: Same-day surgery is an increasingly utilized and cost-effective strategy to manage common surgical conditions. However, many institutions limit ambulatory surgical services to only healthy individuals. There is also a paucity of data on the safety of same-day discharge among high-risk patients. This study aims to determine whether same-day discharge is associated with higher major morbidity and readmission rates compared with overnight stay in high-risk general surgery patients. METHODS: This is a retrospective cohort using the data from the National Surgical Quality Improvement Program from 2005 to 2017. Patients with an American Society of Anesthesiologists class ≥3 undergoing general surgical procedures amenable to same-day discharge were identified. Primary and secondary outcomes were major morbidity and readmission at 30 d. A multivariable logistic regression model using mixed effects was used to adjust for the effect of same-day discharge. RESULTS: Of 191,050 cases, 137,175 patients (72%) were discharged on the same day. At 30 d, major morbidity was 1.0%, readmission 2.2%, and mortality <0.1%. Adjusted odds ratio of same-day discharge was 0.59 (95% confidence interval 0.54-0.64; P < 0.001) for major morbidity and 0.75 (95% confidence interval 0.71-0.80; P < 0.001) for readmission. Significant risk factors for morbidity and readmission included nonindependent functional status, ascites, renal failure, and disseminated cancer. CONCLUSIONS: Major morbidity and readmission rates are low among this large sample of high-risk general surgery patients undergoing common ambulatory procedures. Same-day discharge was not associated with increased adverse events and could be considered in most high-risk patients after uncomplicated surgery.

Access to bariatric surgery among older patients in a publicly funded regionalized care system.

BACKGROUND: Bariatric surgery in older patients is safe and effective. Current guidelines do not endorse age limits for surgery; however, older patients may encounter difficulties with access given perceived risks. This study compares the adjusted probability of failing to receive bariatric surgery between older (≥ 60 years) and younger (< 60 years) patients referred to a publicly funded program. STUDY DESIGN: This is a retrospective cohort study of adult patients referred to a bariatric surgery program in Ontario from 2010-2016. Ontario health administrative databases and the Ontario Bariatric Registry were used for the analysis. The primary outcome was receipt of bariatric surgery within 3 years of referral. A multivariable logistic regression analysis was performed to determine the adjusted effect of older age (≥ 60 years) on the probability of not receiving surgery. Sensitivity analysis was performed using only healthy patients. RESULTS: Among 19,510 patients referred to the program, 1,795 patients (9.2%) were ≥ 60 years old, of which 60% received bariatric surgery within 3 years compared to 90% in younger patients. The odds older patients do not receive surgery after adjustment were significantly higher compared to younger patients (OR 1.69 [1.52-1.88], P < .001). This effect persists even among a subgroup of older patients with a Charlson Comorbidity Index = 0 (OR 1.78 [1.56-2.04], P < .001). CONCLUSIONS: Age alone, rather than comorbidities had a more significant effect on the access to bariatric surgery in older patients. Given the demonstrated benefits of bariatric surgery in older populations, ensuring equity in access to bariatric surgery should be encouraged. Future research is required to explore the underlying reasons why older patients who could benefit from bariatric surgery may not have the opportunity.

Interventional radiology-assisted transgastric endoscopic drainage of peripancreatic fluid collections.

Summary: Peripancreatic fluid collections (PFCs) occur as a consequence of pancreatitis. Most PFCs resolve spontaneously, although 1%-2% persist and may require intervention. Conventional transluminal endoscopic drainage methods require the PFC to be bulging into the gastric wall; however, it is not uncommon for this to be absent. Imaging guidance for transluminal endoscopic PFC drainage allows the endoscopist to localize nonbulging pseudocysts that cannot be localized using endoscopy alone, to identify and avoid vascular structures between the cyst and the gastric lumen, and to reveal solid or necrotic components within the pseudocyst cavity. Although endoscopic ultrasound (EUS) has been used to meet this need, timely access to therapeutic EUS remains a limiting factor at many centres. We report our technique and experience performing transgastric endoscopic drainage of PFCs under computed tomography (CT) interventional radiology guidance.

Operating during COVID-19: Is there a risk of viral transmission from surgical smoke during surgery?

Summary: The World Health Organization declared a pandemic when coronavirus disease 2019 (COVID-19) started to sweep the globe. Growing concerns for the safety of health care workers was raised when up to 80% of people with COVID-19 showed mild or no symptoms at all. Some surgical procedures will be inevitable during the pandemic, and proper safety measures must be in place to avoid transmission risks. Surgical smoke is a common by-product from the use of energy devices in the operating room. The effects of surgical smoke have been studied for more than 40 years, and potential health hazards have been reported. Chemicals, carcinogens and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. To ensure the safety of operating room personnel, we must consider whether there is any concern of viral transmission from the inhalation of surgical smoke.

