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Background: Postoperative pain remains undertreated in critically ill patients. We hypothesized that the adequacy of pain control in our Surgical Intensive Care Unit (SICU) was above the reported average of 71 % in the literature and that the introduction of the critical care pain observation tool (CPOT) could improve it. We used a Lean Six Sigma methodology to improve our processes and quantify our improvement., Patients and Methods: We retrospectively review 713 consecutive veterans admitted to our SICU. Between December 2014 and February 2015, postoperative pain was assessed every 2 h and rated "acceptable," "unacceptable," or "unable to assess". Between March 2015 and October 2015, postoperative pain was assessed with CPOT. Concurrently, we implemented a postoperative pain education program and documented this activity in the electronic medical record., Results: The baseline adequacy of pain control was 78 %, which improved to 99 % after the introduction of CPOT. We concurrently achieved a 100 % median documentation of postoperative pain education in the electronic medical record. The introduction of CPOT improved the process σ from 2.3 to 3.8. The process of documenting pain education achieved a process σ of 3.1., Conclusions: The proportion of veterans with acceptable pain control in our SICU is higher than that reported in the literature and the application of a Six Sigma methodology that involved the introduction of the CPOT has allowed us to improve the perception of pain control and comply with the newest regulatory directives.

A giant colonic diverticulum is a diverticulum of the colon greater than 4 cm in diameter that can present, albeit rarely, as a complication of diverticular disease. We discuss the three different histologic subtypes that have been described and the challenges in the diagnosis and treatment.

From the earliest description of dysphagia relieved by dilatation with a whalebone in 1674 we have witnessed the evolution of esophageal function testing from the conventional manometry to the high-resolution manometry (HRM) and esophageal topography pressure plotting that have led to the revised Chicago classification for esophageal motility disorders in 2014. The goals of this paper are, therefore, (1) to highlight the historical milestones that have led to the diagnostic definition of achalasia, as we know it today; (2) to describe the evaluation process of patients with suspected achalasia; (3) to describe the diagnostic value of the HRM and the usefulness of the Chicago classification in predicting treatment outcomes. The value of Chicago classification is linked to the ability of the clinician to perform a thorough clinical evaluation to identify and correlate specific clinical phenotypes to specific manometric subtypes and predict treatment outcomes. Chicago classification, however, cannot predict which treatment, pneumatic dilatation, or Heller myotomy, should be selected for those with a specific subtype of achalasia.

Epiphrenic diverticula are a rare disease almost always associated with an underlying motility disorder of the esophagus, such as achalasia. Treatment of any underlying motility disorder must be included in the management of epiphrenic diverticula to prevent postoperative complications and recurrences. Therefore, the goal of this paper is to describe the pathophysiology, clinical presentation, and proper methods of diagnosis and treatment of patients with epiphrenic diverticula. In addition, we aim to provide an overview of the surgical management and discuss the indications for surgery and choice of surgical approach. In general, surgical intervention is favored for symptomatic patients and the optimal surgical approach depends on the size and location of the diverticulum. Surgery is not without seemingly high rates of morbidity when a myotomy is not performed together with the diverticulectomy, even in those with normal manometry. The risk of carcinoma is exceedingly rare and it is usually discovered at later stages; therefore, no surveillance programs have been established in asymptomatic patients with unresected diverticula.

New trends have emerged regarding the best minimally invasive access approaches to perform gastrointestinal surgery. However, these newer approaches are seen critically by those who demand a more strict assessment of outcomes and safety. An international panel of expert gathered at the 2014 American College of Surgeons Meeting with the goal of providing an evidence-based understanding of the real value of these approaches in gastrointestinal surgery. The panel has compared the efficacy and safety of most established approaches to gastrointestinal diseases to those of new treatment modalities: peroral esophageal myotomy vs. laparoscopic myotomy for achalasia, transgastric vs. transvaginal approach, and single-incision vs. multi-port access minimally invasive surgery. The panel found that (1) the outcome of these new approaches was not superior to that of established surgical procedures; (2) the new approaches are generally performed in few highly specialized centers; and (3) transgastric and transvaginal approaches might be safe and feasible in very experienced hands, but cost, training, operative time, and tools seem to limit their application for the treatment of common procedures such as cholecystectomy and appendectomy. Because the expected advantages of new approaches have yet to be proven in controlled trials, new approaches should be considered for adoption into practice only after thorough analyses of their efficacy and effectiveness and appropriate training.

Importance: Although the diagnostic evaluation and technical elements for a successful laparoscopic fundoplication have been clearly identified, 10% to 20% of patients will eventually experience recurrence of their symptoms. The management of patients who fail antireflux surgery is complex and not well codified., Objective: To provide an evidence- and experience-based analysis of the causes of failed antireflux surgery and to underscore the principles of treatment., Evidence Review: PubMed was searched for articles published between 1980 and 2014. The search terms included were the following: heartburn, regurgitation, dysphagia, gastroesophageal reflux disease, cough, aspiration, laryngitis, GERD, GORD, endoscopy, manometry, pH monitoring, proton pump inhibitors, and Nissen fundoplication., Findings: Before planning therapy, a careful workup is necessary to determine whether the symptoms are due to recurrent reflux and to understand what caused the recurrence. Subsequently, therapy needs to be individualized based on the symptoms and on the findings of the workup. In some patients, a nonesophageal cause will be identified. Among patients with recurrent reflux, some will do well with acid-reducing medications and others will need another operation., Conclusions and Relevance: Laparoscopic antireflux surgery is a very effective and long-lasting treatment for gastroesophageal reflux disease. Its success is based on a careful preoperative evaluation and on the performance of a fundoplication that respects the key technical elements. Patients who are still symptomatic postoperatively must be thoroughly evaluated to identify the cause of failure, and treatment must be individualized.

Introduction: Morbid obesity and achalasia may coexist in the same patient. The surgical management of the morbidly obese patient with achalasia is complex, and the most effective treatment still remains controversial. The goal of our report is to provide our evidence-based approach for the surgical management of the patient with achalasia and morbid obesity., Results: Three main surgical approaches have been used for the concomitant treatment of morbid obesity and achalasia: 1) a laparoscopic Heller myotomy and a laparoscopic Roux-en-Y gastric bypass (LRYGB); 2) a laparoscopic Heller myotomy with bilio-pancreatic diversion; and 3) a laparoscopic Heller myotomy with a sleeve gastrectomy. Our approach of choice is the first one discussed, that is the laparoscopic Heller myotomy with a LRYGB, as this approach can provide excellent relief of symptoms and control of reflux while at the same time treating obesity and its comorbidities., Conclusions: Achalasia and obesity can coexist, albeit infrequently. A laparoscopic Heller myotomy with a LRYGB allows the simultaneous treatment of both diseases. When a morbidly obese patient with achalasia chooses to have a myotomy alone and not a LRYGB, a thorough discussion of the risks and benefits should occur and the autonomy of the patient's decision-making should be respected.

The advent of endoscopic techniques has transformed the surgical therapy of Zenker's diverticula. Although the treatment paradigm has shifted to minimally invasive approaches with endoscopic stapling-assisted or laser-assisted repair, traditional transcervical procedures can still play a role in selected cases. The goal of this article is to illustrate our tailored approach to patients with Zenker's diverticula and illustrate our open surgical and endoscopic techniques. The discussion will also include the evidence-based rationale for our preoperative assessment and choice of technique.

Background: The topic of "when and what" for gastroesophageal reflux disease (GERD) procedures centers on the correct indications for antireflux surgery gleaned from a thorough preoperative evaluation (the "when") and on the right antireflux operation to perform once the ideal candidate is identified (the "what")., Aims: The goals of this evidence-based review are the following: (1) to identify the key indications for surgery and predictors of good outcomes in the initial evaluation of patients with symptoms of GERD; (2) to describe the operations for GERD in the armamentarium of the general surgeon and their indications, as well as the technical elements of the operation; and (3) to describe the optimal surgical treatment of GERD and obesity when the two diseases coexist.

Background: The year 2014 marks the 100th anniversary of Dr. Heller's description of the surgical treatment of patients with achalasia with a cardiomyotomy. This 100-year-old operation, which is today performed laparoscopically with the addition of a partial fundoplication, is considered the treatment of choice for patients with achalasia., Purpose: Our goals are to revisit the accounts from the beginning of the twentieth century in which surgeons tried to identify the pathophysiology of achalasia and proposed several operative techniques and to follow the evolution of the surgical treatment until modern days.

Background: Gastroesophageal reflux disease (GERD) is thought to lead to aspiration and bronchiolitis obliterans syndrome after lung transplantation. Unfortunately, the identification of patients with GERD who aspirate still lacks clear diagnostic indicators. The authors hypothesized that symptoms of GERD and detection of pepsin and bile acids in the bronchoalveolar lavage fluid (BAL) and exhaled breath condensate (EBC) are effective for identifying lung transplantation patients with GERD-induced aspiration., Methods: From November 2009 to November 2010, 85 lung transplantation patients undergoing surveillance bronchoscopy were prospectively enrolled. For these patients, self-reported symptoms of GERD were correlated with levels of pepsin and bile acids in BAL and EBC and with GERD status assessed by 24-h pH monitoring. The sensitivity and specificity of pepsin and bile acids in BAL and EBC also were compared with the presence of GERD in 24-h pH monitoring., Results: The typical symptoms of GERD (heartburn and regurgitation) had modest sensitivity and specificity for detecting GERD and aspiration. The atypical symptoms of GERD (aspiration and bronchitis) showed better identification of aspiration as measured by detection of pepsin and bile acids in BAL. The sensitivity and specificity of pepsin in BAL compared with GERD by 24-h pH monitoring were respectively 60 and 45 %, whereas the sensitivity and specificity of bile acids in BAL were 67 and 80 %., Conclusions: These data indicate that the measurement of pepsin and bile acids in BAL can provide additional data for identifying lung transplantation patients at risk for GERD-induced aspiration compared with symptoms or 24-h pH monitoring alone. These results support a diagnostic role for detecting markers of aspiration in BAL, but this must be validated in larger studies.

The goal of this review is to illustrate our approach to patients with achalasia in terms of preoperative evaluation and surgical technique. Indications, patient selection and management are herein discussed. Specifically, we illustrate the pathogenetic theories and diagnostic algorithm with current up-to-date techniques to diagnose achalasia and its manometric variants. Finally, we focus on the therapeutic approaches available today: medical and surgical. A special emphasis is given on the surgical treatment of achalasia and we provide the reader with a detailed description of our pre and postoperative management.

Since their introduction in the early 1990s, minimally invasive techniques have gained widespread acceptance because of the significant benefits that patients are able to experience. Some of these benefits include reduced postoperative pain, earlier return to normal activity, and improved cosmesis when compared with open surgery. For these reasons, since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has been increasingly utilized for a safe surgical removal of the spleen with nearly equivalent or superior short- and long-term outcomes when compared with the open approach. In this technical report, we aim to describe our preoperative and postoperative management of patients undergoing LS and to illustrate our preferred surgical technique, its rationale, and our results.

Introduction: Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the USA. Heartburn is the symptom most commonly associated with this disease, and the highly commercialized medical treatment directed toward relief of this symptom represents a 10-billion-dollar-per-year industry., Discussion: Unfortunately, there is often little awareness that GERD can be potentially a lethal disease as it can cause esophageal cancer. Furthermore, there is even less awareness about the relationship between GERD and respiratory disorders with the potential for severe morbidity and even mortality.

The increased prevalence of gastroesophageal reflux disease (GERD) in lung transplantation patients has been established; however, many questions persist regarding the relationship of GERD to aspiration and its potential to induce pulmonary allograft failure. Moreover, the biological implications of aspiration in lung transplantation have yet to be fully elucidated. The goal of this review was to assess the relationship between GERD and aspiration, focusing on the role of these events in the development of allograft injury after lung transplantation.

Until recently catheter-based 24-h pH monitoring has been the primary methodology for the objective diagnosis of gastroesophageal reflux disease. Yet, this system has some drawbacks, such as patient discomfort, marginal sensitivity, and the inability to detect nonacid reflux. Hampered by these limitations, several new techniques have been recently introduced in clinical practice. In particular, wireless capsule pH monitoring and multichannel intraluminal impedance-pH testing have been forwarded as more sophisticated means of enhancing patient comfort during testing as well as our ability to diagnose gastroesophageal reflux disease, especially in those patients who complain of symptoms of gastroesophageal reflux disease despite adequate acid suppression therapy. The goal of this review is to compare the clinical applicability, advantages and drawbacks of catheter-based 24-h pH testing, wireless capsule pH monitoring, and multichannel intraluminal impedance-pH., (Copyright © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Introduction: Several studies have confirmed that gastroesophageal reflux disease (GERD) in lung transplant patients is a risk factor for the development and progression of bronchiolitis obliterans syndrome (BOS), a form of rejection after lung transplantation. Moreover, numerous reports indicate that surgical correction of GERD may control the decline in lung function characteristic of BOS. Although laparoscopic fundoplication is an accepted treatment option for these patients with GERD, the surgical technique, which often includes a laparoscopic pyloroplasty, has not been standardized., Methods: The purpose of this article is to describe a step-by-step approach to the laparoscopic treatment of GERD in lung transplant patients. We also address specific technical concerns encountered in the surgical management of this high-risk patient population; we provide data on the safety of this operation; and we illustrate the evidence-based rationale for each technical step of the procedure.