American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity.

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity.

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

Gender dysphoria and gender-affirming surgery: The New York state experience.

BACKGROUND: Transgender and gender nonconforming (TGNC) individuals experience incongruence between their self-identified gender versus their birth-assigned sex. In some cases, TGNC patients undergo gender-affirming surgical (GAS) procedures. Although GAS is an evolving surgical field, there is currently limited literature documenting patient characteristics and procedures. Addressing this knowledge gap, this retrospective cohort analysis described the characteristics of New York State's TGNC residents with gender dysphoria (GD) diagnosis, including patients undergoing at least one gender-affirming surgical procedure. METHODS: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2002 to 2018, we identified patients' first-time TCNC records and their risk characteristics. Patients who received GAS procedures were sub-classified as top-only, bottom-only, or combined top/bottom procedures and were compared with TGNC patients who did not receive GAS. RESULTS: Of 24,615 records extracted from TGNC SPARCS database, 11,427 (46.4%) were transmasculine (female-to-male) and 13,188 (53.6%) were transfeminine (male-to-female). Overall, 2.73% of transgender patients received at least one GAS procedure. Of these patients, 78.2% had masculinizing and 21.8% had feminizing surgeries. After a diagnosis of GD, the positive predictors for a GAS-based procedure included female birth sex, pediatric age (<18 years) or older age (60+ years), commercial insurance coverage, and Hispanic race. In contrast, negative GAS predictors included male birth sex and government insurance coverage (i.e., Medicare and Medicaid). CONCLUSIONS: Compared with transgender women, transgender men were more likely to receive at least one GAS procedure. Because the race, ethnicity, and payor status of TGNC patients can impact GAS treatment rates, additional research is warranted to examine post-diagnosis GAS treatment disparities among TGNC patients.

Efficacy of Bowel Regimen in Decreasing Postoperative Constipation in Bariatric Surgery Patients.

PURPOSE: Postoperative constipation after bariatric surgery is a common complaint, decreasing patient quality of life. No literature exists examining the efficacy of a preoperative bowel regimen in reducing postoperative constipation in this cohort. This study aims explore the efficacy of a well-established bowel regimen, polyethylene glycol (PEG), in reducing constipation frequency and severity after bariatric surgery. METHODS: This was a retrospective study of adult patients undergoing primary and revisional bariatric procedures. The use of PEG bowel prep for bariatric patients was introduced as an institutional quality improvement measure. Patients during the first 3 months after PEG implementation were surveyed for postoperative constipation. For the year after implementation, patients were followed for 30-day emergency room visits or hospitalization secondary to constipation. This cohort was compared to historical controls from the previous year. Student t-tests were used for statistical analysis. RESULTS: During the 3-month exploratory phase, 28/49 (57.14%) patients fully completed the bowel regimen. In total, 0/56 (0%) patients reported preoperative constipation, and 5/28 (17.9%) patients reported constipation at the 3-week follow-up. In the 1 year post-implementation cohort, 2/234 (0.85%) patients had constipation-related occurrences at 30-day follow-up, compared to 8/219 patients (3.65%) in the historical cohort (p = 0.04). CONCLUSIONS: The implementation of a PEG-based bowel regimen did not eliminate self-reported constipation. However, there were significant differences in rates of constipation-related ED visits and hospital readmissions, suggesting that the bowel regimen decreases rates of severe constipation. Finally, patient compliance was limited. Future work should aim towards increasing compliance.

Effect of gender discordance on surgical outcomes in predominantly female patient surgeries in NYS.

