A Delphi Method for Development of a Barrett's Esophagus Question Prompt List as a Communication Tool for Optimal Patient-physician Communication.

BACKGROUND METHODS: The question prompt list content was derived through a modified Delphi process consisting of 3 rounds. In round 1, experts provided 5 answers to the prompts "What general questions should patients ask when given a new diagnosis of Barrett's esophagus" and "What questions do I not hear patients asking, but given my expertise, I believe they should be asking?" Questions were reviewed and categorized into themes. In round 2, experts rated questions on a 5-point Likert scale. In round 3, experts rerated questions modified or reduced after the previous rounds. Only questions rated as "essential" or "important" were included in Barrett's esophagus question prompt list (BE-QPL). To improve usability, questions were reduced to minimize redundancy and simplified to use language at an eighth-grade level (Fig. 1). RESULTS: Twenty-one esophageal medical and surgical experts participated in both rounds (91% males; median age 52 years). The expert panel comprised of 33% esophagologists, 24% foregut surgeons, and 24% advanced endoscopists, with a median of 15 years in clinical practice. Most (81%), worked in an academic tertiary referral hospital. In this 3-round Delphi technique, 220 questions were proposed in round 1, 122 (55.5%) were accepted into the BE-QPL and reduced down to 76 questions (round 2), and 67 questions (round 3). These 67 questions reached a Flesch Reading Ease of 68.8, interpreted as easily understood by 13 to 15 years olds. CONCLUSIONS: With multidisciplinary input, we have developed a physician-derived BE-QPL to optimize patient-physician communication. Future directions will seek patient feedback to distill the questions further to a smaller number and then assess their usability.

Esophageal Motility Patterns in Paraesophageal Hernia Patients Compared to Sliding Hiatal Hernia: Bigger Is Not Better.

BACKGROUND: In patients with paraesophageal hernias (PEH), the course of the esophagus is often altered, which may affect esophageal motility. High-resolution manometry (HRM) is frequently used to evaluate esophageal motor function prior to PEH repair. This study was performed to characterize esophageal motility disorders in patients with PEH as compared to sliding hiatal hernia and to determine how these findings affect operative decision-making. METHODS: Patients referred for HRM to a single institution from 2015 to 2019 were included in a prospectively maintained database. HRM studies were analyzed for the appearance of any esophageal motility disorder using the Chicago classification. PEH patients had confirmation of their diagnosis at the time of surgery, and the type of fundoplication performed was recorded. They were case-matched based on sex, age, and BMI to patients with sliding hiatal hernia who were referred for HRM in the same period. RESULTS: There were 306 patients diagnosed with a PEH who underwent repair. When compared to case-matched sliding hiatal hernia patients, PEH patients had higher rates of ineffective esophageal motility (IEM) (p<.001) and lower rates of absent peristalsis (p=.048). Of those with ineffective motility (n=70), 41 (59%) had a partial or no fundoplication performed during PEH repair. CONCLUSION: PEH patients had higher rates of IEM compared to controls, possibly due to a chronically distorted esophageal lumen. Offering the appropriate operation hinges on understanding the involved anatomy and esophageal function of each individual. HRM is important to obtain preoperatively for optimizing patient and procedure selection in PEH repair.

Exploring the Influence of Gender on Surgical Clerkship Grades and Test Scores: A Single Institution, Multisite Comparison.

OBJECTIVE: General surgery remains a male-dominated specialty. Women constitute 54% of medical students at the University of Washington, but only 3.4% of full professors within the Department of Surgery. Many believe surgical attrition and "the leaky pipeline" starts during medical school clerkships, but the exact deterrents remain undefined. This study examined the impact of gender on grading during the third-year surgical clerkship. DESIGN: Retrospective analysis of confidential final clerkship grades, examination scores and subjective clerkship grades was conducted. These were compared by gender, time period, and type of clerkship site. Chi-square analyses were performed. SETTING: Clerkship sites across multiple academic (n = 6) and nonacademic (n = 14) locations. PARTICIPANTS: All third-year medical students undergoing a core surgical clerkship over 2 time periods-2007 to 2010 (period 1) and 2016 to 2019 (period 2)-were included. RESULTS: There were 539 medical students in period 1 and 792 in period 2. The percentage of women was stable over time (52.0% vs 54.2%, p = 0.43). Final clerkship grades of Honors increased significantly from period 1 to 2 (22.3% vs 44.3%, p < 0.0001) and was similarly distributed by gender (women: 21.4% vs 48.0%, p < 0.0001; men 23.2% vs 39.9%, p < 0.0001). Honors on examinations remained stable over time and did not differ by gender. Women earned more final clerkship honors than men at academic sites in period 2 (48.4% vs 30.9%, p < 0.001). This finding was not identified in period 1, nor at nonacademic sites. CONCLUSION: There was a significant increase in surgical clerkship honors over the past decade, independent of gender. Women attained more clinical and final clerkship honors than men and similar exam grades as time progressed, suggesting that gender bias in the subjective grading of women at this institution does not directly contribute to the loss of talented women as they progress from medical student to faculty within the department, with said gender imbalance not related to clerkship evaluations.

