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Background: Historically, DeMeester score over 14.7 has been used to diagnose GERD. The 2022 American Gastroenterological Association clinical guidelines define GERD based on acid exposure time (AET) instead of DeMeester score. We aim to compare outcomes after laparoscopic Nissen fundoplication (LNF) in patients based on differing GERD diagnostic criteria. Methods: Patients who underwent first-time LNF between 2009 and 2017 were identified. Demographics, objective GERD evaluation, and outcomes were maintained in an IRB-approved database. Disease-specific quality of life was assessed with a survey (GERD-HRQL) with higher values representing more symptomatic disease. Descriptive statistics, Fischer’s exact test and logistic regression were used to analyze the data, p-value < 0.05. Results: 225 patients were stratified into two groups: borderline GERD (AET 4–6%, n= 25.11%) and GERD (AET ≥ 6%, n= 200.89%). The mean age was 50.1 ± 13.4 years and 169 (75%) were female. Baseline GERD-HRQL was lower in the borderline group (24.3 vs 30.0, p= 0.031). Short-term (5 weeks [IQR 4, 8]), medium-term (14 months [IQR 7.25, 31]) and long-term (6.75 years [IQR 5.5, 8]) follow-up was performed. GERD-HRQL scores did not differ between borderline and GERD patients at short-(6.0 vs 7.1, p= 0.630), medium-(12.0 vs 12.1, p= 0.818), or long-term follow-up (10.0 vs 9.0, p= 0.757). The absolute long-term improvement in GERD-HRQL was −12.3 (p= 0.022) vs. −21.3 (p< 0.001). At long-term follow-up there was no difference in PPI use (50% vs 47%, p= 0.852), satisfaction (58% vs 76%, p= 0.187), willingness to repeat the procedure given the benefit of hindsight (75% vs 85%, p= 0.386), or need for reoperation (14% vs 13%, p= 0.910). Conclusion: Both patients with borderline GERD and GERD achieve GERD-HRQL improvements at 7 years following laparoscopic Nissen fundoplication and demonstrate similar long-term PPI usage and satisfaction with surgical results. Borderline GERD patients have lower GERD-HRQL at baseline, and thus have smaller improvements in their QOL scores. Anti-reflux surgery should be considered for patients with a diagnosis of borderline GERD refractory to medical therapy.

Background: Laparoscopic fundoplication (LF) is the gold standard for gastroesophageal reflux disease (GERD). Recurrent GERD is a known complication; however, the incidence of recurrent GERD-like symptoms and long-term fundoplication failure is rarely reported. Our objective was to identify the rate of recurrent pathologic GERD in patients with GERD-like symptoms following fundoplication. We hypothesized that patients with recurrent GERD-like symptoms refractory to medical management do not have evidence of fundoplication failure as indicated by a positive ambulatory pH study. Methods: This is a retrospective cohort study of 353 consecutive patients undergoing LF for GERD between 2011 and 2017. Baseline demographics, objective testing, GERD-HRQL scores, and follow-up data were collected in a prospective database. Patients with return visits to clinic following routine post-operative visits were identified (n= 136, 38.5%), and those with a primary complaint of GERD-like symptoms (n= 56, 16%) were included. The primary outcome was the proportion of patients with a positive post-operative ambulatory pH study. Secondary outcomes included proportion of patients with symptoms managed with acid-reducing medications, time to return to clinic, and need for reoperation. Pvalues < 0.05 were considered significant. Results: Fifty-six (16%) patients returned during the study period for an evaluation of recurrent GERD-like symptoms with a median interval of 51.2 (26.2–74.7) months. Twenty-four patients (42.9%) were successfully managed expectantly or with acid-reducing medications. Thirty two (57.1%) presented with GERD-like symptoms and failure of management with medical acid suppression and underwent repeat ambulatory pH testing. Of these, only 5 (9%) were found to have a DeMeester score of > 14.7, and three (5%) underwent recurrent fundoplication. Conclusion: Following LF, the incidence of GERD-like symptoms refractory to PPI therapy is much higher than the incidence of recurrent pathologic acid reflux. Few patients with recurrent GI symptoms require surgical revision. Evaluation, including objective reflux testing, is critical to evaluating these symptoms.

