Integrated stakeholder prioritization criteria for environmental management.

It is widely recognized that stakeholder engagement can lead to improved decision making. However, decision makers must identify and engage appropriate stakeholder groups. This can be challenging when there is a wide and diverse range of potential stakeholders, often the case in environmental management. Some fields, business and public relations for example, have proposed criteria or methodologies for prioritizing stakeholders for inclusion in decision making, but current methods of stakeholder evaluation in environmental management focus on stakeholder identification, categorization, and relationship analysis, none of which explicitly prioritize stakeholders. In this paper we propose a set of ten criteria, drawn from the literature, that can be used to prioritize stakeholders for environmental management decision making. These criteria are: level of interest, level of influence, magnitude of impact, probability of impact, urgency/temporal immediacy, proximity, economic interest, rights, fairness, and underrepresented/underserved populations. Not all criteria will be relevant to all decision makers, but we suggest this set of criteria encompasses those stakeholder engagement factors most commonly considered by decision makers. This paper proposes these criteria that form the basis of future decision support approaches in environmental management contexts and we argue for development and testing of these criteria to connect stakeholder prioritization and environmental decision making.

Ecosystem services consideration in the remediation process for contaminated sites.

In 2009, the U.S. Environmental Protection Agency's Science Advisory Board recommended activities to advance consideration of ecosystem services (ES) to enhance existing remediation and redevelopment processes in the U.S. This article examines advancements in the decade since, focusing on providing those involved in cleanup of contaminated sites a basic understanding of ES concepts and guidelines for considering ES at cleanup sites using a new, four-step transferable framework. Descriptions, including activities for site teams and case study applications of ES tools, are presented for each step: (1) identify site-specific ES; (2) quantify relevant ES; (3) examine how cleanup activities affect ES; and (4) identify, select, and implement solutions (e.g., Best Management Practices). The goal of this article is to provide site cleanup stakeholders, including project managers, contractors, and site responsible parties, with a stronger foundation and shared understanding to consider ES during the cleanup process for their given site. Anticipated outcomes include identifying ES benefits to inform management and tradeoff analyses, a reduction in unintended impacts on ES during site operations, and attention to developing a robust suite of ES relevant for site reuse.

The ecosystem service of property protection and exposure to environmental stressors in the Gulf of Mexico.

Environmental stressors such as sea-level rise, erosion, and increased storm frequency and intensity are exposing coastal properties to greater amounts of damage. Coastal habitats like beaches, dunes, seagrasses, and wetlands can help reduce exposure and property damage. Using InVEST's Coastal Vulnerability Model, an exposure index value was calculated for every 250 m2 segment along the coastline in Escambia and Santa Rosa counties in Florida, USA. Nineteen sea level-by-habitat management scenarios were evaluated for a suite of shoreline segments across multiple exposures that can be used to inform local decision making as part of larger strategies for coastal management. Overall, a rise in sea level and degradation of coastal habitats could decrease the number of lower exposed shoreline segments and increase the number of higher exposed shoreline segments. These results were used to identify changes in the amount of potential residential property damage among different scenarios. Under high sea levels, additional protection to coastal habitats could reduce the amount of residential property damage resulting from one tropical cyclone event by $50.4 million (2018 US dollars (USD)) (by the year 2050) and by $71.8 million (2018 USD) (by the year 2100) in Escambia and Santa Rosa counties. This research demonstrates the effects that habitat type/abundance and sea-level rise could have on vulnerable coastlines. The results of the modeled scenarios can be incorporated into several recent community resiliency planning initiatives in the region to develop more robust management plans and preparations for a changing environment.

Strategies for surgical remediation of the multi-fundoplication failure patient.

BACKGROUND: Outcomes are not well studied in patients undergoing remediation for multi-fundoplication failure, that is, two or more prior failed fundoplications. Re-operation must balance reflux control and restoration of the ability to eat with the challenge of reconstructing a distorted hiatus and GE junction. The purpose of this study is to present our experience with surgical remediation for multi-fundoplication failure. METHODS: Medical records were retrospectively reviewed of 91 patients who underwent third time or more esophagogastric operation for fundoplication failure at a single institution from 2007 to 2016. Dysphagia was present in 56% and heartburn in 51%. Median number of prior operations was 2 with range up to 6. Anatomic failure consisted of slipped wrap in 26 cases, wrap herniation in 23, hiatal stenosis in 24, hiatal mesh complication in 8, and wrap dehiscence in 10. Operative approaches generally followed an institutional algorithm and consisted of hiatal hernia repair with: re-do fundoplication in 55%, takedown of fundoplication alone in 24%, Roux-en-Y gastrojejunostomy in 14%, and GE junction resection in 7%. Laparoscopic approach was successful in 81%. RESULTS: Mean duration of operations was 217 min and median length of stay was 3 days. The complication rate was 13%, with 7% undergoing unplanned early re-operation. Patients were followed for mean 11 months, and recurrent hiatal hernia was detected in 13%. Late re-operation was performed in 6% for recurrent hiatal hernia. Recurrent reflux symptomatology resolved in 93%. Dysphagia resolved in 84%. There were no significant differences in outcomes with regard to number of prior operations, operative approach, BMI, or age. CONCLUSIONS: There is no single best approach to remediation in the multi-fundoplication failure patient. Re-do fundoplication is appropriate in over half of patients. Reoperation for multi-fundoplication failure can be performed via minimally invasive approach with excellent remediation of symptoms, low morbidity, and low recurrence rates.

Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence?

BACKGROUND: Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence. METHODS: We prospectively collected data on PEH characteristics, variations in operative techniques, and surgeon factors for 595 patients undergoing laparoscopic PEH repair from 2008 to 2015. Upper GI study was performed at 6 months postoperatively and selectively thereafter-any supra-diaphragmatic stomach was considered hiatal hernia recurrence. Exclusion criteria included revisional operation (22.4%), size <5 cm (17.6%), inadequate follow-up (17.8%), and confounding concurrent operations (6.9%). Inclusion criteria were met by 202 patients (31% male, median age 71 years, and median BMI 28.7). RESULTS: At a median follow-up of 6 months (IQR 6-12), overall anatomic recurrence rate was 34.2%. Symptom recurrence rate was 9.9% and revisional operation was required in ten patients (4.9%). Neither patient demographics nor PEH characteristics (size, presence of Cameron erosions, esophagitis, or Barrett's) correlated with anatomic recurrence. Technical factors at operation (mobilized intra-abdominal length of esophagus, Collis gastroplasty, number of anterior/posterior stitches, use of crural buttress, use of pledgeted or mattress sutures, or gastrostomy) were also not correlated with recurrence. Regarding surgeon factors, annual volume of fewer than ten cases per year was associated with increased risk of anatomic failure (54 vs 33%, P = 0.02). Multivariate analysis identified surgeon experience (<10 cases per year) as an independent factor associated with early hiatal hernia recurrence (OR 3.7, 95% CI 1.34-10.9). CONCLUSIONS: Laparoscopic repair of giant PEH is associated with high anatomic recurrence rate but excellent symptom control. PEH characteristics and technical operative variables do not appear to significantly affect rates of recurrence. In contrast, surgeon volume does appear to contribute significantly to durability of repair.

Increased live births after day 5 versus day 6 transfers of vitrified-warmed blastocysts.

PURPOSE: An investigation into the clinical implications of delayed blastulation (day 5 versus day 6) was carried out for cryo cycles, as heterogeneous results persist in the current literature. METHODS: We performed a retrospective study comparing clinical pregnancies and live births between 178 blastocysts vitrified and warmed on day 5 versus 149 on day 6. The stage of blastocyst development was taken into account and adjustment for confounding factors was performed. RESULTS: Our results demonstrate a significant difference in clinical pregnancy (43 versus 23% p value < 0.001) and live birth rates (34 versus 16% p value < 0.001) regarding the day of vitrification, in favour of day 5. This difference persisted after adjustment for confounding factors. The adjusted odds ratio for clinical pregnancies and deliveries for the day 5 group compared to that of the day 6 group was 2.83 (95%CI, 1.48 to 5.41) and 2.94 (95%CI, 1.39 to 6.22), respectively. When the stage of development of the blastocyst was taken into consideration, we still observed a significant advantage of day 5 versus day 6 vitrification. CONCLUSIONS: Day of vitrification (day 5 versus day 6) appears to be an independent predictor of clinical outcomes. Stratification of our cohort was carried out according to the developmental stage, and significant differences persisted. Although the transfer of day 6 cryopreserved embryos remains a viable option, giving priority to a day 5 embryo would reduce the time to pregnancy.

Linking People to Coastal Habitats: A meta-analysis of final ecosystem goods and services on the coast.