The impact of the COVID-19 pandemic on medical student education: Implementation and outcome of a virtual general surgery curriculum.

BACKGROUND: Due to the COVID-19 pandemic, medical schools were forced to adapt clinical curricula. The University of Washington School of Medicine created a hybrid in person and virtual general surgery clerkship. METHODS: The third year general surgery clerkship was modified to a 4-week in person and 2-week virtual clerkship to accommodate the same number of learners in less time. All students completed a survey to assess the impact of the virtual clerkship. RESULTS: The students preferred faculty lectures over national modules in the virtual clerkship. 58.6% indicated they would prefer the virtual component before the in-person experience. There was no change from previous years in final grades or clerkship exam scores after this hybrid curriculum. CONCLUSIONS: If the need for a virtual general surgery curriculum arises again in the future, learners value this experience at the beginning of the clerkship and prefer faculty lectures over national modules.

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.

Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients.

In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.

Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn.

BACKGROUND: Heartburn that persists despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with reflux-reducing medication (e.g., baclofen) or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators (e.g., desipramine). METHODS: Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20 mg of omeprazole twice daily for 2 weeks, and those with persistent heartburn underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the Gastroesophageal Reflux Disease (GERD)-Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at 1 year. RESULTS: A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomization procedures excluded 288 patients: 42 had relief of their heartburn during the 2-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had non-GERD esophageal disorders, and 99 had functional heartburn (not due to GERD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomization. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to that with active medical treatment (7 of 25 patients, 28%; P = 0.007) or control medical treatment (3 of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and the control medical group was 16 percentage points (95% confidence interval, -5 to 38; P = 0.17). CONCLUSIONS: Among patients referred to VA gastroenterology clinics for PPI-refractory heartburn, systematic workup revealed truly PPI-refractory and reflux-related heartburn in a minority of patients. For that highly selected subgroup, surgery was superior to medical treatment. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT01265550.).

Nonerosive reflux disease: clinical concepts.

Esophageal symptoms can arise from gastroesophageal reflux disease (GERD) as well as other mucosal and motor processes, structural disease, and functional esophageal syndromes. GERD is the most common esophageal disorder, but diagnosis may not be straightforward when symptoms persist despite empiric acid suppressive therapy and when mucosal erosions are not seen on endoscopy (as for nonerosive reflux disease, NERD). Esophageal physiological tests (ambulatory pH or pH-impedance monitoring and manometry) can be of value in defining abnormal reflux burden and reflux-symptom association. NERD diagnosed on the basis of abnormal reflux burden on ambulatory reflux monitoring is associated with similar symptom response from antireflux therapy for erosive esophagitis. Acid suppression is the mainstay of therapy, and antireflux surgery has a definitive role in the management of persisting symptoms attributed to NERD, especially when the esophagogastric junction is compromised. Adjunctive approaches and complementary therapy may be of additional value in management. In this review, we describe the evaluation, diagnosis, differential diagnosis, and management of NERD.

Surgical treatments for esophageal cancers.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Barrett's esophagus: surgical treatments.

The following on surgical treatments for Barrett's esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non-GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.

Barrett's esophagus: prevalence and incidence of adenocarcinomas.

The following on prevalence and incidence of adenocarcinomas in Barrett's esphophagus (BE) includes commentaries on the mechanisms of a potential protective effect of proton pump inhibitors (PPIs) on progression of BE to high-grade dysplasia; evaluation of the role of PPIs in decreasing the risk of degeneration; the geographical variations of incidence of BE; the role of the nonmorphologic biomarkers; the relationship between length of BE and development of cancer; the confounding factors in incidence rates of BE; the role of the increase of cell differentiation and apoptosis induced by PPIs in the diminution of cancer risk; the frequency of occult neoplastic foci and unsuspected invasive cancer in surgical specimens; the influence on the indications of endoscopic therapy; the overestimation of regression in surgical series; attempts to evaluate the reasons for variations of cancer incidence in the literature; and progress in screening and surveillance for BE.

High-resolution manometry.