BACKGROUND: Preliminary evidence demonstrates female surgeons have improved post-operative outcomes compared to male colleagues despite underrepresentation in surgery. This study explores the effect of patient-surgeon gender discordance on outcomes in three specialties with high female patient populations: bariatric, foregut, colorectal. METHODS: This is a retrospective study using the New York State (NYS) SPARCS database and first study evaluating outcomes based on surgeon/patient concordance in NYS. Bariatric, foregut, and colorectal surgery cases from 2013 to 2017 were identified. RESULTS: Bariatric: female patients (FP) with CC had lower 30-day readmissions but higher complications compared with DC. Male patients (MP) with CC trended towards higher 30-day readmissions but lower complications compared with DC. FP received significantly better influence from CC in 30-day readmission, but disadvantages in complications. There was no significant difference in LOS or ED visits between CC and DC groups for either FP or MP. Foregut: FP with CC had lower LOS, 30-day readmissions, and 30-day ED visits compared with DC. MP showed opposite trends between CC and DC, although non-significant. The benefit from concordance was pronounced in FP compared to MP in LOS, 30-day readmissions, and 30-day ED visit. Concordance vs discordance did not significantly affect complications within either FP or MP group. Colorectal: the difference between CC and DC was not significant within FP or MP groups in any outcomes. When comparing the difference of 30-day readmissions in CC vs DC between FP and MP, there is a significant difference. CONCLUSION(S): Overall, our results show DC between patient and surgeon has significant effect on patient outcomes. A negative effect is seen for female patients in certain specialties, most pronounced in foregut surgery. This emphasizes need for surgeons to be conscious of care provided to opposite gender patients and underscores increasing female surgeons in high FP fields.

The impact of interval cholecystectomy timing after percutaneous transhepatic cholecystostomy on post-operative adverse outcomes.

OBJECTIVE: This study aims to explore how timing of interval of cholecystectomy (IC) after percutaneous transhepatic cholecystostomy tube (PTC) placement impacts post-operative outcomes. METHODS: A retrospective database analysis of New York State SPARCs database of IC between 2005 and 2015. The timing for IC ranged between > 1 week and < 2 years. Patients undergoing this procedure were further divided into quartiles using 4-time intervals; 1-5 weeks (Q1), 5-8 weeks (Q2), 8-12 weeks(Q3), and > 12 weeks(Q4). The study's primary outcome was hospital length of stay (LOS). Secondary outcomes included discharge status, 30-day readmission, 30-day ED visit, and 90-day reoperation, surgery type, complication, and bile duct injury. Multivariable regression models were used to compare patients across the four-time intervals after adjusting for confounding factors. RESULTS: A total of 1038 patients with a history of PTC followed by IC between > 1 week and < 2 years were included in the final analysis. The median time to IC was 7.7 weeks. Q2 and Q3 both had a significantly higher median LOS of 3 days versus Q1 and Q4 at median of 5 days (p < 0.0001). Patients from racial and ethnic minorities (e.g., African Americans and Hispanics) were more likely to get their IC after 12 weeks (p < 0.05). Further, Black patients had a significantly higher median LOS than White, non-Hispanic patients (8 days vs 4 days, p < 0.0001) and were more likely to have open procedure. Multivariable regression analysis identified shorter LOS during Q2 (Ratio, 0.76, 95%, 0.67-0.87, p < 0.0001), and Q3 (Ratio 0.75, 95% CI, 065-0.86, p < 0.0001) compared to those who got their IC in Q4. Similar findings exist when comparing Q2 and Q3 to those receiving treatment during Q1. CONCLUSION: A time interval of 5-12 weeks between PTC and IC was associated with a decreased LOS. This study also suggests the persistence of racial disparities among these patients.

Demographic and practice patterns among minimally invasive surgery fellowship graduates.

INTRODUCTION: Previous reports show that over 85% of general surgery residents choose to pursue fellowship training after completing residency. There continues to be an increase interest among general surgery residents in minimally invasive surgery (MIS) fellowship. Moreover, demographic disparities, particularly gender disparities continue to persist among surgical sub-specialties. In this study, we evaluated the gender disparities and practice patterns among graduating MIS fellows. METHODS AND PROCEDURES: MIS fellows were surveyed, and 169 results were received from fellows who completed training in the years: 2010, 2015-2019. Surveys collected were used to create a descriptive analysis of the demographics, practice patterns and job finding measures. Loglinear regression model was performed to assess gender trend variation over training years. RESULTS: Fellows self-reported gender showed 65% male, 30% female, and 5% prefer not to say. The cohort of participants was described as 45.3% white, 5.3% African American, and 6.5% Hispanic or Latino. Further, results showed 87.1% of fellows work in MIS surgery with 91.8% reporting their fellowship experience facilitated their ability to find a job. Most alumni pursue a comprehensive MIS practice. Moreover, the proportion of female fellows increased from 29 to 41%, but this increase over time was not significant using loglinear regressions [p-value = 0.0810, Relative risk = 1.1994 (95% CI 0.9778, 1.4711)]. CONCLUSION: Overall, there is good evidence to support that fellowship training facilitates future career advancements. Further, MIS fellows have differential practice patterns. Finally, females remain underrepresented among the MIS fellows which should call for leadership action to bridge these gaps.

