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Background No platform for objective, synchronous and on-line evaluation of both intraoperative error and surgeon physiology yet exists. Electrokardiogram (EKG) metrics have been associated with cognitive and affective features that are known to impact surgical performance but have not yet been analyzed in conjunction with real-time error signals using objective, real-time methods. Methods EKGs and operating console point-of-views (POVs) for fifteen general surgery residents and five non-medically trained participants were captured during three simulated robotic-assisted surgery (RAS) procedures. Time and frequency-domain EKG statistics were extracted from recorded EKGs. Intraoperative errors were detected from operating console POV videos. EKG statistics were synchronized with intraoperative error signals. Results Relative to personalized baselines, IBI, SDNN and RMSSD decreased 0.15% (S.E. 3.603e−04; P = 3.25e−05), 3.08% (S.E. 1.603e−03; P P = 5.66e−06), respectively, during error. Relative LF RMS power decreased 1.44% (S.E. 2.337e−03; P = 8.38e−10), and relative HF RMS power increased 5.51% (S.E. 1.945e−03; P Conclusions Use of a novel, on-line biometric and operating room data capture and analysis platform enabled detection of distinct operator physiological changes during intraoperative errors. Monitoring operator EKG metrics during surgery may help improve patient outcomes through real-time assessments of intraoperative surgical proficiency and perceived difficulty as well as inform personalized surgical skills development. Graphical abstract

BackgroundThe coronavirus pandemic has caused a worldwide health crisis. Bariatric patients require extensive pre- and post-operative follow-up, which may be less feasible during public health social distancing mandates. We assessed the impact of the pandemic on the behaviors and weight loss outcomes of our pre- and post-operative bariatric patients.MethodsA retrospective review of a prospectively maintained database identified patients who underwent either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at a single institution between March 2018 and May 2020. A cohort undergoing surgery within 12months before the pandemic as well as a cohort undergoing a medically supervised diet prior to surgery was surveyed regarding pre- and post-COVID-19 lifestyle habits. Excess weight loss (EWL) outcomes from a group of pre-COVID surgical patients were compared to that of a group of post-COVID surgical patients. Primary outcome was whether the lockdown changed 1-year weight loss outcomes. Secondary outcome was whether patient lifestyle behaviors were changed during the pandemic.ResultsThere was no difference in 1-year EWL between pre- and post-COVID SG patients (51.7% versus 55.9%, p = 0.35), or between pre- and post-COVID RYGB patients (88.9% versus 80.4%, p = 0.42). Pre-stay-at-home order, 91.8% endorsed physical activity compared to 80.3% post-stay-at-home order (p = 0.0025). Mean physical activity decreased from 4.2h/week to 2.7h/week after the stay-at-home order (p

BackgroundEarly experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease.MethodsA Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n= 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year.ResultsThe model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year.ConclusionThe current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.

Laparoscopic cholecystectomy with fluorescent cholangiography using indocyanine green dye (FC) identifies extrahepatic biliary structures, potentially augmenting the critical view of safety. We aim to describe trends for the largest single-center cohort of patients undergoing FC in laparoscopic cholecystectomy.A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy with FC at a single academic institution. Patient factors included age, sex, BMI, and American Society of Anesthesiologists score. Outcomes included operative time, conversion to open procedure, biliary injury, length of stay, and complications.A total of 828 patients underwent FC. Of these, 74.3% were female, the mean age was 50.4 years, and the average BMI 28.8 kg/m 2 . Mean operating room time was 68.6 minutes. There were no mortalities or common bile duct injuries. Morbidities included 4 bile leaks and 1 retained stone. Six patients required conversion to an open approach. Operative time, length of stay, and open conversion significantly decreased after a standard indocyanine green protocol (plt; 0.05). Compared with white light, FC demonstrated lower operative times (99 vs 68 minutes), length of stay (1.4 vs 0.4 days), open conversions (8% vs 0.7%), emergency department visits (13% vs 8%) and drain placements (12% vs 3%) (all plt; 0.05). Patients with BMI greater than 30 saw elevated operative times and length of stay.In conclusion, this paper demonstrates improved operative outcomes with the use of FC through the consistent ability to delineate biliary anatomy, even in the setting of complex anatomy. No common bile duct injuries have occurred in our 7-year experience with FC. We recommend FC as the standard of care when performing laparoscopic cholecystectomies.

Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the “critical view of safety” with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes. A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion. A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15–94), average BMI 29.4 kg/m2 (13.3–55.6). 989 patients (71.2%) underwent LC without fluorescence and 400 (28.8%) underwent FC with ICG. 30-day mortality detected 2 cases in the non-ICG group and zero with ICG. ICG reduced operative time by 26.47 min per case (p

Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4–8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed > 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or > 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE). Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival. 97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36–85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04). Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients.

Compared to other common outpatient operations, laparoscopic cholecystectomy has higher rates of unanticipated hospital admission with reports ranging from 1.0 to 39.5%. Identification of simple preoperative risk factors for admission can aid appropriate patient selection. The aim of this study was to evaluate the association of obesity with need for hospital admission and day of surgery postoperative complications. The ACS NSQIP database from 2007 to 2016 was used to evaluate patients ≥ 18 years old who had undergone outpatient laparoscopic cholecystectomy. The primary outcome was hospital admission, defined as hospital length of stay ≥ 24 h. The secondary endpoint was postoperative complications on day of surgery. A multivariable logistic regression was used to evaluate the association of body mass index (BMI) and the outcomes of interest. Odds ratio (OR) and their 95% confidence interval (CI) were reported. 192,750 patients underwent laparoscopic cholecystectomy in the outpatient setting. 38,945 (20.20%) required hospital admission. 89 (0.05%) had postoperative complications on the day of surgery. On multivariable logistic regression analysis, when compared to the baseline cohort of BMI ≥ 30 and 50 kg/m2 should be considered on a case-by-case basis.

Delayed gastric emptying (DGE) can be caused by gastric motility disorders such as gastroparesis with idiopathic background, diabetic neuropathy, or postsurgical nerve damage. Currently, a variety of endoscopic and surgical treatment options are available. We noted clinical improvement of gastric emptying with reduction of the gastric fundus following both fundoplication and fundectomy. As a consequence, we explored the effect of sleeve gastrectomy on gastric emptying. The focus of this paper is to investigate the role of laparoscopic sleeve gastrectomy (LSG) in the treatment of gastroparesis.Patients with symptoms suggestive of gastroparesis received diagnostic work-up (gastric emptying scintigraphy and/or Radiographic Barium-Sandwich Emptying studies). Patients with fundic emptying problems and moderate gastric dilation were selected for a LSG. All perioperative parameters were documented regarding patients characteristics, complications, and outcomes expressed as symptoms and quality of life (GIQLI gastrointestinal quality of life index). Assessment of DGE: Barium Emptying Radigraphy Index (BERI) 0-5.From 122 patients with gastroparesis, 19 patients were selected for LSG (mean age 54 years (23-68); 10 males/9 females. Morbidity 2/19; no mortality; follow-up mean 24 months (12-60); preop/postop: BERI: 2, 31/1, 27 (p 0.01); we noted significant improvement of the quality of life (preoperative GIQLI 78 (44-89)) to postoperative values of 114 (range 87-120) (p 0.0001). Preoperative median BMI of these 19 patients was 24 [1-10], which was not significantly changed in the 15 patients at 1 year follow-up with 23 [1-8]. Postoperative recurrence of DGE occurred in 3 patients who were reoperated after 1 year follow-up.LSG is a potential surgical treatment option for selected patients with gastroparesis and fundic emptying problems.

Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair.A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention.Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective.Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

Transanal hybrid rectal and colon resection have been introduced in recent years at dedicated surgical centers. The anus is used as a natural orifice for large size access. The use of transanal hybrid colectomy techniques is still in its infancy with outcomes and unique complications being identified. The purpose of this work is the evaluation of outcomes for transanal hybrid colon resections (ta-CR), including intra operative and postoperative complications, results, and advantages. A prospectively maintained database was analyzed. Inclusion criteria were any patient who underwent ta-CR for rectal prolapse, slow transit, obstructive defaecation, and chronic sigmoid diverticulitis. Patients were excluded from ta-CR if BMI > 30, major previous abdominal surgery, or presence of a large inflammatory mass in diverticulitis. Transanal access was used for all operative steps requiring access of more than 5 mm, such as staplers, large graspers, and specimen retrieval. Data acquisition and analysis was performed for operative time, complications, and postoperative quality of life. From 2012 to 2017, 82 patients underwent ta-CR [33 males, 49 females, median age 58 (24–80)]. Transanal-subtotal colectomy and ta-CR for constipation was performed in 12 patients; ta-CR and rectopexy in 31, and ta-CR for diverticulitis was performed in 39 patients. Conversion to traditional approach was required in 3 cases (3.6%). Intraoperative complication included 1 rectal tear requiring intervention. Post-op complications included 3 leaks requiring laparoscopic and 1 open revision, the latter developed wound infection and an incisional hernia. Gastrointestinal Quality of Life Index (GIQLI) improved significantly from preoperative 89 to postoperative 119 (p

Introduction: Paraesophageal hernias readily affect the elderly with a median age of presentation between 65 and 75 years. Laparoscopic paraesophageal hernia repair (PEHR) is a technically challeng...

This is a pre-copyedited, author-produced version of an article accepted for publication in Diseases of the Esophagus following peer review. The version of record Fuchs, K. H., DeMeester, T. R., Otte, F., Broderick, R. C., Breithaupt, W., Varga, G. & Musial, F. (2021). Severity of GERD and disease progression. Diseases of the Esophagus, ?(?), ?. is available online at: https://doi.org/10.1093/dote/doab006 Background - Many factors may play a role in the severity and progression of gastroesophageal reflux disease (GERD) since pathophysiology is multifactorial. Data regarding the progression of GERD are controversial: some reports of increased esophageal acid exposure (EAE) and mucosal damage were considered as evidence for a stable disease course, while others interprete these findings as disease progression. The aim of this study is to analyze a large patient-population with persisting symptoms indicative of GERD under protonpumpinhibitor-therapy and identify components characterizing disease severity and progression. Methods - Patients with symptoms indicative of GERD were included in the study in a tertiary referral center (Frankfurt, Germany). All selected patients were under long-term protonpumpinhibitor-therapy with persistant symptoms. All patients underwent investigations to collect data on their physical status, EAE, severity of esophagitis, anatomical changes, and esophageal functional defects as well as their relation to the duration of the disease. Incidence over time was plotted as survival curves and tested with Log-rank tests for the four main disease markers. Multivariate modeling with COX-regression model was used to estimate the general impact of the four main disease markers on the time course of the disease. In order to elucidate possible causal relationships over time, a path analysis (structural equation model) was calculated. Results - From the database with 1480 data sets, 972 patients were evaluated (542 males, 430 females). The mean age was 50.5 years (range18–89). The mean body mass index was 27.2(19–48). The mean time between the onset of symptoms and the diagnostic investigations was 8.2 years (1–50). A longer disease history for GERD was significantly associated with a higher risk for LES-incompetence. The mean duration from symptom onset to the time of clinical investigation was 9 years for patients with LES-incompetence (n = 563), compared to a mean of 6 years for those with mechanically intact LES (n = 95). A longer period from symptom onset to diagnostics was significantly associated with higher acid exposure. The pathway analysis was significant for the following model: ‘history’ (P P Conclusion - LES-incompetence, the functional deterioration of the LES, and the anatomical alteration at the esophagogastric junction (Hiatal Hernia) as well as an increased EAE were associated with a long history of suffering from GERD. Path modeling suggests a causal sequence overtime of the main disease-parameters, tentatively allowing for a prediction of the course of the disease.

Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the United States, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring biliary tree cannulation with intraoperative cholangiogram (IOC). Literature review and analysis of our institutional data shows fluorescence cholangiography used in conjunction with the “critical view of safety” is a noninvasive adjunct to laparoscopic cholecystectomy with improved patient outcomes. These findings support ICG as standard of care during laparoscopic cholecystectomy.

The development of advanced minimally invasive therapies has increased the involvement of endoscopic therapeutic procedures in the gastrointestinal tract. One of the most challenging maneuvers is the resection of lesions in the gut endoscopically, particularly in endoscopic submucosal dissection and full-thickness resection. An endoscopic platform developed by Fortimedix Surgical was trialed at our institution. The current state of the technology as well as its capabilities in a porcine model is described in this chapter.

The introduction of more complex transanal assisted hybrid procedures such as colorectal tumor resection and colon resection for benign disorders was followed by a rather quick acceptance by many surgeons. The most important idea behind the transanal/transcolonic route is the use of the anastomotic site as the access point into the peritoneal cavity. There is no additional risk of access site infection and complications, compared to a regular laparoscopic colorectal resection, since there is no additional site of transmural passage. Transanal endoscopic surgery has a large potential in representing the future method for a number of indications in colorectal surgery. The technological basis of these procedures needs to be developed further and optimized to facilitate the work of the endoscopists and surgeons in order to provide the adequate safety for the patients.

One early form of “Rendezvous” maneuver was developed by using laparoscopic and endoscopic techniques. This technique was applied in patients with gastric tumors and gastric lesions, which needed to be resected for histologic evaluation. By now, several other “Rendezvous” techniques have been developed and reported. Quite often these approaches are individual procedures reasoned and indicated by special individual situations of a patient. Based on these ideas, one could develop more perspectives for combined concepts to facilitate or enable an individualized technical approach for a special situation.

With the development of advanced minimally invasive therapy, the role of endoscopic involvement in therapeutic procedures in the gastrointestinal tract has substantially increased. The trend of minimizing access trauma has stimulated gastroenterologists and surgeons to use interventional endoscopic technology to replace a number of procedures, which were a mainstay in open surgery and even some in laparoscopic surgery. An endoscopic surgical platform should be able to maneuver within the gut with its intraluminal restrictions and at the same time carry the potential to be used for basic surgical tasks such as cutting, dissecting, traction, and countertraction as well as suturing. A number of new technologies have been demonstrated. Further developments in endoscopic, surgical, and multifunctional platforms are necessary in the future. Optimal multitasking platforms should have changeable end-effectors, image guidance, possibility of traction, and countertraction, as well as sufficient triangulation and at the same time steerable stability to increase precision in manipulations.

Since diseases in the upper gastrointestinal tract, especially gastric problems, were a frequent issue among patients in the twentieth century, both internists and general surgeons were very keen to have a tool to more accurately explore the esophagus, stomach, and duodenum as well as the colon to solve diagnostic questions. As a consequence, both gastroenterologists and surgeons have pushed the development of flexible endoscopy to an excellent diagnostic and therapeutic tool in the past decades. Flexible endoscopy has become a political issue especially in Europe between gastroenterologists and gastrointestinal surgeons, which limits the full exploitation of this great technology for the benefit of patients with GI disease. For GI surgeons it is important to be able to develop endoscopic understanding and skills, the possibility to request at any moment during an operation flexible endoscopic assistance. As a consequence, gastroenterologists and GI surgeons should cooperate in this great technology, since many of the actual endoscopic interventions have replaced surgical procedures or have at least widened the therapeutic spectrum in GI disease.

Antecedentes Los lipomas gastricos corresponden al 5% de los lipomas gastrointestinales. Muchos de ellos son solitarios, pequenos y asintomaticos, pero tambien pueden ocasionar sintomas obstructivos y sangrados. El tratamiento estandar es quirurgico. Caso clinico Mujer de 50 anos con antecedente de obesidad morbida, indice de masa corporal de 47.4 kg/m2, que se presenta con sintomas de epigastralgia y anemia. Se diagnostica un lipoma gastrico de 6.3 cm mediante tomografia y se confirma por biopsia endoscopica. Discusion La paciente fue exitosamente tratada a traves de gastrectomia laparoscopica en manga. Conclusion La gastrectomia laparoscopica en manga es el procedimiento de eleccion para el tratamiento de los lipomas gastricos gigantes en los pacientes con obesidad morbida cuando la anatomia lo permite. Background Gastric lipomas account for 5% of all gastrointestinal lipomas. Most of them are solitary, small and asymptomatic, however, they can cause severe symptoms such as obstruction, bleeding and intussusception. The standard treatment is surgical resection. Case report 50 years old female with history of morbid obesity with a body mass index (BMI) of 47.4 Kg/m2, who presented with symptoms of epigastric pain and anemia. CT scan of the abdomen revealed a 6.3 cm gastric lipoma, confirmed by endoscopic biopsy. Discussion Laparoscopic sleeve gastrectomy is the procedure of choice for the excision of giant gastric lipomas in the morbidly obese, when anatomically feasible.

Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA.A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients.Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/mAdequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement.

Summary Horgan et al. described the first robotic-assisted transhiatal esophagectomy in 2003. Although there is debate regarding the oncologic appropriateness of transhiatal versus thoracic approach to esophagectomy in malignancy, comparative data are still lacking. This paper with video describes step by step how and when to perform a transhiatal robotic-assisted resection in patients with esophageal cancer.

Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4-8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE).Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival.97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36-85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy 90 days after CRT (n = 62) to 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04).Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients.

Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the "critical view of safety" with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes.A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion.A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15-94), average BMI 29.4 kg/mICG cholangiography is a non-invasive adjunct to laparoscopic cholecystectomy, leading to improved patient outcomes with respect to operative times, decreased conversion to open procedures, and shorter length of hospitalization. Fluorescence cholangiography improves visualization of biliary anatomy, thereby decreasing rate of CBDI, Strasberg A injuries, and mortality. These findings support ICG as standard of care during laparoscopic cholecystectomy.

Opioid use in the U.S. has increased dramatically over the last 15 years, recently being declared a public health emergency. Opioid use is associated with esophageal dysmotility lending to a confusing clinical picture compared to true achalasia. Patients exhibit symptoms and elicit diagnostic results consistent with esophageal motility disorders, in particular type III achalasia. Modified therapeutic strategies and outcomes become challenging. Differentiating true achalasia from opioid-induced achalasia is critical. Conventional surgical interventions, i.e., myotomy, are ineffective in the absence of true achalasia. We assess the utility of esophageal muscle layer mapping with endoscopic ultrasound (EUS) in distinguishing primary from opioid-induced achalasia.From 2016 to 2019, patients with abnormal manometry and suspected achalasia underwent esophagogastroduodenoscopy and EUS mapping of esophageal round muscle layer thickness. Maximum round layer thickness and length of round muscle layer thickness 1.8 mm were collected and compared between opioid users and non-opioid users using Wilcoxon Rank sum test.45 patients were included: 12 opioid users, 33 non-opioid users. Mean age 56.8 years (range 24-93), 53.3% male patients. Mean BMI in the opioid-induced achalasia group was 30.2 kg/mEndoscopic ultrasound is an essential tool that has improved our treatment algorithm for suspected achalasia in patients with chronic opioid usage. Incorporation of EUS findings into treatment approach may prevent unnecessary surgery in opioid users.

Many laparoscopic surgeons use mesh augmentation at the hiatus with nonresorbable or absorbable mesh currently. Substantial controversies are present, and surgical meetings often feature controversial discussions. Based on the available evidence, implantation of mesh in a regular GERD patient with a small to midsize hiatal hernia cannot be recommended as a routine procedure, since the advantages seem to be quite limited with recurrence and risk of long-term complication. In large hiatal hernias (>5 cm), current evidence and meta-analysis suggest that the use of a mesh can be considered, but the risk for complications is substantial and therefore the patient should be informed about these risks. Early results on bioabsorbable mesh are promising for reduction in early recurrence, but longer-term data is needed to determine the durability of the repair. In centers of antireflux surgery with a large experience in upper GI surgery, the use of a mesh may not reduce the necessity of revisional surgery even in large hiatal hernias. Therefore, the indication for mesh implantation should be tailored and focused to each individual patient. It is the opinion of the authors that permanent mesh should not be placed for hiatal reinforcement under any circumstance due to the potentially devastating consequences of erosion or frozen hiatus. Early reports of bioabsorbable mesh placement are promising, but require longer-term follow-up.

Hiatal hernias present a clinical and anatomical entity that must be fully appreciated for safe and effective management. They are an uncommon form of hiatal hernia that present clinically in the population of patients over 65 years of age. The most common symptomatic presentations of a paraesophageal hernia (PEH) include dysphagia, regurgitation, gastroesophageal reflux, dyspnea, chest or epigastric pain or pressure, and anemia. Robotic repair of a paraesophageal hernia is an efficient and ergonomic approach to this challenging anatomical problem. Added precision and extended accessibility and visualization of the thorax from an abdominal approach makes the robotic repair a preferred surgical method. Paraesophageal hernia repair may be performed via a trans-thoracic or trans-abdominal approach. Open, laparoscopic, and robotic techniques may be applied.

The Montreal classification has described the presentation of symptoms in patients with gastroesophageal reflux disease (GERD). The authors of the Montreal classification define the disease with symptoms: “GERD is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.” Heartburn and regurgitation are the most typical symptoms characterizing GERD. In clinical practice, a variety of esophageal and extraesophageal symptoms can be documented in patients referred for the diagnostic confirmation or exclusion of GERD. GERD may present with a large variety of symptoms such as heartburn, regurgitation, thoracic pain, epigastric pain, respiratory symptoms, globus, and others. There can be an overlap with symptoms from other esophageal and gastric disorders such as dyspepsia, esophageal motility disorders, functional heartburn, hypersensitive esophagus, irritable stomach, and bowel and somatoform disorders. Since the symptom spectrum is complex, the use of objective studies can help further diagnose GERD. Objective studies and patient questionnaires should be always performed to verify the disease and help in determining treatment for GERD.

Gastroesophageal reflux disease (GERD) is a common comorbidity in the obese population. Prevalence in the obese population is estimated to be around 37-72%. Therefore, GERD may be preexisting or may occur de novo after a bariatric operation. GERD results from a failure of normal anti-reflux barriers, centered around the esophagus, lower esophageal sphincter (LES), the crural portion of the hiatus, and the stomach. The pathophysiology behind obesity-related GERD appears to be the result of a multitude of anatomic and physiologic changes at the LES imposed by the central and visceral adiposity of obesity. Fundoplication has been considered the gold standard for surgical treatment of reflux disease. Beyond RYGB, laparoscopic sleeve gastrectomy (SG) has become the most popular primary bariatric operation, but not in the treatment of GERD. While sleeve gastrectomy has shown good results of excess weight loss, the high pressure system of a sleeve has shown mixed results or increased rate of GERD. The effects of SG on GERD symptoms is debated, with studies showing both improvement of GERD symptoms as well as worsening or even de novo development. Severe GERD following sleeve gastrectomy is a well-established complication. Preoperative predictors of severe reflux should be used to have an informed discussion with patients regarding their best options for primary bariatric surgical technique. Medical therapy remains the primary therapy in worsening or de novo GERD after sleeve gastrectomy; however, surgical techniques such as conversion to RYGB or MSA are safe and effective.

Compared to other common outpatient operations, laparoscopic cholecystectomy has higher rates of unanticipated hospital admission with reports ranging from 1.0 to 39.5%. Identification of simple preoperative risk factors for admission can aid appropriate patient selection. The aim of this study was to evaluate the association of obesity with need for hospital admission and day of surgery postoperative complications.The ACS NSQIP database from 2007 to 2016 was used to evaluate patients ≥ 18 years old who had undergone outpatient laparoscopic cholecystectomy. The primary outcome was hospital admission, defined as hospital length of stay ≥ 24 h. The secondary endpoint was postoperative complications on day of surgery. A multivariable logistic regression was used to evaluate the association of body mass index (BMI) and the outcomes of interest. Odds ratio (OR) and their 95% confidence interval (CI) were reported.192,750 patients underwent laparoscopic cholecystectomy in the outpatient setting. 38,945 (20.20%) required hospital admission. 89 (0.05%) had postoperative complications on the day of surgery. On multivariable logistic regression analysis, when compared to the baseline cohort of BMI ≥ 30 and 40 kg/mPatients with super obesity have a 10% increased odds of hospital admission following laparoscopic cholecystectomy. Obesity is not associated with increased odds of same-day postoperative complications. Ambulatory laparoscopic cholecystectomy for the morbidly obese is safe; however, those with BMI 50 kg/m

This chapter contains a review on presently available and evolving endoscopic malabsorptive devices for the treatment of obesity: duodenal-jejunal bypass liner, gastroduodenojejunal bypass sleeve, duodenal mucosal resurfacing, and gastric aspiration therapy. These therapies may be a modestly effective adjunct to fill a treatment gap between lifestyle/pharmacotherapy and more invasive bariatric surgical options. The efficacy, safety, procedural review, and durability are reviewed.

This is the peer-reviewed but unedited manuscript version of the following article: Broderik, R., Fuchs, K.-H., Breithaupt, W., Varga, G., Schulz, T., Babic, B., ... Horgan, S. (2019). Clinical Presentation of Gastroesophageal Reflux Disease: A Prospective Study on Symptom Diversity and Modification of Questionnaire Application. Digestive Diseases. https://doi.org/10.1159/000502796. The final, published version is available at https://www.karger.com/Article/FullText/502796. Introduction - Symptoms occurring in gastroesophageal reflux disease (GERD) such as heartburn, regurgitation, thoracic pain, epigastric pain, respiratory symptoms, and others can show a broad overlap with symptoms from other foregut disorders. The goal of this study is the accurate assessment of symptom presentation in GERD. Methods - Patients with foregut symptoms were investigated for symptoms as well as endoscopy and gastrointestinal-functional studies for presence of GERD and symptom evaluation by standardized questionnaire. Questionnaire included a graded evaluation of foregut symptoms documenting severity and frequency of each symptom. The three types of questionnaires include study nurse solicitated, self-reported, and free-form self-reported by the patient. Results - For this analysis, 1,031 GERD patients (572 males and 459 females) were enrolled. Heartburn was the most frequently reported chief complaint, seen in 61% of patients. Heartburn and regurgitation are the most common (82.4/58.8%, respectively) in overall symptom prevalence. With regard to modification in questionnaire technique, if patients fill in responses without prompting, there is a trend toward more frequent documentation of respiratory symptoms (up to 54.5% [p < 0.01]), fullness (up to 93.9%), and gas-related symptoms (p < 0.001). Self-reported symptoms are more diverse (e.g., throat-burning [12%], mouth-burning [9%], globus [6%], dyspnea [9%], and fatigue [7%]). Conclusions - GERD symptoms are commonly heartburn and regurgitation, but overall symptom profile for patients may change depending on the type of questionnaire.

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are commonly performed bariatric procedures in obesity management. Gastroesophageal reflux disease (GERD) in this population has reported rates of 23–100%. GERD after LSG has been noted with recent studies demonstrating de novo reflux or symptom exacerbation despite weight loss. Fundoplication is not an option, and medically refractory GERD after LSG is usually treated with conversion to RYGB. GERD post-RYGB is a unique entity, and management poses a clinical and technical challenge. We evaluate safety and effectiveness of magnetic sphincter augmentation after bariatric surgery. A retrospective review of a prospectively maintained database was performed identifying patients that underwent LINX placement for refractory GERD after LSG, LRYGB, or duodenal switch across three institutions. Outcomes included complications, length of stay, PPI use, GERD-HRQL scores, and patient overall satisfaction. From March 2014 through June 2018, 13 identified patients underwent LINX placement after bariatric surgery: 8 LSG, 4 LRYGB, and 1 duodenal switch. The patients were 77% female, with mean age 43 and average BMI 30.1. Average pre-operative DeMeester score was 24.8. Pre-operatively, 5 patients were on daily PPI, 6 on BID PPI, and 1 on PPI + H2 blocker. We noted decreased medication usage post-operatively, with 4 patients taking daily PPI, and 9 off medication completely. A GERD-HRQL score was obtained pre- and post-operatively in 6 patients with average reduction from 25 to 8.5 (p value 0.002). Two patients experienced complications requiring endoscopic dilation after LINX placement. 100% of patients reported overall satisfaction post procedure. LINX placement is a safe, effective treatment option for surgical management of refractory GERD after bariatric surgery. It can relieve symptoms and obviate the requirement of high-dose medical management. Magnetic lower esophageal sphincter augmentation should be another tool in the surgeon’s toolbox for managing reflux after bariatric surgery in select patients.