The following presents commentaries on the interest of high-resolution manometry for understanding the anatomy and physiology of the esophagogastric junction; the subtypes of achalasia, as diagnosed by high-resolution manometry; the interest of high-resolution manometry in the evaluation of dysphagia following fundoplication; and the appropriate clinical protocol for high-resolution manometry.

High-resolution manometry in evaluation of factors responsible for fundoplication failure.

BACKGROUND: From 10% to 25% of patients undergoing antireflux procedures eventually redevelop symptoms as a result of anatomic failure of the hiatal repair or fundoplication. High-resolution manometry (HRM) allows for reliable evaluation of the lower esophageal sphincter (LES) in detail, including subtle evidence of a hiatus hernia. The aim of this study was to characterize the dynamics and function of the LES postoperatively using HRM to determine which elements may contribute to recurrent symptoms after antireflux surgery. STUDY DESIGN: Twenty-three patients with recurrent symptoms and/or abnormal 24-hour pH monitoring after Nissen fundoplication (Unsuccessful group) and 11 asymptomatic post-Nissen patients tested as routine follow-up (Successful group) underwent HRM. Tracings were analyzed for percentage of peristalsis, LES pressure, length of the high-pressure zone (HPZ), LES residual pressure, and the presence of a dual HPZ (indicating a recurrent hiatus hernia). Results were compared between the 2 groups. RESULTS: Mean LES pressure tended to be greater in the Successful group compared with the Unsuccessful group (p = 0.068). There were no differences in length of the HPZ, residual pressures, and peristalsis. A dual HPZ was identified in 13 Unsuccessful group patients (56%), and 1 (9%) of the Successful group patients (p < 0.05). Abnormal DeMeester scores were observed in 79% of patients with a dual HPZ, compared with 35% of patients without a dual HPZ (p < 0.05). CONCLUSIONS: The presence of a dual HPZ on HRM in patients after fundoplication appears to be a strong predictor of recurrent gastroesophageal reflux disease. In patients with recurrent symptoms after antireflux surgery, HRM also provides valuable information about peristalsis and LES characteristics that help guide appropriate management.

Expanding surgical clerkships to remote community sites: the success of the Washington, Wyoming, Alaska, Montana, and Idaho experience.

BACKGROUND: The purpose of this analysis was to determine if the surgical clerkship model and site affect educational outcomes and student postclerkship perceptions. METHODS: Data from University of Washington students participating in surgical clerkships at traditional/academic or community/apprentice sites across Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) between 2005 and 2007 were gathered retrospectively. Comparisons of final examination scores as well as postclerkship student evaluations of the educational experience were made between traditional and community training sites. RESULTS: The mean final examination scores at WWAMI sites were significantly higher than those at traditional academic sites. Furthermore, WWAMI sites were rated higher with respect to time spent by faculty in direct observation, quality of the clerkship as a whole, and overall contribution to medical education. CONCLUSIONS: Community surgical clerkship sites remote from an academic institution can provide an excellent learning experience for students.

How I do it: laparoscopic Heller myotomy with Toupet fundoplication for achalasia.

Achalasia, an esophageal motility disorder characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation, is most effectively treated by surgical ablation of the LES. In this report, we describe our technique of laparoscopic extended Heller myotomy with Toupet partial posterior fundoplication. The technical details of this procedure include careful division of the longitudinal and circular muscle fibers of the LES anteriorly, including extension of the myotomy 3 cm distal to the esophagogastric junction onto the gastric cardia. The Toupet procedure, involving a posterior wrap of the gastric fundus which is secured to both edges of the myotomy as well as to the crura of the hiatus, is added to prevent post-myotomy gastroesophageal reflux. From a recently published report, mean dysphagia scores remained low (3 out of 10 severity on a visual analog scale) and symptoms of reflux were reported minimally in a series of 63 patients followed for a median of 45 months. This technique provides excellent and durable relief of dysphagia associated with achalasia while minimizing post-myotomy acid reflux symptoms.

Complications of PTFE mesh at the diaphragmatic hiatus.

Paraesophageal hernia repair has been associated with a recurrence rate of up to 42%. Thus, in the last decade, there has been increasing interest in the use of mesh reinforcement of the hiatal repair. Polytetrafluoroethylene (PTFE) is one of the materials that have been used for this purpose, as it is thought to induce minimal tissue reaction. We report two cases in which complications specific to the use of PTFE mesh in this location developed over time. In the first patient, a gastrectomy was required to remove a large PTFE mesh which had eroded into the esophagogastric junction and gastric cardia. The second patient experienced severe dysphagia resulting from a stricture caused by the implant, requiring removal of the mesh. Although such complications have only rarely been reported, the severity and consequences of these incidents, as reported in the literature and in light of our observations, suggest that an alternative to PTFE should be considered for crural reinforcement during paraesophageal hernia repair.

Return of esophageal function after treatment for achalasia as determined by impedance-manometry.

BACKGROUND: Treatment for achalasia is aimed at the lower esophageal sphincter (LES), although little is known about the effect, if any, of these treatments on esophageal body function (peristalsis and clearance). We sought to measure the effect of various treatments using combined manometry (peristalsis) with Multichannel Intraluminal Impedance (MII) (esophageal clearance). METHODS: We enrolled 56 patients with Achalasia referred to the University of Washington Swallowing Center between January 2003 and January 2006. Each was grouped according to prior treatment: 38 were untreated (untreated achalasia), 10 had undergone botox injection or balloon dilation (endoscopic treatment), and 16 a laparoscopic Heller myotomy. The preoperative studies for 8 of the myotomy patients were included in the untreated achalasia group. Each patient completed a dysphagia severity questionnaire (scale 0-10). Peristalsis was analyzed by manometry and esophageal clearance of liquid and viscous material by MII. RESULTS: Mean dysphagia severity scores were significantly better in patients after Heller Myotomy than in either of the other groups (2.0 vs. 5.3 in the endoscopic group and 6.5 in untreated achalasia, p < 0.05). Peristaltic contractions were observed in 63% of patients in the Heller myotomy group, compared with 40% in the endoscopic group and 8% in untreated achalasia (p < 0.05 for both treatment groups vs. untreated achalasia). Liquid clearance rates were significantly better in both treatment groups: 28% in Heller myotomy and 16% in endoscopic treatment compared to only 5% in untreated achalasia (p < 0.05). Similarly, viscous clearance rates were 19% in Heller myotomy and 11% in endoscopic treatment, vs. 2% in untreated achalasia (p < 0.05). In the subset of patients who underwent manometry/MII both pre- and postoperatively, peristalsis was observed more frequently postoperatively than in preop studies (63% of patients exhibiting peristalsis vs. 12%), as was complete clearance of liquid (35% of swallows vs. 14%) and viscous boluses (22% of swallows vs. 14%). These differences were not significant, however. In the patients who had a myotomy the return of peristalsis correlates with effective esophageal clearance (liquid bolus: r = 0.46, p = 0.09 and viscous bolus: r = 0.63, p < 0.05). There is no correlation between peristalsis and bolus clearance in the endoscopic treatment group. CONCLUSIONS: With treatment Achalasia patients exhibit some restoration in peristalsis as well as improved bolus clearance. After Heller Myotomy, the return of peristalsis correlates with esophageal clearance, which may partly explain its superior relief of dysphagia.

Achalasia treatment: improved outcome of laparoscopic myotomy with operative manometry.

HYPOTHESIS: Operative manometry detects residual esophagogastric junction (EGJ) high pressure, ensuring complete myotomy. DESIGN: Consecutive patients undergoing laparoscopic myotomy. SETTING: Tertiary care academic medical center. PATIENTS: From 1997 to 2003, 139 patients with achalasia underwent laparoscopic myotomy. INTERVENTIONS: We assessed myotomy completeness by operative endoscopy and performed operative manometry to measure pressure across the EGJ myotomy. Residual high pressure was isolated and intact muscle divided. MAIN OUTCOME MEASURES: Esophageal manometry, quality of life, and dysphagia severity score. RESULTS: Median lower esophageal sphincter pressure was 27 mm Hg preoperatively; 10 patients had sigmoid esophagus and 57 had previous dilation and/or toxin injection. There were 136 laparoscopic myotomies and 3 conversions to open procedures (2%). Operative endoscopy was performed in all patients. Operative manometry, completed in 132 patients (95%), identified residual EGJ high pressure leading to myotomy revision in 45 patients (31 in the first 70 treated). Small perforations occurred in 19 patients, associated with previous dilation and/or toxin injection in 12 patients. One-month follow-up was available in 136 patients (98%); 126 patients had minimal symptoms (93%), whereas 1 had recurrent EGJ high pressure, 5 esophagitis, 3 sigmoid esophagus, and 1 paraesophageal hernia. In 60 patients with complete 1-year follow-up, quality of life and dysphagia improved (P <.05); mean lower esophageal sphincter pressure decreased to 7.6 mm Hg (P <.05). CONCLUSIONS: Operative manometry identifies residual EGJ high pressure and reduces the incidence of incomplete myotomy. Laparoscopic myotomy improves quality of life and dysphagia symptoms and may be the treatment of choice in most patients with achalasia.