Correlation of surgical trainee performance on laparoscopic versus endoscopic simulation.

BACKGROUND: Both laparoscopy and endoscopy are image-based procedures, which are less intuitive than traditional open surgery and require extensive training to reach adequate proficiency. Currently, there is lack of understanding as to how the skills in one image-based procedure translate to another, such as endoscopy to laparoscopy and vice versa. The aim of our study was to explore the relationship between endoscopic and laparoscopic skills using a Fundamentals of Laparoscopic Surgery (FLS) trainer, a traditional virtual reality endoscopic trainer and a "desk-top" endoscopic physical simulator. METHODS: Senior surgical residents from across Canada participating in an advanced laparoscopic foregut training course were enrolled in the study. Participants were assessed performing the FLS laparoscopic suturing task, the Endobubble 2 task (Simbionix, GI Mentor), and a forward viewing peg transfer on the novel Basics in Endoscopic Skills Training Box (BEST Box). RESULTS: There was significant correlation between the participant's skill in simulated laparoscopic suturing and simulated endoscopic skill using the BEST box (Pearson coefficient (r) was 0.551 (p = 0.033) and the coefficient of determination (r2) was 0.304). There was a trend towards correlation between laparoscopic suturing time and Endobubble 2 score, but this did not reach statistical significance (r = 0.458, p = 0.086; r2 = 0.210). CONCLUSIONS: Performance in the two physical simulators, laparoscopic suturing and simulated flexible endoscopy using the BEST box, showed a correlation. This study adds to the growing body of evidence that laparoscopic and endoscopic skills are complementary and has the potential to impact simulation training involving both skill sets.

Management of colonoscopic perforation: a systematic review and treatment algorithm.

BACKGROUND: The aim of this review is to evaluate and summarize the current strategies used in the management of colonoscopic perforations as well as propose a modern treatment algorithm. METHODS: Articles published between January 2004 and January 2019 were screened. A total of 167 reports were identified in combined literature search, of which 61 articles were selected after exclusion of duplicate and unrelated articles. Only studies that reported on the management of endoscopic perforation in an adult population were retrieved for review. Case reports and case series of 8 patients or less were not considered. Ultimately, 19 articles were considered eligible for review. RESULTS: A total of 744 cases of colonoscopic perforations were reported in 19 major articles. The cause of perforation was mentioned in 16 articles. Colonoscopic perforations were reported as a consequence of diagnostic colonoscopies in 222 cases and therapeutic colonoscopies in 248 cases. The site of perforation was mentioned in 486 cases. Sigmoid colon was the predominant site followed by the cecum. The management of colonoscopic perforations was reported in a total of 741 patients. Surgical intervention was employed in 75% of the patients, of these 15% were laparoscopic and 85% required laparotomy. The predominant surgical intervention was primary repair. CONCLUSION: Management strategies of colon perforations depend upon the etiology, size, severity, location, available expertise, and general health status. Usually, peritonitis, sepsis, or hemodynamic compromise requires immediate surgical management. Endoscopic techniques are under continuous evolution. Newer developments have offered high success rate with least amount of post-procedure complications. However, there is a need for further studies to compare the newer endoscopic techniques in terms of success rate, cost, complications, and the affected part of colon.

S093: pneumatic balloon dilation for palliation of recurrent symptoms of achalasia after esophagomyotomy.

