Esophageal impedance planimetry during per-oral endoscopic myotomy guides myotomy extent.

INTRODUCTION: Peroral endoscopic myotomy (POEM) is the standard treatment for achalasia. Functional luminal imaging probe (FLIP) technology enables objective measurement of lower esophageal sphincter (LES) geometry, with literature linking specific values to improved post-POEM outcomes. Our study assesses FLIP's intraoperative use in evaluating myotomy extent in real-time. METHODS: Retrospective data from all patients undergoing POEM with intraoperative FLIP measurements were extracted from June 2020 to January 2023. The primary endpoint was intraoperative FLIP measurements, management changes, and symptom improvement (Eckardt score). RESULTS: Fourteen patients (age 56 ± 14 years, BMI 28 ± 7 kg/m2) were identified. Most patients were female (64%). Predominantly, patients presented with type II achalasia (50%). FLIP measurements were taken before and after myotomy, demonstrating increases in mean distensibility index (DI) 1.6 ± 1. 4 to 5.4 ± 2.1 mm2/mmHg (p < 0.05) and mean diameter (Dmin) 6 ± 1.8 to 10.9 ± 2.3 mm (p < 0.05) at 50 ml balloon fill. Additional myotomy was performed in one patient when an inadequate increase in FLIP values were noted. Mean operative time was 98 ± 28 min, and there were no intraoperative complications. At the 30-day follow-up, median Eckardt score decreased from mean a preoperative score of 7 ± 2 to a post-operative mean of 2 ± 3, with 10 patients (78%) having a score ≤ 2. In total, four patients experienced symptom recurrence, with repeat FLIP values revealing a significant decrease in DI from 7 ± 2.2 post-POEM to 2.5 ± 1.5 at recurrence. FLIP technology identified LES pathology in 3 out of 4 (75%) patients, facilitating referral to LES-directed therapy. CONCLUSION: Our study adds to the literature supporting the use of FLIP technology during the POEM procedure, with most patients achieving ideal values after a standard-length myotomy. This suggests the potential benefits of shorter myotomies guided by FLIP to achieve comparable outcomes and reduce postoperative GERD risk. Collaborative standardization of study designs and outcome measures is crucial for facilitating prospective trials and cross-setting outcome comparisons.

Neuroinflammatory Biomarkers Associated With Mild Traumatic Brain Injury History in Special Operations Forces Combat Soldiers.

BACKGROUND: Special Operations Forces (SOF) combat soldiers are frequently exposed to blast and blunt neurotrauma, most often classified as mild traumatic brain injury (mTBI). Repetitive mTBI may increase the risk of developing long-term neurological sequelae. Identifying changes in neuroinflammatory biomarkers before chronic conditions emerge could serve as preliminary evidence of developing neuropathology. OBJECTIVE: To determine the effects of mTBI history, lifetime mTBI incidence, and recency on blood biomarker concentrations of axonal protein neurofilament light (NfL), glycolytic enzyme neuron-specific enolase (NSE), astrocyte-expressed S100 calcium-binding protein B (S100B), and neurotrophic cytokine interleukin-6 (IL-6) in healthy, active duty SOF combat soldiers. METHODS: Self-reported mTBI history/recency and fasted blood samples were collected in this cross-sectional study of 104 asymptomatic SOF combat soldiers. Biomarker concentrations were quantified using commercial enzyme-linked immunosorbent assays. Mann-Whitney U and Kruskal-Wallis tests were used to compare groups. Post hoc tests with appropriate corrections were conducted as warranted. RESULTS: Soldiers with mTBI history had higher NSE concentrations than those without (z = -2.60, P = .01). We also observed significant main effects of lifetime mTBI incidence on NSE (χ(3) = 9.52, P = .02) and S100B (χ(3) = 8.21, P = .04) concentrations and a significant main effect of mTBI recency on NfL concentration (χ(2) = 6.02, P = .049). CONCLUSION: The SOF combat soldiers with mTBI history had increased NSE. Longitudinal studies in this population are needed due to between-subject heterogeneity in biomarker concentrations. The NfL concentrations in our SOF combat soldiers-regardless of mTBI history or recency-were similar to values previously reported in civilian acute TBI patients.

First description of a histopathologic grading system and relationship to outcomes after robotic median arcuate ligament release with celiac ganglionectomy and lymphadenectomy.

BACKGROUND: Two dominating theories regarding median arcuate ligament syndrome include vascular and neurogenic etiologies from celiac artery and ganglion compression, respectively. Celiac ganglionectomy is not routine during surgery, and specimens are rarely excised; therefore, the extent of nerve involvement and histopathology are unknown. Our study aims to characterize histopathologic findings in median arcuate ligament syndrome, establish a histopathologic grading system, and correlate with clinical outcomes. METHODS: Robotic median arcuate ligament release, celiac ganglionectomy, and lymphadenectomy were performed with specimens excised and stained using hematoxylin & eosin, trichrome, and S100. Neurofibrosis, adiposity, and reactive changes were described, a grading scale was developed, and results were analyzed with clinical outcomes. RESULTS: Fifty-four patients were evaluated, of whom 36 met inclusion criteria (81% female, 34.9 [25.9-47.5] years, body mass index 23.5 [19.6-28.1] kg/m2). Histopathologic evaluation revealed fibrosis (hematoxylin & eosin and trichrome median score 1.5 [0-2.5]), reactive lymphadenopathy (89%), intraparenchymal nerves (31%), and lipogranulomas (31%). Greater fibrosis was associated with a lack of preoperative celiac plexus block relief (100% vs. 30%, P = .044) and lower postoperative celiac artery velocities (198 vs 323 cm/s, P = .02). Intraparenchymal nerves were associated with greater decreases in pre to postoperative velocities (161 vs 84 cm/s, P = .037). Symptoms improved in 28 patients (78%). CONCLUSION: We developed the first histopathologic grading system and identified unique findings of intraparenchymal nerves and lipogranulomas. Histopathologic abnormalities were associated with objective improvement and symptomatic relief postoperatively. These findings support nerve compression and inflammation as predominant contributors to median arcuate ligament syndrome pain, celiac ganglia resection to treat symptoms, and continued histopathologic analysis to better elucidate median arcuate ligament syndrome etiology.

Bariatric Surgery Outcomes in Patients with Severe Obesity Compared to Patients with Non-Severe Obesity at A New Institution in The United Arab Emirates.

Background: Bariatric surgery is an effective treatment for weight loss, but a higher body mass index (BMI) may lead to higher postoperative complication rates. This study aims to compare perioperative and postoperative outcomes between UAE patients with severe obesity (SO) [BMI ≥ 50 kg/m2] and non-severe obesity (NSO) [BMI < 50 kg/m2] undergoing primary bariatric surgery. Methods: From September 2015 to July 2019, 542 patients, 94 SO (56.5 ± 6.2 kg/m2) and 448 NSO (41.8 ± 4.1 kg/m2), were retrospectively reviewed. Results: Patients with SO were younger (33.8 ± 13.4 vs. 37.0 ± 11.5 years, p = 0.02) but otherwise had similar demographic characteristics. Their rates of Roux-en-Y gastric bypass (39.4% SO vs. 44.4% NSO, p = 0.37) and sleeve gastrectomy (60.6% vs. 55.6%, p = 0.37) were similar. There were no differences between perioperative complications (6.4% SO vs. 5.8% NSO, p = 0.83), major postoperative complications (5.3% vs. 3.5%, p = 0.42), readmissions (5.3% vs. 3.3%, p = 0.36), or reoperations (3.2% vs. 2.7%, p = 0.78). There were no mortalities. Their total body weight loss was comparable at 12 months (28.1 ± 10.2% vs. 29.0 ± 7.7%, p = 0.58). Conclusions: Although a higher BMI may pose operative challenges, UAE patients with SO do not have worsened outcomes in bariatric surgery, demonstrating similarly low morbidity to patients with NSO, and similar rates of improvement in their BMI.

Neurovascular Coupling in Special Operations Forces Combat Soldiers.

The purpose of this study was to investigate how concussion history affects neurovascular coupling in Special Operations Forces (SOF) combat Soldiers. We studied 100 SOF combat Soldiers [age = 33.5 ± 4.3 years; height = 180.4 ± 6.0 cm; 55 (55.0%) with self-reported concussion history]. We employed transcranial Doppler (TCD) ultrasound to assess neurovascular coupling (NVC) via changes in posterior cerebral artery (PCA) velocity in response to a reading and a visual search task. Baseline TCD data were collected for 2 min. NVC was quantified by the percent change in overall PCA response curves. We employed linear mixed effect models using a linear spline with one knot to assess group differences in percent change observed in the PCA velocity response curves between SOF combat Soldiers with and without a concussion history. Baseline PCA velocity did not significantly differ (t98 = 1.28, p = 0.20) between those with and without concussion history. Relative PCA velocity response curves did not differ between those with and without a concussion history during the reading task (F1,98 = 0.80, p = 0.37) or the visual search task (F1,98 = 0.52, p = 0.47). When assessing only SOF combat Soldiers with a concussion history, differential response to task was significantly greater in those with 3 or more concussions (F1,4341 = 27.24, p < 0.0001) relative to those with 1-2 concussions. Despite no main effect of concussion history on neurovascular coupling response in SOF combat Soldiers, we observed a dose-response based on lifetime concussion incidence. While long-term neurophysiological effects associated with head impact and blast-related injury are currently unknown, assessing NVC response may provide further insight into cerebrovascular function and overall physiological health.

The relationship between neurovascular coupling, vision and sensory performance, and concussion history in Special Operations Forces combat soldiers.

OBJECTIVE: To determine the relationship between neurovascular coupling (NVC), vision and sensory performance in Special Operations Forces (SOF) combat soldiers with and without concussion history. METHODS: We studied 61 SOF combat soldiers (male, age = 33.8 ± 3.7 years, n = 40 with concussion history [Median = 3; range = 1-10+]). We instrumented our participants with transcranial Doppler to quantify NVC response during reading and visual search tasks. All participants completed vision and sensory performance testing (Senaptec Sensory Station). We performed separate multiple regressions to determine if relationships between NVC and vision and sensory performance testing existed while controlling for concussion history, and to investigate the interaction between NVC and concussion history. RESULTS: Those with higher visual search NVC response magnitudes demonstrated significantly worse contrast sensitivity when controlling for concussion history (F1,60=4.57, ß = 0.03, p = .04, R2 = 12.6%). We did not observe any other significant relationships between NVC and visual and sensory performance tests nor did we observe any significant interactions between NVC and concussion history (p > .05). CONCLUSIONS: Heightened NVC response magnitudes are related to reduced contrast sensitivity in SOF combat soldiers. Because concussion history does not impact the relationships between outcomes, these measures may be utilized for performance evaluation at any point in a soldier's career. The lack of relationships between NVC response magnitude and some of the other vision and sensory performance outcomes suggests that implementing NVC assessment may add unique information and enable clinicians to detect physiological deficits that may otherwise go undetected.