Background: Laparoscopic magnetic sphincter augmentation (MSA) has emerged as an alternative to laparoscopic Nissen fundoplication (LNF) for the management of symptomatic gastroesophageal reflux disease (GERD). While short-term outcomes of MSA compare favorably to those of LNF, direct comparisons of long-term outcomes are lacking. We hypothesized that the long-term patient-reported outcomes of MSA would be similar to those achieved with LNF. Methods: We tested this hypothesis in a retrospective cohort undergoing primary LNF or MSA between March 2013 and July 2015. The primary outcome was GERD-Health Related Quality of Life (GERD-HRQL) score at long-term follow-up relative to baseline. Secondary outcomes included dysphagia and bloating scores, proton-pump inhibitor (PPI) cessation, reoperations, and overall satisfaction with surgery. Results: 70 patients (25 MSA, 45 LNF) met criteria for study inclusion. MSA patients had lower baseline BMI (median: 27.1 [IQR: 22.7–29.9] versus 30.4 [26.4–32.8], p= 0.02), lower total GERD-HRQL (26 [19–32] versus 34 [25–40], p= 0.02), and dysphagia (2 [0–3] versus 3 [1–4], p= 0.02) scores. Median follow-up interval exceeded 5 years (MSA: 68 [65–74]; LNF: 65 months [62–69]). Total GERD-HRQL improved from 26 to 9 after MSA (p< 0.001) and from 34 to 7.5 after LNF (p< 0.01); these scores did not differ between groups (p= 0.68). Dysphagia (MSA: 1 [0–2]; LNF: 0 [0–2], p= 0.96) and bloating (MSA: 1.5 [0.5–3.0]; LNF: 3.0 [1.0–4.0], p= 0.08) scores did not show any statistically significant differences. Device removal was performed in 4 (16%) MSA patients and reoperation in 3 (7%) LNF patients. Eighty-nine percent of LNF patients reported satisfaction with the procedure, compared to 70% of MSA patients (p= 0.09). Conclusions: MSA appears to offer similar long-term improvement in disease-specific quality of life as LNF. For MSA, there was a trend toward reduced long-term bloating compared to LNF, but need for reoperation and device removal may be associated with patient dissatisfaction.

Background: Our group has previously demonstrated that low socioeconomic status (SES) independently predicts ≤ 25th percentile weight-loss following bariatric surgery (BS). Given that sociodemographic metrics can be separated into income, education, and race, we sought to investigate how each metric independently impacted weight loss following BS. Methods: Patients from a single academic institution who underwent bariatric surgery from 2014 to 2016 were retrospectively reviewed. Patients were stratified by income (low/high), education (≤ high school/ ≥ college), and race (black/white) then compared using univariate analysis. Variables significant on univariate analyses were subsequently used for a greedy 1:3 propensity score match with a caliper of 0.2. After matching, groups were balanced on demographics, social/medical/psychological history, and surgery type. Percent excess body weight loss for each post-operative time point was compared using appropriate univariate analyses. A p-value ≤ 0.05 was considered statistically significant. Results: 571 patients were included. Unmatched race analysis demonstrated black patients were significantly younger (p= 0.05), single (p< 0.0001), in a lower income bracket (p< 0.0001), and experienced less weight loss at 2- (p= 0.01), 6- (p= 0.007), 12- (p= 0.008) and 24- (p= 0.007) months post-op. After matching, black patients continued to experience less weight loss at 2- (p= 0.01) and 6- (p= 0.03) months, which trended at 1 year (p= 0.06). Initial income analysis demonstrated patients in the low-income group (LIG) were more likely to be black (p< 0.0001), have ≤ high school education (p= 0.004), a higher preoperative BMI (p= 0.008), and lower postoperative weight loss at 2- (p= 0.001), 6- (p= 0.01), and 12- (p= 0.04) months after surgery. After matching, no differences were observed up to 3-years post-op. Analysis of education demonstrated no effect on weight loss in both unmatched and matched analyses. Conclusion: Unmatched analysis demonstrated that low income and race impact short-term weight loss after BS. After matching, however, race, not socioeconomic status, predicted weight loss outcomes up to 1-year.

