Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©.

Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.

Laparoscopic management of gastric band erosions: a 10-year series of 49 cases.

BACKGROUND: Intragastric erosion is a rare but major complication of laparoscopic adjustable gastric band (LAGB) surgery for morbid obesity. Many techniques to treat this problem have been described, with little supporting evidence. The authors review their experience with laparoscopic removal of eroded gastric bands. METHODS: The prospectively collected bariatric surgery database of the authors' practice was queried for the period January 2000 until February 2011, and the medical records for all patients with the diagnosis of band erosion were reviewed. Symptoms, time to erosion, interval between diagnosis and treatment, and complications of treatment were reviewed. All patients had undergone laparoscopy, cut-down onto the band, unclasping or division of the band near the buckle, removal of the band, and primary closure of the gastrotomy with omental patch reinforcement. RESULTS: During the study period, 2,097 LAGB operations were performed and 53 (2.53%) of these resulted in intragastric erosion. All the bands placed were LapBands (Allergan, Inc., Irvine, CA, USA). Erosions occurred with 14 of the 10-cm bands, 11 of the Vanguard bands, 14 of the AP Small bands, and 14 of the AP Large bands. Three patients elected to have their revisional surgery elsewhere and thus were lost to follow-up evaluation. One patient declined to have her band removed. The remaining 49 patients were included in the analysis. The mean time from band placement to the diagnosis of erosion was 31.5 months, and the mean time from diagnosis to band removal was 32 days. The mean hospital stay was 4 days. The complications included one postoperative leak, four superficial wound infections, and one pleural effusion. There were no deaths. CONCLUSIONS: This review demonstrates the safety of laparoscopic removal of eroded gastric bands with primary closure and omental patch repair. The time from diagnosis of erosion to treatment can be short, in contrast to endoscopic removal, in which the requirement for further erosion of the band to free the buckle often necessitates delayed treatment.

The effect of surgical volume and the provision of residency and fellowship training on complications of major hepatic resection.

BACKGROUND: Positive volume-outcomes relationships have been demonstrated for hepatic resection using arbitrary criteria to define high-volume centers. The safety of training programs has not been evaluated. The association of surgical volume, as a continuous variable and the influence of a surgical residency and a fellowship program on outcomes after major hepatectomy were determined. METHODS: The Nationwide Inpatient Sample (NIS) was queried from 1998 to 2006. Quantification of patients' comorbidities was made using the Charlson index, and mortality, and complication rates were determined. Institutions' annual case volumes were correlated with risk-adjusted outcomes over time, as well as presence or absence of residency or fellowship training program using logistic regression modeling. RESULTS: A total of 5,298 major hepatectomies were recorded, representing a weighted nationwide total of 26,396 cases. In-hospital unadjusted mortality for the study period was 6%. Adjusting for comorbidities, greater major hepatectomy volume was associated with improvements in the incidence of most measured complications, with plateauing of mortality of between 2% and 3% at approximately 50 cases per year. The mortality rate increased once greater than approximately 70 cases were performed per annum. Hospitals supporting a surgical residency program had lower overall morbidity and mortality. A fellowship program however was not associated with overall lower morbidity and mortality and appeared to result in a higher rate of certain complications. CONCLUSIONS: Greater annual major hepatectomy volume improves outcomes with reduced mortality up to a certain point. The presence of surgical residency program but not a fellowship program is associated with reduced predicted morbidity and mortality.

National trends in esophageal surgery--are outcomes as good as we believe?

INTRODUCTION: Positive volume-outcome relationships in esophagectomy have prompted support for regionalization of care; however, outcomes have not recently been analyzed. This study examines national trends in provision of esophagectomy and reassesses the volume-outcome relationship in light of changing practice patterns and training paradigms. METHODS: The Nationwide Inpatient Sample was queried from 1998 to 2006. Quantification of patients' comorbidities was made using the Charlson Index. Using logistic regression modeling, institutions' annual case volumes were correlated with risk-adjusted outcomes over time, as well as presence or absence of fellowship and residency training programs. RESULTS: A nationwide total of 57,676 esophagectomies were recorded. In-hospital unadjusted mortality fell from 12% to 7%. Adjusting for comorbidities, greater esophagectomy volume was associated with improvements in the incidence of most measured complications, though mortality increased once greater than 100 cases were performed. Hospitals supporting fellowship training or a surgical residency program did not have higher rates of mortality or total complications. CONCLUSIONS: The current national mortality rate of 7% following esophagectomy is higher than is reported in most contemporary case series. A greater annual esophagectomy volume improves outcomes, but only up to a point. Current training paradigms are safe.