Internal hernia trends following gastric bypass surgery.

BACKGROUND: Internal hernia is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGB), with reported rates ~ 5% within three months to three years after surgery. Internal hernia through a mesenteric defect can lead to small bowel obstruction. Mesenteric defects began to be more routinely closed, often considered standard practice by 2010. To our knowledge, there are no large population-based studies looking at rates of internal hernia post-LRYGB. This study utilizes a statewide database to characterize the trends of internal hernia post-LRYGB over the last two decades in multiple centers. METHODS: LRYGB procedure records between January 2005 and September 2015 were extracted from the New York SPARCS database. Exclusion criteria included age < 18, in-hospital deaths, bariatric revision procedures, and internal hernia repair during the same hospitalization as LRYGB. Time to internal hernia was calculated from initial LRYGB hospital stay to admission date of the first internal hernia repair record. A multivariable proportional sub-distribution hazards model was utilized to analyze the trend of internal hernia incidence within three-year post-LRYGB. RESULTS: 46,918 patients were identified between 2005 and 2015, with 2950 (6.29) undergoing internal hernia repair post-LRYGB by the end of 2018. The cumulative incidence of internal hernia repair at the 3rd-year post-LRYGB was 4.80% (95% CI: 4.59%-5.02%). By the end of the 13th year, the longest follow-up period, the cumulative incidence was 12.00% (95% CI: 11.30%-12.70%). Overall, there was a decreasing trend over time of undergoing internal hernia repair within three-year post-LRYGB (HR = 0.94, 95% CI: 0.93-0.96), after adjusting for confounding factors. CONCLUSION: This multicenter study maintains the rate of internal hernia following LRYGB reported in smaller studies and provides a longer follow-up period demonstrating decreasing occurrences of internal hernia after bypass as a function of year of index operation. This data is important as internal hernia continues to be a complication post-LRYGB.

SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM).

BACKGROUND: Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM. METHODS: Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research. RESULTS: The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence. CONCLUSIONS: These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.

An American Board of Surgery Pilot of Video Assessment of Surgeon Technical Performance in Surgery.

OBJECTIVE: The American Board of Surgery (ABS) sought to investigate the suitability of video-based assessment (VBA) as an adjunct to certification for assessing technical skills. BACKGROUND: Board certification is based on the successful completion of a residency program coupled with knowledge and reasoning assessments. VBA is a new modality for evaluating operative skills that have been shown to correlate with patient outcomes after surgery. METHODS: Diplomates of the ABS were initially assessed for background knowledge and interest in VBA. Surgeons were then solicited to participate in the pilot. Three commercially available VBA platforms were identified and used for the pilot assessment. All participants served as reviewers and reviewees for videos. After the interaction, participants were surveyed regarding their experiences and recommendations to the ABS. RESULTS: To the initial survey, 4853/25,715 diplomates responded. The majority were neither familiar with VBA, nor the tools used for operative assessments. Two hundred seventy-four surgeons actively engaged in the subsequent pilot. One hundred sixty-nine surgeons completed the postpilot survey. Most participants found the process straightforward. Of the participants, 74% felt that the feedback would help their surgical practice. The majority (81%) remain interested in VBA for continuing medical education credits. Using VBA in continuous certification could improve surgeon skills felt by 70%. Two-thirds of participants felt VBA could help identify and remediate underperforming surgeons. Identified barriers to VBA included limitations for open surgery, privacy issues, and technical concerns. CONCLUSIONS: VBA is promising as an adjunct to the current board certification process and should be further considered by the ABS.