Introduction: Tobacco use worsens gastrointestinal reflux disease (GERD). Smoking cessation improves GERD symptoms, but its impact on the efficacy of laparoscopic anti-reflux surgery (LARS) is unclear. In this retrospective cohort study, we hypothesized that non-smokers would demonstrate greater long-term improvements in disease-specific quality of life than active smokers. Methods: Data were maintained in an IRB-approved prospective database, and patients were stratified according to tobacco use. Postoperative follow-up occurred in clinic and long-term follow-up via telephone interview. Outcomes measured were gastroesophageal health-related quality of life (GERD-HRQL) and GERD symptom scale (GERSS) scores, proton pump inhibitor (PPI) cessation, and satisfaction with surgery. Results: Two hundred and thirty-five patients underwent primary LARS, and 31 (13%) were active smokers with 18 median pack-years [10–30]. Baseline PPI use (96% vs. 94%, p= 0.64), presence of a hiatal hernia (79% vs. 68%, p= 0.13), esophagitis (28% vs. 45%, p= 0.13), and DeMeester score (41.9 vs. 33.6, p= 0.47) were similar. Baseline GERD-HRQL and GERSS scores and their post-surgical decreases were also similar between groups. PPI cessation was achieved in 92% of non-smokers and 94% of smokers (p= 0.79), and GERD-HRQL scores decreased to 4 [1–7] and 5 [0–12], respectively (p= 0.53). After 59 [25–74] months, GERD-HRQL scores were 5 [2–11] and 2 [0–13] (p= 0.61) and PPI cessation was maintained in 69% and 79% of patients (p= 0.59). Satisfaction with surgery was similar between smokers and non-smokers (88% vs. 87%, p= 0.85). Female gender was significantly associated with increased improvements in GERD-HRQL (p< 0.01) and GERSS scores (p= 0.04) postoperatively but not at long-term follow-up. Patients without a hiatal hernia were less likely to achieve long-term PPI cessation compared to those with a hernia (OR 0.23, p< 0.01). Conclusions: After 5 years, smokers demonstrate similar symptom resolution, PPI cessation rates, and satisfaction with surgery as non-smokers. Active smoking does not appear to negatively impact long-term symptomatic outcomes of LARS.

Background: Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is used for psychological screening of bariatric surgery (BS) candidates. To date, no studies have analyzed the relationship between MMPI-2 and early returns to hospital. The aim of this study was to determine whether high Tscores on the MMPI-2 clinical scales were associated with early return to hospital after primary bariatric surgery. Methods: Patients who completed an MMPI-2 evaluation, undergoing primary BS from 2014 to 2016 were evaluated. Tscore for the tested scales were collected and stratified into a high Tscore (T> 65) vs not (T< 65). The optimal ‘cut-point’ (specific number of high Tscores predicting likelihood for 30-day ED-visit/hospital readmission) was calculated using Youden’s Index (J) = Max(c) [sensitivity (c) + specificity (c) − 1], where c= number of scales with a Tscore > 65. Patients were stratified based on the optimal cut-point which was determined to be ≥ 4 high Tscores. Univariate and multivariate logistic regression analyses were used to identify differences between groups and predictors for early ED-visits and hospital readmissions. Results: 375 patients had psychological evaluations available for review. Patients were divided into those with ≥ 4 high Tscores (Scr(≥4); n= 86) versus not (Scr (<4); n= 289). Multivariate analysis showed Scr(≥ 4)(aOR 2.99, CI 1.20–7.47; p= 0.019), bipolar disorder (aOR 4.82, CI 1.25–18.83; p= 0.022), and urgent hospital complications (aOR 6.81, CI 2.02–22.91; p= 0.002), were significant independent predictors of 30-day readmissions. Early ED-visits were significantly predicted by public insurance (aOR 3.30, CI 1.22–8.91; p= 0.019), but the effect of the Scr(≥4)profile (aOR 2.42, CI 0.97–6.09; p= 0.06), while influential, did not reach significance. Conclusion: Differences in personality traits may be associated increased 30-day readmissions following primary bariatric surgery. Our study represents a novel application of the MMPI-2.