Coastal ecosystem goods and services (EGS) have steadily gained traction in the scientific literature over the last few decades, providing a wealth of information about underlying coastal habitat dependencies. This meta-analysis summarizes relationships between coastal habitats and final ecosystem goods and services (FEGS) users. Through a "weight of evidence" approach synthesizing information from published literature, we assessed habitat classes most relevant to coastal users. Approximately 2,800 coastal EGS journal articles were identified by online search engines, of which 16% addressed linkages between specific coastal habitats and FEGS users, and were retained for subsequent analysis. Recreational (83%) and industrial (35%) users were most cited in literature, with experiential-users/hikers and commercial fishermen most prominent in each category, respectively. Recreational users were linked to the widest diversity of coastal habitat subclasses (i.e., 22 of 26). Whereas, mangroves and emergent wetlands were most relevant for property owners. We urge EGS studies to continue surveying local users and identifying habitat dependencies, as these steps are important precursors for developing appropriate coastal FEGS metrics and facilitating local valuation. In addition, understanding how habitats contribute to human well-being may assist communities in prioritizing restoration and evaluating development scenarios in the context of future ecosystem service delivery.

In vitro fertilization for women infected by hepatitis C virus: a matched case-control study and a systematic literature review.

PURPOSE: The aim of this study was to investigate whether infection of women by the hepatitis C virus (HCV) reduces the chance of conceiving after in vitro fertilization (IVF). METHODS: We performed a retrospective blind matched case-control study where IVF outcomes for the first 37 cycles of HCV sero-positive women were compared to those of 107 cycles of an uninfected control group. Our results were included in a systematic literature review. RESULTS: Out of five eligible studies, ours included, three observed an impact of HCV infection, though at various levels including response to stimulation, fertilization, implantation, and pregnancy rates. Two studies differentiated results for patients with confirmed active viral replication. Matching criteria and populations studied varied between studies. CONCLUSIONS: More and larger studies with well-defined groups are needed to clarify the eventual impact of the HCV on IVF outcomes. Data concerning the infectious status of a patient as well as her health state should be systematically recorded. A multi-disciplinary approach as well as a thorough knowledge of the patient's general health state might prove useful in the management and counseling of these patients in terms of success in conceiving.

In vitro fertilization when men, women, or both partners are positive for HIV: a case-control study.

PURPOSE: The aim of this study was to compare the outcomes of in vitro fertilization (IVF) for couples where one or both partners were positive for the human immunodeficiency virus (HIV) to matched control couples. METHODS: A matched case-control retrospective study was performed. Data for 104 couples where the woman was HIV-positive; for 90 couples where the man was HIV-positive; and for 33 couples where both partners were HIV-positive were prospectively analyzed in comparison to matched controls treated in our center during the same period. The main outcomes were clinical pregnancy and live birth rates. RESULTS: For couples involving an HIV-positive man, clinical outcomes were comparable to controls and resulted in the birth of 18 healthy babies after 90 cycles. When the woman was affected, cycle cancelation, number of retrieved oocytes, and on-going clinical pregnancy rates per transfer were statistically reduced. Implantation rates were comparable to those of non-affected controls. Seven healthy babies for 104 cycles were obtained. For a couple in which both partners were HIV-positive, only one healthy birth occurred after 33 cycles. Pregnancy rates were systematically reduced though not significantly probably due to sample size. CONCLUSIONS: Our data suggest that IVF outcomes were similar to controls when men were HIV-positive and remain acceptable when women were HIV-positive. IVF outcomes were severely reduced in our sero-concordant couples; however, many patients had severe HIV disease previously, and therefore, these results should be reassessed in patients treated early in their disease.

Oocytes affected by smooth endoplasmic reticulum aggregates: to discard or not to discard?

PURPOSE: Oocytes containing smooth endoplasmic reticulum aggregates (SERa) have been associated with reduced fertilization and clinical pregnancy rates as well as compromised neonatal outcomes. It was therefore recommended by an Alpha-ESHRE Consensus to discard oocytes presenting this dysmorphism. The data in the literature are nevertheless conflicting and healthy babies have recently been obtained from affected oocytes. The objectives of this study were to compare clinical outcomes between ICSI cycles with and without oocytes affected by smooth endoplasmic reticulum aggregates and to confirm whether affected oocytes can produce healthy babies. METHODS: A prospective observational study was performed comparing 714 SERa- ICSI cycles to 112 SERa+ cycles. Among the SERa+ cycles, 518 SERa- oocytes and 213 SERa+ oocytes were analyzed. Fertilization, embryo quality, and pregnancy rates as well as neonatal outcomes were compared between SERa+ and SERa- cycles as well as between SERa+ and SERa- oocytes. RESULTS: The presence of SERa was not associated with an adverse effect on embryological, clinical or neonatal data for SERa+ cycles and oocytes. Seven healthy babies were born from embryos originating from SERa+ oocytes. CONCLUSIONS: These results are encouraging and might contribute in the future to a revision of the Alpha-ESHRE Consensus. Larger studies, including a correlation between frequency and size of SERa, clinical outcomes and malformation rates, as well as the follow-up of babies born are nevertheless necessary. In the meantime, the currently conflicting data requires caution when considering transfers of embryos affected by SERa.

Policy of IVF centres towards oocytes affected by Smooth Endoplasmic Reticulum aggregates: a multicentre survey study.

PURPOSE: The presence of Smooth Endoplasmic Reticulum aggregates (SERa) has been reported to be associated with adverse outcomes. An Alpha-ESHRE Consensus was published in 2011, strongly recommending to not inseminating affected oocytes. On the other hand, healthy babies have been born from oocytes presenting this dysmorphism. We surveyed several European IVF centres, to assess their attitudes concerning affected oocytes. METHODS: This survey is based on a computer format and includes questions regarding the fate of affected oocytes. RESULTS: About 14 % of centres who answered our survey discard SERa+ oocytes. 43 % of centres that do not discard the oocytes, register and follow up neonatal data. About a quarter of centres inform their patients about this dysmorphism. Half of them require an informed consent prior to transferring affected embryos. Twenty-one centres reported having SERa+ births, with one reporting a malformation. 48 % of centres declared having been influenced by the Alpha-ESHRE Consensus, in their management policy of SERa+ oocytes. CONCLUSIONS: Few centres scrupulously respect the recommendations of the Alpha-ESHRE Consensus and discard affected oocytes. Since it is essential to determine if there truly is an impact of this dysmorphism and whether the guidelines are still valid, transfer of affected embryos should only be done when accompanied with data recording and monitoring of all foetal malformations from IVF. Clarifying the situation will allow IVF centres to correctly inform patients about the risk of birth malformations as well as whether a decreased chance of pregnancy exists.

Can healthy babies originate from oocytes with smooth endoplasmic reticulum aggregates? A systematic mini-review.

STUDY QUESTION: Is it time to reconsider whether oocytes affected by smooth endoplasmic reticulum aggregates (SERa) should still be destroyed? SUMMARY ANSWER: At the time of writing, the literature shows that 171 apparently healthy babies have been born from SERa+ cycles amongst which 22 were from SERa+ oocytes. WHAT IS KNOWN ALREADY: The SER dysmorphism has been associated with negative embryological, clinical and neonatal outcomes, which led to a recommendation in 2011 to avoid inseminating affected oocytes. The data in the literature are nevertheless conflicting and some centres have continued using SERa+ oocytes. STUDY DESIGN, SIZE, DURATION: A systematic mini-review of the literature to 7 November 2013 was performed with the keywords 'Smooth Endoplasmic Reticulum' and 'oocyte', limited to humans and written in English. PARTICIPANTS/MATERIALS, SETTING, METHODS: Articles (Pubmed) and major abstracts where the effect of the SER dysmorphism was studied as an individual feature on embryological, clinical or neonatal outcomes were included in this review. MAIN RESULTS AND THE ROLE OF CHANCE: From a total of 297 publications identified, 13 were selected as being relevant to this review. One hundred eighty-three babies have been reported to be born from SERa+ cycles, 171 were healthy, 8 live births presented malformations, 3 were neonatal deaths, 1 was a stillborn and additionally 4 terminations of pregnancy occurred. LIMITATIONS, REASONS FOR CAUTION: Data concerning SERa+ oocytes in the literature are scarce, the studies are small, heterogeneous and results are conflicting. The malformations observed could be due to over-reporting of scattered alarming results. Alternatively, an under-reporting of complications cannot be excluded. WIDER IMPLICATIONS OF THE FINDINGS: Centres that have or that are including transfers of SERa+ embryos in their IVF procedures should publish their clinical and neonatal outcomes as well as the follow-up of children. The birth of healthy babies from SERa+ embryos is encouraging and might lead in the future to a revision of the current consensus on the SER dysmorphism. Further research is needed to understand the origin of this dysmorphism and help avoid its occurrence. Therefore, until we have a better understanding of the situation, transfers of affected embryos should be carried out with caution. STUDY FUNDING/COMPETING INTEREST(S): We have no conflicts of interest to declare and no funding was received.

Supporting neurodivergent nursing students in their practice placements.

Neurodivergent conditions such as autism, attention deficit hyperactivity disorder (ADHD), dyslexia, dyspraxia, dyscalculia and Tourette's syndrome are common, and it is highly likely that practice assessors and supervisors will be asked to support neurodivergent nursing students in their practice learning environments. This article details the strengths that neurodivergent students can bring to nursing, as well as some of the challenges they may experience in practice settings. It outlines how practice assessors and supervisors can develop neuro-inclusive learning environments where neurodivergent students can thrive, as well as how to support them if they are not meeting their required proficiencies. The authors also discuss how appropriate reasonable adjustments can be implemented by using a collaborative approach with students.

Connecting stakeholder priorities and desired environmental attributes for wetland restoration using ecosystem services and a heat map analysis for communications.

Framing ecological restoration and monitoring goals from a human benefits perspective (i.e., ecosystem services) can help inform restoration planners, surrounding communities, and relevant stakeholders about the direct benefits they may obtain from a specific restoration project. We used a case study of tidal wetland restoration in the Tillamook River watershed in Oregon, USA, to demonstrate how to identify and integrate community stakeholders/beneficiaries and the environmental attributes they use to inform the design of and enhance environmental benefits from ecological restoration. Using the U.S. Environmental Protection Agency's Final Ecosystem Goods and Services (FEGS) Scoping Tool, we quantify the types of ecosystem services of greatest common value to stakeholders/beneficiaries that lead to desired benefits that contribute to their well-being in the context of planned uses that can be incorporated into the restoration project. This case study identified priority stakeholders, beneficiaries, and environmental attributes of interest to inform restoration goal selection. This novel decision context application of the FEGS Scoping Tool also included an effort focused on how to communicate the connections between stakeholders, and the environmental attributes of greatest interest to them using heat maps.

Vitrification of blastocysts derived from fair to poor quality cleavage stage embryos can produce high pregnancy rates after warming.

PURPOSE: This study investigates whether certain embryos considered unsuitable for cryopreservation on day 3 might nevertheless have the potential to develop into worthwhile blastocysts that could be vitrified in the same cycle. METHODS: Retrospective study: between 2010 and 2011, embryo transfers and cryopreservation took place mainly on day 3 in our centre. Supernumerary embryos of intermediate to poor quality were reassessed on days 5/6 and any good quality blastocysts were vitrified. RESULTS: Out of 914 cleavage stage (day 3) embryos left in culture, 16 % were vitrified on days 5/6. Fifty blastocyst warming cycles resulted in a 76 % survival rate, 44 % clinical pregnancy rate and 39 % implantation rate. During the same time period, 213 warming cycles of good quality cleavage stage embryos rendered survival rates, clinical pregnancy and implantation rates of 97 %, 23 % and 16 % respectively. CONCLUSIONS: Supernumerary average quality day 3 embryos should be given a second chance to be selected for cryopreservation. If blastocysts are obtained and survive vitrification, there is a good chance of implantation thus reducing embryo waste.

Ecosystem Services Profiles for Communities Benefitting from Estuarine Habitats along the Massachusetts Coast, USA.

The Massachusetts Bays National Estuary Partnership is one of 28 programs in the United States Environmental Protection Agency's National Estuary Program (NEP) charged with developing and implementing comprehensive plans for protecting and restoring the biological integrity and beneficial uses of their estuarine systems. The Partnership has recently updated their comprehensive management plan to include restoration targets for coastal habitats, and as part of this effort, the program explored how to better demonstrate that recovery of ecological integrity of degraded ecosystems also provides ecosystem services that humans want and need. An essential step was to identify key stakeholders and understand the benefits important to them. The primary objective of the study presented here was to evaluate variability in beneficial uses of estuarine habitats across coastal communities in Massachusetts Bays. We applied a text mining approach to extract ecosystem services concepts from over 1400 community planning documents. We leveraged a Final Ecosystem Goods and Services (FEGS) classification framework and related scoping tool to identify and prioritize the suite of natural resource users and ecosystem services those users care about, based on the relative frequency of mentions in documents. Top beneficiaries included residents, experiencers and viewers, property owners, educators and students, and commercial or recreational fishers. Beneficiaries had a surprising degree of shared interests, with top ecosystem services of broad relevance including for naturalness, fish and shellfish, water movement and navigability, water quality and quantity, aesthetic viewscapes, availability of land for development, flood mitigation, and birds. Community-level priorities that emerged were primarily related to regional differences, the local job industry, and local demographics. Identifying priority ecosystem services from community planning documents provides a starting point for setting locally-relevant restoration goals, designing projects that reflect what stakeholders care about, and supporting post-restoration monitoring in terms of accruing relevant benefits to local communities.

Synthesis of Two Decades of US EPA's Ecosystem Services Research to Inform Environmental, Community, and Sustainability Decision Making.

A conceptual framework is helpful to understand what types of ecosystem services (ES) information is needed to support decision making. Principles of structured decision making are helpful for articulating how ES consideration can influence different elements in a given decision context resulting in changes to the environment, human health, and well-being. This article presents a holistic view of an ES framework, summarizing two decades of the US EPA's ES research, including recent advances in final ES, those ES that provide benefits directly to people. Approximately 150 peer-reviewed publications, technical reports, and book chapters characterize a large ES research portfolio. In introducing framework elements and the suite of relevant US EPA research for each element, both challenges and opportunities are identified. Lessons from research to advance each of the final ES elements can be useful for identifying gaps and future science needs. Ultimately, the goal of this article is to help the reader develop an operational understanding of the final ES conceptual framework, an understanding of the state of science for a number of ES elements, and an introduction to some ES tools, models, and frameworks that may be of use in their case-study applications or decision-making contexts.

Medical Student Perceptions of Emergency Medical Technician Training During the First Year of Medical School.

PURPOSE: Medical schools look for ways to provide clinical experiences and skill development in connection with knowledge. One method used is to provide emergency medical technician (EMT) training to medical students; however, limited data are available concerning EMT training in medical education. Therefore, the aim of this study was to review student feedback about the EMT curriculum through multiple iterations of the curriculum. METHODS: Students completed a voluntary school administered survey upon completion of their first year of medical school. Student responses to statements related to the EMT course and program were analyzed for classes matriculating in academic years 2012-2017. A one-way ANOVA with post hoc Tukey Honestly Significant Difference (HSD) was performed across all years for each survey statement. RESULTS: Mean response scores to statements related to the EMT course were higher when the EMT course was a standalone course and lower when integrated with biomedical science coursework. Students "strongly agreed" or "agreed" with most statements related to experiences and clinical skill development provided by the EMT program. Response rates ranged between 46-52 (88-100%) for 2012, 40-46 (74-85%) for 2013, 72-79 (88-96%) for 2014, 73-86 (71-83%) for 2015, 47-65 (46-63%) for 2016, 62-82 (59-78%) for 2017. CONCLUSION: Our data show that first year medical students liked the course design best when the EMT course was a standalone course at the start of the M.D. program while students liked experiences and clinical skill development provided by the EMT program regardless of course design.

Short-Term Outcomes Predict Long-Term Satisfaction in Patients Undergoing Laparoscopic Magnetic Sphincter Augmentation.

INTRODUCTION: Laparoscopic magnetic sphincter augmentation (MSA) has been shown to be efficacious therapy for gastroesophageal reflux disease (GERD) refractory to maximal medical management. Herein, we present our experience with this procedure and an analysis of our outcomes. MATERIALS AND METHODS: Medical records were retrospectively reviewed of 98 patients who underwent laparoscopic MSA for GERD at a single institution from 2012 to 2016. Symptoms were assessed with gastroesophageal reflux disease-health-related quality of life (GERD-HRQL) questionnaire. Objective testing included pH testing, manometry, endoscopy, and upper GI series. Postimplantation interventions were recorded. Median follow-up was 46 months. RESULTS: Median preoperative DeMeester score was 32 (interquartile range 21-46). Esophagitis was present in 18%. Hiatal hernia was present in 59%. Operation required full hiatal dissection in 16%. There were no intraoperative complications. Mean hospital stay postimplantation was 18 hours. Reoperative intervention with device explant was necessary in 5 cases, one of which was for intraluminal device erosion. Median GERD-HRQL scores were 25 preoperatively, 8 in short-term follow-up at median 1 month, and 5 in long-term follow-up at median 46 months. Improvement in GERD-HRQL scores was statistically significant with both short and long term compared with preoperative (P < .05), but no different between short- and long-term follow-up. Daily bothersome dysphagia was present in 19 patients preoperatively and in 9 at long-term follow-up. CONCLUSIONS: Laparoscopic MSA is associated with excellent outcomes with decrease in GERD-HRQL scores in short term that are durable to longer term follow-up, and with low rates of new-onset dysphagia.