Surgical approach to microwave and radiofrequency liver ablation for hepatocellular carcinoma and colorectal liver metastases less than 5 cm: a systematic review and meta-analysis.

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the two most common malignant neoplasms of the liver. The objective of this study was to assess outcomes of surgical approaches to liver ablation comparing laparoscopic versus percutaneous microwave ablation (MWA), and MWA versus radiofrequency ablation (RFA) in patients with HCC or CRLM lesions smaller than 5 cm. METHODS: A systematic review was conducted across seven databases, including PubMed, Embase, and Cochrane, to identify all comparative studies between 1937 and 2021. Two independent reviewers screened for eligibility, extracted data for selected studies, and assessed study bias using the modified Newcastle Ottawa Scale. Random effects meta-analyses were subsequently performed on all available comparative data. RESULTS: From 1066 records screened, 11 studies were deemed relevant to the study and warranted inclusion. Eight of the 11 studies were at high or uncertain risk for bias. Our meta-analyses of two studies revealed that laparoscopic MW ablation had significantly higher complication rates compared to a percutaneous approach (risk ratio = 4.66; 95% confidence interval = [1.23, 17.22]), but otherwise similar incomplete ablation rates, local recurrence, and oncologic outcomes. The remaining nine studies demonstrated similar efficacy of MWA and RFA, as measured by incomplete ablation, complication rates, local/regional recurrence, and oncologic outcomes, for both HCC and CRLM lesions less than 5 cm (p > 0.05 for all outcomes). There was no statistical subgroup interaction in the analysis of tumors < 3 cm. CONCLUSION: The available comparative evidence regarding both laparoscopic versus percutaneous MWA and MWA versus RFA is limited, evident by the few studies that suffer from high/uncertain risk of bias. Additional high-quality randomized trials or statistically matched cohort studies with sufficient granularity of patient variables, institutional experience, and physician specialty/training will be useful in informing clinical decision making for the ablative treatment of HCC or CRLM.

The durability of revisional sleeve gastrectomy and Roux-en-Y gastric bypass after previous adjustable gastric band.

BACKGROUND: Patients with adjustable gastric banding (AGB) often require revision to one-stage or two-stage sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). OBJECTIVE: To compare the long-term durability of revisional SG and RYGB, in terms of subsequent revision or conversion (RC). METHODS: The New York Statewide Planning and Research Cooperative Systems dataset was queried from 2006 to 2013 for patients who underwent primary SG and RYGB, one-stage, and two-stage conversion from AGB to SG and RYGB. Patients who required RC were identified. A multivariable Cox proportional hazard model was used to compare the RC risk among these groups. RESULTS: 13,749 had primary SG, 621 one-stage, and 321 two-stage AGB to SG. 31,814 had primary RYGB, 555 one-stage, and 248 two-stage AGB to RYGB. The estimated 5-year cumulative RC incidence rate was significantly lower after primary surgery than after prior AGB (one-stage AGB to SG 14.4%, two-stage AGB to SG 11.6%, primary SG 5.2%, one-stage AGB to RYBG 3.4%, two-stage AGB to RYGB 2.9%, and primary RYGB 1.1%, p-value < 0.0001). RYGB and SG did not differ significantly in terms of the elevation effect of one- and two-stage AGB conversion over primary surgeries (RYGB vs SG: one stage vs primary ratio of HR = 0.97, 95% CI = [0.58, 1.63], p-value = 0.9153; two stage vs primary ratio of HR = 1. 02, 95% CI = [0.50, 2.07], p-value = 0.9596). CONCLUSION: RC after AGB to SG or RYGB is more frequent compared to primary surgeries with procedures following AGB to SG being more common than AGB to RYGB. However, that difference was proportionally similar to the RC rate ratio differences noted for primary SG and RYGB.

Implementation of entrustable professional activities into fellowship council accredited programs: a pilot project.

OBJECTIVE: The Fellowship Council (FC) is transitioning to a competency-based medical education (CBME) model, including the introduction of Entrustable Professional Activities (EPAs) for training and assessment of Fellows. This study describes the implementation process employed by the FC during a ten-month pilot project and presents data regarding feasibility and perceived value. METHODS: The FC coordinated the development of EPAs in collaboration with the sponsoring societies for Advanced GI/MIS, Bariatrics, Foregut, Endoscopy and Hepatopancreaticobiliary (HPB) fellowships encompassing the preoperative, intraoperative, and postoperative phases of care for key competencies. Fifteen accredited fellowship programs participated in this project. The assessments were collected through a unique platform on the FC website. Programs were asked to convene a Clinical Competency Committee (CCC) on a quarterly basis. The pilot group met monthly to support and improve the process. An exit survey evaluated the perceived value of EPAs. RESULTS: The 15 participating programs included 18 fellows and 106 faculty. A total of 655 assessments were initiated with 429 (65%) completed. The average (SD) number of EPAs completed for each fellow was 24(18); range 0-72. Intraoperative EPAs were preferentially completed (71%). The average(SD) time for both the fellow and faculty to complete an EPA was 27(78) hours. Engagement increased from 39% of fellows completing at least one EPA in September to 72% in December and declining to 50% in May. Entrustment level increased from 6% of EPAs evaluated as "Practice Ready" in September to 75% in June. The exit survey was returned by 63% of faculty and 72% of fellows. Overall, 46% of fellows and 74% of program directors recommended full-scale implementation of the EPA framework. CONCLUSION: A competency-based assessment framework was developed by the FC and piloted in several programs. Participation was variable and required ongoing strategies to address barriers. The pilot project has prepared the FC to introduce CBME across all FC training programs.

[S073]-The impact of interval appendectomy timing on follow-up adverse outcomes.

OBJECTIVE: This study aims to compare the timing of interval appendectomy (IA) and its impact on post-operative outcomes. METHODS: A retrospective analysis was performed for adult patients diagnosed with appendicitis between 2006 and 2017. IA was defined as a follow-up appendectomy > 1 week and < 2 years after the initial presentation. Time intervals were divided into 4 groups based on patient quartiles: 1-6 weeks, 7-9 weeks, 10-15 weeks, and > 15 weeks. The primary outcome measure was length of stay (LOS). Secondary outcomes included 30-day readmission and IA post-operative complications. Tertiary outcomes included 30-day mortality and colonoscopy suggesting neoplasm or Inflammatory Bowel Disease. RESULTS: A total of 5069 patients' records whose interval appendectomy fell > 1 week and < 2 years after initial presentation were analyzed. Among them, 1006 (19.85%) underwent an initial percutaneous abscess drainage at diagnosis. The median timing for IA was 9.2 weeks. Patients with IA at 1-6 weeks were more likely to have longer LOS when compared to 7-9 weeks (ratio 1.33, 95% CI 1.2-1.48) and 10-15 weeks (ratio 1.38, 95% CI 1.25-1.52). IA between 7 and 9 weeks (ratio 0.81, 95% CI 0.73-0.89) and 10-15 weeks (ratio 0.78, 95% CI 0.71-0.86) was associated with significantly shorter LOS compared to those receiving the operation after 15 weeks. Further, patients requiring abscess drainage (ratio 1.2, 95% CI 1.13-1.34) or those with comorbidities (ratio 1.51, 95% CI 1.39-1.63) were more likely to have longer LOS at IA. Socioeconomic and demographic differences including Black, Hispanic, and those with Medicare and Medicaid insurance had a greater LOS after their IA. CONCLUSION: LOS remains lowest among patients undergoing IA between 7-9 weeks and 10-15 weeks after initial appendicitis presentation. Patients with lower socioeconomic status or from racial minorities had a longer LOS after IA.

Socioeconomic disparities in the utilization of primary robotic hernia repair.

OBJECTIVE: This study aimed to examine socioeconomic disparities in the utilization of primary robotic hernia repair (RHR), utilizing statewide population-level data. It was funded by the SAGES Robotic Surgery Research Grant. METHODS AND PROCEDURES: The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was used to identify adult patients who underwent primary open, laparoscopic, and robotic hernia repair (inguinal, femoral, umbilical, ventral) from 2010 through 2016. Utilization trends were compared between the surgical approaches, assessing for difference in age, sex, race, insurance status, and socioeconomic status (as defined by median income for zip code). Multivariable regression models were used with statistical significance set at 0.05. RESULTS: A total of 280,064 patients underwent primary hernia repair: n = 216,892 (77.4%) open, n = 61,037 (21.8%) laparoscopic, and n = 2,135 (0.8%) robotic. After adjusting for confounding variables, senior age (OR 1.01, p = 0.002), male sex (OR 1.35, p < 0.001), and non-Hispanic race (OR 1.3-1.54, p < 0.001) were significantly associated with the use of robotic compared to open or laparoscopic surgery. Additionally, patients with commercial insurance were more likely to undergo RHR compared to those with Medicare (OR 1.32) or Medicaid (OR 1.54) (p < 0.0001). Income was significantly correlated with RHR such that every $10,000 increase in income would increase the odds of having RHR by 6% (OR 1.06, p < 0.0001). Academic facilities were also associated with a significantly higher likelihood of utilizing RHR (OR 1.88, p < 0.0001). CONCLUSION: There are significant socioeconomic disparities in the utilization of robotic compared to laparoscopic or open hernia repair. While the robotic approach is overall increasing in popularity, adoption of new technology should not be limited to specific socioeconomic cohorts of the population. Recognizing these disparities is a necessary first step in providing equal and consistent care.

Laparoscopic Heller Myotomy and Dor Fundoplication.

INTRODUCTION: Achalasia is an esophageal motility disorder characterized by disordered esophageal peristalsis with failed relaxation of the lower esophageal sphincter resulting in a functional obstruction.Treatment can include medical, endoscopic, or surgical interventions. Although none of these are curative, they each offer methods to create esophageal outflow. MATERIALS AND METHODS: This article discusses our preferred surgical technique used for laparoscopic Heller myotomy with Dor fundoplication. This technique has been developed over the author's career. CONCLUSION: The technique discussed provides a safe and effective strategy to manage achalasia.

The impact of bariatric surgery on the risk of coronary revascularization.

BACKGROUND: Metabolic surgery is associated with improved cardiovascular risk profile. Randomized and observational studies exploring the impact of bariatric surgery on follow-up coronary revascularization (CR) as a primary endpoint are limited. OBJECTIVES: To identify the impact of metabolic surgery on the risk of follow-up CR, including percutaneous coronary revascularization (PCI) and coronary artery bypass grafting (CABG) SETTING: Stony Brook Department of Surgery, Stony Brook University Hospital, New York, United States. METHODS: A retrospective analysis was performed for patients with obesity between 2006 and September 2015. Patients were divided into those with history of metabolic surgery and those without. Patient were also stratified by bariatric surgery type. All study groups were followed till 2018 and for at least 3 years to monitor the development of the primary endpoint-any CR including PCI or CABG. RESULTS: The study population with obesity was 515,307 patients; 95,901 with history of surgery versus 419,406 matched patients without. A total of 12,873 (13.4%) with surgery and 51,478 (12.27%) without were lost to follow-up by 2018. The group with history of surgery had a reduced risk of future CR (hazard ratio [HR], .46; 95% confidence interval [CI]: .42-.50; P < .0001), PCI (HR, .45; 95% CI: .41-.49; P < .0001) and CABG (HR, .49; 95% CI:.42-.56; P < .0001). In subgroup analysis, laparoscopic adjustable gastric banding compared with Roux-en-Y gastric bypass (RYGB) was associated with higher follow-up CR (HR, 1.34; 95% CI: 1.11-1.63; P < .01) and PCI (HR, 1.34; 95% CI: 1.07-1.68; P < .05). CONCLUSION: Bariatric surgery is associated with reduced risk of future CR, PCI, and CABG. Upon subgroup analysis, RYGB was associated with reduced risk of PCI and CR.

SAGES 2022 guidelines regarding the use of laparoscopy in the era of COVID-19.

BACKGROUND: SARS-CoV-2 has changed global healthcare since the pandemic began in 2020. The safety of minimally invasive surgery (MIS) utilizing insufflation from the standpoint of safety to the operating room personnel is currently being explored. The aims of this guideline are to examine the existing evidence to provide guidance regarding MIS for the patient with, or suspecting of having, the SARS-CoV-2 as well as the healthcare team involved. METHODS: Systematic literature reviews were conducted for 2 key questions (KQ) regarding the safety of MIS in the setting of COVID-19 pandemic. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria. Evidence-based recommendations were formulated using a narrative synthesis of the literature by subject experts. Recommendations for future research were also proposed. RESULTS: In KQ1, a total of 1361 articles were reviewed, with 2 articles meeting inclusion. In KQ2, a total of 977 articles were reviewed, with 4 articles met inclusions criteria, of which 2 studies reported on the SARS-CoV2 virus specifically. Despite many publications in the field, very little well-controlled and unbiased data exist to inform the recommendations. Of that which is available, it shows that both laparoscopic and open operations in Covid-positive patients had similar rates of OR staff positivity rates; however, patients who underwent laparoscopic procedures had a lower perioperative mortality than open procedures. Also, SARS-CoV-2 particles have been detected in the surgical plume at laparoscopy. CONCLUSION: With demonstrated equivalence of operating room staff exposure, and noninferiority of laparoscopic access with respect to mortality, either laparoscopic or open approaches to abdominal operations may be used in patients with SARS-CoV-2. Measures should be employed for all laparoscopic or open cases to prevent exposure of operating room staff to the surgical plume, as virus can be present in this plume.

The incidence of reintervention and reoperation following Heller myotomy across multiple indications.

INTRODUCTION: Achalasia is a debilitating primary esophageal motility disorder. Heller myotomy (HM) is a first-line therapy for the treatment of achalasia patients who have failed other modalities. Other indications for HM include diverticulum, diffuse esophageal spasm, and esophageal strictures. However, long-term outcomes of HM are unclear. This study aims to assess incidence of reintervention, either endoscopically or through minimally invasive or resectional procedures, in patients who underwent HM in New York State. METHODS: The Statewide Planning and Research Cooperative System (SPARCS) administrative longitudinal database identified 1817 adult patients who underwent HM between 2000 and 2008 for achalasia, esophageal diverticulum, diffuse esophageal spasm, and esophageal strictures, based on ICD-9 and CPT codes. Through the use of unique identifiers, patients requiring reintervention were tracked up to 2016 (for at least 8 years follow-up). Primary outcome was incidence of subsequent procedures following HM. Secondary outcomes were time to reintervention and risk factors for reintervention. RESULTS: Of the 1817 patients who underwent HM, 320 (17.6%) required subsequent intervention. Of the 320 patients, 234 (73.1%) underwent endoscopic reinterventions, 54 (16.9%) underwent minimally invasive procedures, and 32 (10%) underwent resectional procedures as their initial revisional intervention. Of the 234 patients who underwent endoscopic reintervention as their initial revisional procedure, only 40 (16.8%) required subsequent surgical procedures. Over a mean follow-up of 7.0 years, the mean time to a subsequent procedure was 4.3 ± 3.74 years. Reintervention rates after 10 years following HM for achalasia, diverticulum ,and other indication were 24.4%, 12.6%, and 37%, respectively. CONCLUSION: The majority of HM reinterventions were managed solely by endoscopic procedures (60.6%). Heller myotomy remains an excellent procedure to prevent surgical reintervention for achalasia and diverticulum.

Guidelines for the performance of minimally invasive splenectomy.

BACKGROUND: Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear. OBJECTIVE: To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS. METHODS: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations. RESULTS: Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions. CONCLUSIONS: Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.