Background: Adipose tissue (AT) inflammation is linked to the development of type 2 diabetes (T2DM) and atherosclerosis in murine models of obesity. Reduced AT regulatory T cells (Tregs), which are anti-inflammatory immune cells, play an important part in this pathogenesis, and we have shown that AT-Tregs are inversely correlated to increasing body-mass-index. The purpose of this study was to evaluate the association between AT-Treg abundance and comorbidity status in patients undergoing bariatric surgery (BS). Methods: Visceral (intra-abdominal) AT was harvested at that time of primary BS (n= 80) and collagenase digested. AT-Treg abundance (CD4+/CD25+/FOXP3+) was characterized using flow cytometry from the AT stromal vascular fraction. The median AT-Treg abundance (3.03%) was utilized to define high (High-Tregs, n= 39) and low AT-Treg (low-Tregs, n= 38) abundance within this cohort. These two groups were compared in terms of baseline demographic data, preoperative obesity-related comorbidities, glycemic parameters, including insulin resistance (HOMA-IR). Results: Age, excess body weight, and sex were not different between groups. Prevalence of hypertension, hyperlipidemia, or T2DM preoperatively were not different between groups. Compared to High-Tregs, patients with low-Tregs were more likely to have insulin-dependent type 2 diabetes (12.5% vs 2.9%, p= 0.04). Within patients with T2DM, low-Treg patients had higher plasma insulin levels compared to high-Tregs (31.8 (28.4–56.5) vs 15.5 (10.1–23.1), p= 0.04) and trended towards higher insulin resistance (HOMA-IR) (9.0 (5.3–18.3) vs 3.5 (2.2–7.7), p= 0.08). Within those diagnosed with hyperlipidemia, preoperative statin use was higher in Low-Treg patients compared to the control cohort (91% vs 50%, p= 0.056). Low-Treg patients with hypertension were more likely to need 2 + anti-hypertensive agents preoperatively compared to their counterparts (71% vs 44%, p= 0.058). Conclusion: Within bariatric candidates, lower visceral AT-Treg abundance was associated with increased baseline medication requirements for type 2 diabetes, hypertension, and hyperlipidemia. This suggests that reduced AT-Tregs may be associated with higher obesity-related comorbidity severity.

Introduction: The optimal management of functional esophagogastric junction outflow obstruction (EJOO) remains controversial particularly in the setting of concomitant gastroesophageal reflux disease (GERD). There remains a paucity of data regarding the outcomes of laparoscopic Nissen fundoplication (LNF) in this patient population. We hypothesized that GERD patients with manometric findings of EJOO on preoperative manometry do not have increased rates of postoperative dysphagia compared to those with normal or hypotensive LES pressures. Materials and methods: This retrospective cohort study of patients undergoing LNF for GERD compared outcomes in patients with and without functional EJOO (fEJOO). The outcomes of interest included disease-specific quality of life improvement, dysphagia scores, and the need for endoscopic dilation following fundoplication. Results: Two hundred and eleven patients underwent LNF for GERD and 15 (7.1%) were classified as having fEJOO. Baseline GERD-HRQL [30.0 (21.5–37) vs. 31 (21–37), p = 0.57] were similar between fEJOO and control patients, respectively. There was no difference in baseline dysphagia scores [3.5 (2–5) vs. 2.0 (1–4), p = 0.64] between the two groups. Postoperative GERD-HRQL [5.0 (2–13) vs. 4.0 (1–8), p = 0.59] scores did not differ between fEJOO and control patients at 6-week follow-up. One year after surgery, GERD-HRQL [8.0 (3–9) vs. 4.5 (2–13), p = 0.97] did not differ between groups. Dysphagia rates were similar at 6-week (p = 0.78) and 1-year follow-ups (p = 0.96). The need for dilation at 1 year following fundoplication was similar in both cohorts (13%, p = 0.96). Conclusion: GERD patients with functional EJOO achieved similar improvements in disease-specific quality of life without increased incidence of dysphagia postoperatively.

Introduction: Contrary to published literature, our institutional data demonstrated reduced weight loss following laparoscopic sleeve gastrectomy (LSG) compared to gastric bypass (LRYGB). The purpose of this study was to determine if known predictors of poor weight loss accounted for this discrepancy at a large volume center. Methods: All patients undergoing primary LSG (n= 322) and LRYGB (n = 249), from 2014 to 2016, at a single institution were retrospectively reviewed. Baseline medical, socioeconomic, and follow-up data (6, 12, 24, and 36 months) were obtained. The first aim characterized differences in LSG and LRYGB. The second objective determined predictors of experiencing the lowest or highest quartile of excess body weight loss [(EBWL), (%EBWL-25th, %EBWL-75th)] at 12, 24, and 36 months. Thirdly, predictors of poor weight loss within sleeve gastrectomy were characterized. Results: In comparison to patients undergoing LRYGB, LSG patients demonstrated lower baseline BMI (47.9 ± 8.2 vs. 51.5 ± 10.1, p< 0.0005), lower incidences of obesity-related comorbidities (p < 0.05), were more likely to have higher education (p = 0.02), and were associated with no-shows up to 2 years post-operatively. LSG remained a strong independent predictor of %EBWL-25th at 12 months (OR = 5.2, p < 0.005), 24 months (OR = 5.3, p < 0.005), and 36 months (OR = 7.3, p = 0.006), after adjusting for comorbidities, education, and no-shows. Predictors of poor weight loss after LSG included hypertension, African American race, major depression, no-shows at 6 and 12 months. Within patients associated with these characteristics, the relative risk of experiencing poor weight loss was significantly higher following LSG compared to LRYGB at 12 months (60% vs. 25.0%, p < 0.05), 24 months (43% vs. 18%, p < 0.05), and 36 months (70% vs. 21%, p < 0.05). Conclusions: LSG remained an independent predictor of poor weight loss at all post-operative time points. Furthermore, the risk of experiencing poor weight loss was significantly higher following LSG compared to LRYGB for patients with high-risk characteristics.