BACKGROUND: Achalasia is a chronic disease affecting the myenteric plexus of the esophagus and lower esophageal sphincter. Treatment is aimed at palliating symptoms to improve quality of life. Treatment options for symptom relapse after esophagomyotomy include botox injection, repeat myotomy, per-oral endoscopic myotomy, or pneumatic balloon dilation (PBD). Data demonstrating the safety and efficacy of PBD for recurrence are scarce. With a lack of published data, guidelines have suggested avoiding PBD for recurrent achalasia because of concern for a high risk of perforation. METHODS: A retrospective review of patients who underwent PBD for recurrent symptoms of achalasia after esophagomyotomy between 2007 and 2017 was conducted. PBD was performed at 30 mm and held for 60 s under fluoroscopic guidance. Patients with residual symptoms had subsequent dilations at increasing 5 mm increments to a maximum of 40 mm. Patient demographics, Eckardt scores, presence of hiatal hernia, time from myotomy to recurrence, and diagnostic modalities were reported. The primary outcome was need for further endoscopic or surgical intervention. Complications are reported as secondary outcomes. RESULTS: One-hundred eight esophagomyotomies were done during the study period. Fourteen patients underwent PBD for recurrent symptoms. The median time to symptom recurrence after esophagomyotomy was 28 months. The median Eckardt score was 6. Ten of 14 patients had an intervention between the initial surgery and PBD (9 standard dilations and 1 botox injection). A total of 23 PBD were done. Seven patients required dilation at 35 mm and two patients required dilation at 40 mm. Eleven patients required no further intervention at a median follow-up of 27.7 months. There were three treatment failures: one required repeat esophagomyotomy and two had no further treatments. There were no periprocedural complications. CONCLUSION: Serial PBD is safe and effective in treatment of recurrent symptoms of achalasia after esophagomyotomy.

Endoscopic mucosal resection versus esophagectomy for intramucosal adenocarcinoma in the setting of barrett's esophagus.

BACKGROUND: Esophagectomy has been the standard of care for patients with intramucosal adenocarcinoma (IMC) in the setting of Barrett's esophagus. It is, however, associated with significant post-operative morbidity and mortality. Endoscopic mucosal resection (EMR) offers a minimally invasive approach with lesser morbidity. This study investigates the transition from esophagectomy to EMR for IMC with respect to eradication rates, post-operative morbidity, and long-term survival. METHODS: Patients diagnosed with IMC from 2005 to 2013 were identified retrospectively. Beginning in 2009, preferred initial therapy for IMC transitioned from esophagectomy to EMR. Esophagectomy was performed either through a transthoracic or transhiatal technique. EMR was repeated until resolution of IMC on pathology or progression of disease. Continuous data are expressed as mean (SD) and analyzed using Student's t test. Categorical data are presented as number (%) and analyzed using Fisher's exact test. RESULTS: We identified 23 patients; 12 patients underwent esophagectomy and 11 patients underwent EMR as initial therapy. Patients were similar with respects to age, gender, and comorbidity index. Most tumors arose from short segment (vs long segment) Barrett's (esophagectomy: 9 (75%) vs. EMR: 10 (91%), p = 0.59) and one patient in each group had superficial invasion into the submucosa (T1sm1), the remainder having mucosal disease. Esophagectomy was associated with 7 (58%) minor complications and 2 (17%) major complications (respiratory failure, anastomotic leak), whereas there were no complications related to EMR (p < 0.01). EMR successfully eradicated IMC in 10 patients (91%) with one progressing to esophagectomy. Patients required 2 (1) endoscopies to achieve eradication. There was one mortality in each group on long-term follow-up (log-rank test, p = 0.62). CONCLUSIONS: EMR was successful in eradicating IMC in 10/11 patients with similar long-term recurrence and mortality to esophagectomy patients. Patients with IMC may benefit from EMR as initial therapy by obviating the need for a complex and morbid operation.

ALPPS: challenging the concept of unresectability--a systematic review.

INTRODUCTION: Hepatic resection for malignancy is limited by the amount of liver parenchyma left behind. As a result, two-staged hepatectomy and portal vein occlusion (PVO) have become part of the treatment algorithm. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently described as a method to stimulate rapid and profound hypertrophy. MATERIALS AND METHODS: A systematic review of the literature pertaining to ALPPS was undertaken. Peer-reviewed articles relating to portal vein ligation (PVL) and in situ split (ISS) of the parenchyma were included. RESULTS: To date, ALPPS has been employed for a variety of primary and metastatic liver tumors. In early case series, the perioperative morbidity and mortality was unacceptably high. However with careful patient selection and improved technique, many centers have reported a 0% 90-day mortality. The benefits of ALPPS include hypertrophy of 61-93% over a median 9-14 days, 95-100% completion of the second stage, and high likelihood of R0 resection (86-100%). DISCUSSION: ALPPS is only indicated when a two-stage hepatectomy is necessary and the future liver remnant (FLR) is deemed inadequate (<30%). Use in patients with poor functional status, or advanced age (>70 years) is cautioned. Discretion should be used when considering this in patients with pathology other than colorectal liver metastases (CRLM), especially hilar tumors requiring biliary reconstruction. Biliary ligation during the first stage and routine lymphadenectomy of the hepatoduodenal ligament should be avoided. CONCLUSIONS: A consensus on the indications and contraindications for ALPPS and a standardized operative protocol are needed.