Introduction: Post-operative non-urgent hospital visits (NUR-HV) are an important quality target for reducing unnecessary healthcare utilization. The primary objective of this study was to characterize 90-day post-operative hospital use and determine independent predictors for NUR-HV and urgent (UR)-HV after elective laparoscopic paraesophageal hernia repair (LPEHR) and Nissen Fundoplication (LNF). Methods: Five hundred and sixty-two primary LPEHR and LNF patients were retrospectively reviewed at a single institution. Ninety-day NUR-HV and UR-HV were compared to patients without post-operative HV using baseline medical and demographic data, preoperative work-up (manometry, pH testing, disease-specific quality of life and symptom scale scores (GERSS), and hospital course. Multiple logistic models were created using univariate associations (p< 0.1) to model independent predictors of NUR-HV and UR-HV. Results: NUR-HV accounted for 52% (n= 30) of all 90-HV, while the remaining were UR-HV (n= 28, 48.3%). Compared to controls, NUR-HV were younger (51.2 ± 16.8 years vs. 57.6 ± 15.2, p= 0.05), had a lower baseline BMI (28.2 ± 6.4 vs. 31.3 ± 5.4, p= 0.003) and ASA scores (p= 0.02), presented with higher GERSS (46 (28–60) vs. 35 (19–48), p= 0.02) and dysphagia scores (3 (1–5) vs. 2 (0–4), p= 0.02), were associated with LNF (77.7% vs. 54.6%, p= 0.02), and experienced more post-operative dysphagia (13.3% vs. 4.6%, p= 0.06). UR-HV were older (64.0 ± 13.2 vs. 57.6 ± 15.2, p= 0.03), associated with LPEHR (67.9% vs. 45.4%, p= 0.02), longer hospital stay (2 (1–3) vs. 1 (1–2), p= 0.003), and increased overall (39.3% vs. 15.1%, p= 0.001) and urgent complications (34.6% vs. 8.3%, p< 0.005). Positive predictors of NUR-HV included ASA score < 3 (OR 4.4, p= 0.02), increasing GERSS (1.04, p= 0.01), and reduced peristalsis (OR 4.7, p= 0.01), while UR-HV were independently predicted by urgent complications (5.0, p< 0.00005). Conclusions: NUR-HV accounted for half of post-operative visits following LNF/LPEHR and were predicted by distinct characteristics compared to UR-HV. This stratification provides novel insight that will guide both preoperative counseling and post-operative quality initiatives.

Background: Anxiety and depression have been associated with an increased perception of gastroesophageal reflux symptoms, but there is a paucity of data regarding the outcomes of laparoscopic Nissen Fundoplication (LNF) in this patient population. Methods: We performed a retrospective cohort study including all patients undergoing LNF between 2011 and 2017. Patients were stratified by baseline usage of serotonin-modulating medication or benzodiazepines as a proxy for depression and anxiety, respectively. Outcome measures included postoperative gastroesophageal health-related quality of life (GERD-HRQL) scores and overall satisfaction rates after surgery. A pvalue of < 0.05 was considered statistically significant. Results: The population consisted of 271 patients of which 103 patients had depression and 44 patients had anxiety. Patients with depression reported no significant difference in pre- or postoperative GERD-HRQL scores compared to patients without depression and long-term satisfaction rates after surgery were similar in both groups at 76% vs 71%, respectively (p= 0.55). Patients with anxiety reported higher baseline HRQL scores (34 vs. 29, p= 0.05). At long-term follow-up (15 months), patients with anxiety reported slightly worse HRQL scores compared to controls (7 vs. 4, p= 0.11) despite no difference in usage of anti-acid medications or need for endoscopic dilations between the two groups. Patients with anxiety were less likely to report being “satisfied” after surgery (40% vs. 71%, p= 0.01) compared to controls. Conclusion: Patients with anxiety have higher subjective reporting of GERD symptoms and are more likely to report being “satisfied” during long-term follow-up after LNF. Patients on medication for depression appear to have similar reporting of GERD symptoms and derive as much benefit from LNF as patients that are not. While LNF does improve the symptom burden in patients with anxiety, satisfaction is rarely achieved in long-term follow-up.

The impact of well-controlled or historical psychiatric diagnoses in patients seeking bariatric surgery (BS) on perioperative outcomes is unclear. The primary objective of this study was to determine the impact of psychiatric diagnoses on hospital length of stay (LOS), 30-day readmission rates after BS, and post-operative weight loss outcomes. Patients who underwent laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (LRNYGB) from 2014 to 2016 at a single academic institution were retrospectively reviewed. Baseline demographic data and psychiatric history including depression, anxiety, and/or bipolar disorder (DAB) were obtained from the electronic medical record. Hospital LOS, 30-day readmissions, and % excess body weight loss (%EBWL) were obtained on all patients and compared between DAB patients and those without any psychiatric history. During the study period, 354 patients were reviewed, of which 78% were female; 60% underwent LSG. The mean preoperative BMI was 48.9 ± 8.4 m/kg2. Major depression was the leading diagnosis (42%), and 13% had both depression and anxiety. The 30-day readmission rate was significantly higher than the control (10.5% vs. 3.7%, p= 0.02). Mean hospital LOS and the incidence of long hospital LOS (≥ 4 days) was not different between the groups, although within LSG patients, the incidence of long hospital LOS trended towards being higher for DAB patients (9.2% vs. 4%, p= 0.10). Patients with depression and anxiety had a higher incidence of long LOS (23.4% vs. 9.2%, p< 0.005). While 6-month %EBWL was significantly lower for DAB patients (41% vs. 46%, p= 0.004), 1-year weight loss outcomes were not different, even when adjusting for surgical procedure. Patients with baseline or historical DAB had significantly higher early readmission rates, and those with multiple diagnoses were associated with a hospital LOS ≥ 4 days. Future studies should focus on elucidating the impact of psychiatric diagnoses on these quality metrics.

Transoral incisionless fundoplication (TIF) offers an endoscopic approach to the treatment of gastroesophageal reflux disease (GERD). Controlled trials have demonstrated the short-term efficacy of this procedure, but long-term follow-up studies are lacking. The objective of this study was to evaluate the long-term impact of TIF on disease-specific quality of life and antisecretory medication use. We performed retrospective cohort study of all patients undergoing TIF between 2007 and 2014 in a large academic medical center. Reflux symptoms and quality of life were assessed using the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) questionnaire at baseline, short-term, and long-term follow-up. Fifty-seven patients with a median age of 46 (37–59) years and an average BMI of 28.8 ± 4.9 kg/m2underwent TIF during the study period. Sixty percent of the patients were female, and all were taking a PPI at least daily. At a median follow-up interval of 97 months, twelve patients had undergone subsequent laparoscopic antireflux surgery (LARS). Of those who had not, 23 had complete long-term follow-up data for analysis and were included in the study. Seventy-three percent reported daily acid-reducing medication use, and the median GERD-HRQL score was 10 (6–14) compared to 24 (15–28) at baseline (p< 0.01). Seventy-eight percent of these patients expressed satisfaction or neutral feelings about their GERD management. There were no significant differences in the baseline characteristics of patients who underwent LARS during the study period and those who did not. This study demonstrates that TIF can produce durable improvements in disease-specific quality of life in some patients with symptomatic GERD. The majority of patients resumed daily PPI therapy during the study period, but with significantly improved GERD-HRQL scores compared to baseline and increased satisfaction with their medical condition.

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. The mean age was 53.4 (range 7–102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n= 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n= 370, 15.5%) and acute biliary pancreatitis (n= 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient’s first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.

Adipose tissue has emerged as an important window into cancer pathophysiology, revealing potential targets for novel therapeutic interventions. The goal of this study was to compare the breast adipose tissue (BrAT) immune milieu surrounding breast carcinoma and contralateral unaffected breast tissue obtained from the same patient.

Late complications after a laparoscopic inguinal hernia repair are extremely rare and have only recently entered into the literature. One such late complication is mesh infection, of which there have been a handful of cases reported in the literature. Mesh infections occurring many years after inguinal hernia repairs are not only of significance because they are not well documented in the literature, and the pathogenesis and risk factors contributing to their development are not well understood. This report details a rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology.