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Jonathan Zadeh, Anthony Andreoni, Daniela Treitl, Kfir Ben-David Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA Background: The initial approach to gastroesophageal reflux disease (GERD) management typically involves lifestyle modification and medical therapy utilizing acid reducing agents such as histamine blockers and proton pump inhibitors. In severe cases refractory to such treatments, surgical therapy may be indicated. The gold standard for surgical treatment of GERD is the laparoscopic Nissen fundoplication. In recent years, a new technique known as magnetic sphincter augmentation (MSA) has been developed using the Linx™ Reflux Management System. This is an implantable ring of magnetic beads that is placed around the esophagus at the gastroesophageal junction to restore lower esophageal integrity. The aim of this review is to discuss the current literature regarding indications, surgical technique, efficacy, and complications of MSA using the Linx device. Methods: A standardized literature search was performed yielding 367 abstracts. After elimination due to duplicates between databases and irrelevance, 96 articles remained. The information found to be significant and non-redundant was included in this review. Conclusion: After several years of clinical application, the Linx device has been shown to not only be effective for the management of GERD but also be as effective as fundoplication. With respect to safety, the most common complication of MSA is dysphagia. This often resolved without intervention, but esophageal dilation or device explanation are occasionally necessary. Not fully appreciated in earlier reviews, erosion of the device into the esophagus appears to be the most significant complication of the device after extended follow-up. While very rare, the potentially severe consequences of this phenomenon suggest that the device should be used with some restraint and that patients should be made aware of this potential morbidity. Fortunately, in the few cases of device erosion described in the literature reviewed, the Linx device was easily and safely removed. Keywords: Linx, magnetic sphincter augmentation, GERD, Nissen fundoplication

Reduced heart rate variability (HRV) is an autonomic nervous system (ANS) response that may indicate dysfunction in the human body. Consistent evidence shows cancer patients elicit lower HRV; however, only select cancer locations were previously evaluated. Thus, the aim of the current study was to explore HRV patterns in patients diagnosed with and in varying stages of the most prevalent cancers. At a single tertiary academic medical center, 798 patients were recruited. HRV was measured via an armband monitor (Warfighter Monitor TM , Tiger Tech Solutions, Inc., Miami, FL, USA) equipped with electrocardiographic capabilities and was recorded for 5 to 7 min with patients seated in an upright position. Three time-domain metrics were calculated: SDNN (standard deviation of the NN interval), rMSSD (the root mean square of successive differences of NN intervals), and the percentage of time in which the change in successive NN intervals exceeds 50ms within a measurement (pNN50). Of the 798 patients, 399 were diagnosed with cancer. Cancer diagnoses were obtained via medical records one week following the measurement. Analysis of variance models were performed comparing the HRV patterns between different cancers, cancer stages (I-IV), and demographic strata. A total of 85% of the cancer patients had breast, gastrointestinal, genitourinary, or respiratory cancer. The cancer patients were compared to a control non-cancer patient population with similar patient size and distributions for sex, age, body mass index, and co-morbidities. For all HRV metrics, non-cancer patients exhibited significantly higher rMSSDs (11.1 to 13.9 ms, p < 0.0001), SDNNs (22.8 to 27.7 ms, p < 0.0001), and pNN50s (6.2 to 8.1%, p < 0.0001) compared to stage I or II cancer patients. This significant trend was consistently observed across each cancer location. Similarly, compared to patients with stage III or IV cancer, non-cancer patients possessed lower HRs (-11.8 to -14.0 bpm, p < 0.0001) and higher rMSSDs (+31.7 to +32.8 ms, p < 0.0001), SDNNs (+45.2 to +45.8 ms), p < 0.0001, and pNN50s (19.2 to 21.6%, p < 0.0001). The HR and HRV patterns observed did not significantly differ between cancer locations ( p = 0.96 to 1.00). The depressed HRVs observed uniformly across the most prevalent cancer locations and stages appeared to occur independent of patients' co-morbidities. This finding highlights the potentially effective use of HRV as a non-invasive tool for determining common cancer locations and their respective stages. More studies are needed to delineate the HRV patterns across different ages, between sexes and race/ethnic groups.

Squamous cell carcinoma (SCC) arising in a Zenker diverticulum (ZD) is an extremely rare entity. Approximately 50 cases have been reported worldwide. We report a case of a 74-year-old man who presented to our institution with chronic regurgitation, dysphagia and halitosis. The patient was initially seen in 2015 at which point he reported a 10-year history of these symptoms and was diagnosed with ZD. A barium swallow was done revealing a large posterior esophageal diverticulum with significant residual contrast within the diverticulum lumen. Given these findings, he was taken for open surgical excision where a SCC was identified. Although it is extremely rare for a SCC to occur in a ZD, patients with ZD must undergo regular surveillance endoscopy of the esophagus and the diverticulum itself to identify any suspicious mass or lesion arising in within., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2022.)

Heterotopic mesenteric ossification (HMO) is abnormal bone formation in tissues which usually do not undergo ossification. There are approximately 75 cases reported worldwide. We present two cases of HMO. The first case is that of a 39-year-old man who presented with abdominal pain and a computerized tomography scan of the abdomen and pelvis revealed an apple core lesion resulting in small bowel obstruction. The second case is that of a 36-year-old woman who presented 2 months after undergoing robotic gastric sleeve resection complaining of weakness and emesis. An esophagogram revealed kinking at the distal esophagus. Surgical resection was performed in both, yielding the diagnosis of HMO. There are various theories as to the pathophysiology of HMO, but no clearly defined mechanism has been established. Management should be conservative whenever possible to prevent further ossification with subsequent surgical intervention.

Cancer research has led to unprecedented advances in treatment in recent decades. Physician-scientists have played a crucial role in these advances given their unique perspective at the intersection between basic research and clinical care, though their representation in cancer research has been in progressive decline. Cancer research programs that feature strong mentorship at the medical student level are associated with increased likelihood of alumni choosing a cancer research career path. In an effort to increase the cancer research medical student training pipeline, senior research faculty from the Tisch Cancer Institute (TCI) at the Icahn School of Medicine at Mount Sinai (ISMMS) developed the TCI Scholars Program, a rigorous mentored research training program funding medical students' summer research. This program is currently in its third year and has garnered significant interest among mentors and students alike from all four TCI Cancer Center Support Grant (CCSG)-funded research programs. Herein, we describe the development, implementation, evaluation, and major outcomes of this program., (© 2021. American Association for Cancer Education.)

Background: Anastomotic leaks (AL) are a major source of post-esophagectomy morbidity and patients are often initially asymptomatic. Debate exists on timing and utility of imaging to detect AL post-esophagectomy. We sought to evaluate the efficacy and timing of radiographic AL evaluation in esophageal cancer patients post-esophagectomy., Methods: A retrospective database of esophageal cancer patients who underwent esophagectomy at a single institution from 2004 to 2020 was used to determine the utilization, timing, and sensitivity of radiologic testing for AL post-esophagectomy., Results: Seventy-six patients were identified of which 37 (49%) had a cervical anastomosis. Sixty-four (84%) underwent 71 "asymptomatic radiographic leak tests" (ARLT), 7 of which had 2 different tests, including: 41 fluoroscopic esophagrams (58%), 18 CT-esophagrams (25%), and 12 upper GI studies (17%). Seventeen patients (22%) developed clinical signs of AL (hemodynamic instability, leukocytosis) and underwent "symptomatic radiographic leak tests" (SRLT) with fluoroscopic esophagram (n = 9, 12%), CT-esophagram (n = 7, 9%), or upper GI study (n = 1, 1%). ARLT and SRLT were positive in 2/64 (3%) and 17/17 (100%) patients, respectively, for 19 total ALs (25%). Among the 17 SRLT( +) patients, 1 was also ARLT( +), 13 were initially ARLT( -), and 3 were not evaluated by ARLT. The median postoperative day for ARLT and SRLT was 4.0 (IQR 3.0-5.5) and 9.0 days (IQR 6.0-13.0), respectively, with a statistically significant difference (p < 0.005). The sensitivity and specificity of ARLT for detecting AL were 13.3% and 100.0%, respectively., Conclusions: Based on the low ARLT sensitivity, routine use of imaging to detect asymptomatic ALs post-esophagectomy may be limited. Symptomatic ALs were often present in a delayed fashion, even after initial negative imaging., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: Athletic pubalgia, commonly referred to as a "sports hernia," is a disease process characterized by groin pain produced by physical exertion often occurring in patients whose athletic activities require them to make rapid changes in direction. The groin pain is due to the traction-countertraction relationship between the adductor muscles and the weaker abdominal muscles. Hence, a few studies have shown inguinal hernia repair with adductor tenotomy to be an effective treatment for this pathology (Brody in Hernia 21:139-147, 2016, https://doi.org/10.1007/s10029-016-1520-8 ; Rossidis et al. in Surg Endosc 29:381-386, 2015, https://doi.org/10.1007/s00464-0143679-3 ). However, these studies are small and few in quantity but have demonstrated promising results. Thus, we sought to further study this combined surgical approach as a treatment for this multifactorial disease to improve our understanding and outcomes., Methods: With IRB approval, we retrospectively reviewed the charts of all patients who underwent adductor tenotomy and inguinal hernia repair for the treatment of athletic pubalgia at Mount Sinai Medical Center, Miami Beach FL. Parameters gathered included basic demographics, past medical and surgical history, athletic activity, length of surgery, length of time between surgery and follow-up, intraoperative and postoperative complications, and time to return to athletic activities., Results: A total of 93 patients underwent inguinal hernia repair with adductor tenotomy. These procedures were all performed by a single surgeon at two academic institutions. The average age of patients was 23.4 years. Athletic activities reported by the patients were as follows: American football (n = 36), soccer (n = 18), triathlon (n  = 11), track and field (n = 8), and baseball (n = 5). Less-represented activities included swimming (n = 3), tennis (n = 2), lacrosse (n = 1), golf (n = 1), and other (n = 8). Mean operative time was 72.4 min. Most patients were found to return to athletic activity in 28 days following a standardized physical therapy regimen (92.5%). Postoperative complications included recurrence of pain/symptoms (7.5%, n = 7), urinary retention (2.2%, n = 2), pain along the adductor magnus/brevis muscle group with more extraneous activity (1.1%,  n = 1), and adductor brevis hematoma 3 months following surgery and rehabilitation (1.1%, n = 1). Of the patients with recurrent pain, 2/7 reported contralateral pain., Conclusions: Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy appears to be a relatively quick and safe procedure with few postoperative complications. The majority of treated athletes are able to return to full athletic activities within 28 days of operation. While a return of symptoms has been seen in some patients, it is frequently observed on the contralateral side.

Background: Laparoscopic Nissen fundoplication is considered the current gold standard of surgical treatment of gastroesophageal reflux disease. Magnetic sphincter augmentation with the LINX ® device was developed as a less technically challenging alternative that has proven to be a safe and effective surgical antireflux procedure. Despite rapid adoption of the robotic platform in many areas of general surgery, no studies have compared laparoscopic and robotic approaches to placement of the LINX device. This retrospective study is the first to compare the robotic platform with the laparoscopic approach for minimally invasive LINX placement. Methods: We conducted a retrospective review of a total cohort of 20 patients who underwent LINX placement with hiatal hernia repair at our institution. Half of the patients underwent surgery using laparoscopy and the other half with robotic technology. Patient characteristics, surgical outcomes, and charge differences were analyzed. Results: We found that there were no significant differences in hospital length of stay, surgical outcomes, use of proton pump inhibitors (PPIs) postoperatively, or postoperative dysphagia. Patients undergoing robotic surgery had longer operative time (139 ± 25 minutes versus 81 ± 14 minutes, P  < .01), higher intraoperative charges ($8980 ± 275 versus $7239 ± 355, P  < .01), and higher charges associated with their hospital stay ($45,037 ± 4112.41 versus $39,565 ± 3731.64, P  < .01). Conclusions: In comparison with laparoscopic LINX procedures, robotic LINX does not offer superior surgical outcomes in terms of postoperative PPI use, dysphagia, or hospital length of stay. Robotic LINX procedures are associated with increased operative time and overall charges.

Background: The corona virus disease of 2019 (COVID-19) imposed new public health constraints that deterred people from coming to the hospital. The outcome of patients who developed appendicitis during mandated COVID-19 quarantine has yet to be examined. The main objective was to establish whether there was an increased rate of perforated appendicitis seen during COVID-19 quarantine. Secondary objectives included observing the type of procedure performed, length of stay, and associated complications. Materials and Methods: This retrospective analysis was designed to look at the rates of appendicitis and perforated appendicitis observed during mandatory "safer at home order" from March to May 2020. The same time period a year earlier was used for comparative analysis. The study utilized data gathered from a single health care system, which consisted of a large regional referral center with three emergency rooms (ERs). Patients were included in the study if they presented to any ER in our health care system with a chief complaint of acute appendicitis. Perforated appendicitis was determined either radiographically or intraoperatively. Interventions included surgery, percutaneous drainage, or medical management. Results: There were 107 patients who were included. During quarantine, a total of 48 patients presented with acute appendicitis, with 16 perforations, compared with the previous year where 59 patients presented with acute appendicitis, with 10 perforations (33% versus 17% P  = .04). Most patients underwent laparoscopic appendectomy (91%, n  = 98), six patients (6%) were managed with intravenous antibiotics and 3 patients (3%) with percutaneous drainage. Patients who perforated had a longer duration of symptoms (2 versus 1, P  = .03), white blood cell count (13,190 versus 15,960 cells/mm 3 , P  = .09), and longer operative time (72 versus 89 minutes, P  = .01). Patients who perforated had an increased length of stay and rate of complication. Conclusion: There was an overall increased rate of perforated appendicitis seen during quarantine compared with the previous year. Patients with perforated appendicitis had an increased length of stay, longer operative time, and increased rate of complications. Thus, although people were staying home due to public health safety orders, it negatively impacted those who developed appendicitis who may have presented to the hospital otherwise sooner.

Steroid-refractory (SR) acute graft-versus-host disease (GVHD) remains a major cause of nonrelapse mortality (NRM) after allogeneic hematopoietic cell transplantation (HCT), but its occurrence is not accurately predicted by pre-HCT clinical risk factors. The Mount Sinai Acute GVHD International Consortium (MAGIC) algorithm probability (MAP) identifies patients who are at high risk for developing SR GVHD as early as 7 days after HCT based on the extent of intestinal crypt damage as measured by the concentrations of 2 serum biomarkers, suppressor of tumorigenesis 2 and regenerating islet-derived 3α. We conducted a multicenter proof-of-concept "preemptive" treatment trial of α-1-antitrypsin (AAT), a serine protease inhibitor with demonstrated activity against GVHD, in patients at high risk for developing SR GVHD. Patients were eligible if they possessed a high-risk MAP on day 7 after HCT or, if initially low risk, became high risk on repeat testing at day 14. Thirty high-risk patients were treated with twice-weekly infusions of AAT for a total of 16 doses, and their outcomes were compared with 90 high-risk near-contemporaneous MAGIC control patients. AAT treatment was well tolerated with few toxicities, but it did not lower the incidence of SR GVHD compared with controls (20% vs 14%, P = .56). We conclude that real-time biomarker-based risk assignment is feasible early after allogeneic HCT but that this dose and schedule of AAT did not change the incidence of SR acute GVHD. This trial was registered at www.clinicaltrials.gov as #NCT03459040., (© 2020 by The American Society of Hematology.)

Introduction: Metastatic disease to the pancreas is a rare entity from all malignant pancreatic masses. Its diagnosis is very challenging, but with the introduction of endoscopic ultrasound (EUS)-fine needle aspiration (FNA), now there is a feasible way to make an accurate histopathological and definitive diagnosis. Materials and Methods: This is a retrospective review of 11 patients with metastasis to the pancreas diagnosed with EUS-FNA in a tertiary referral center over a period of 3 years. We describe our institutional experience in diagnosing metastatic disease to the pancreas through EUS-FNA. Results: Between January 2015 and June 2018, 115 patients were diagnosed with pancreatic malignancy by EUS-FNA and only 11 (10%) with metastatic disease to the pancreas. Most common primary malignancy was renal cell carcinoma, followed by colon carcinoma, squamous/small cell carcinoma of the lung, and urothelial carcinoma. Five of 11 patients presented as a solitary pancreatic mass on initial imaging without any evidence of primary or metastatic disease elsewhere. Conclusions: In our experience, metastatic disease to the pancreas can represent up to 10% of solid pancreatic masses, which is lower compared to the reported incidence in previous literature. Our findings reveal that early identification and diagnosis help patient management and limit surgical morbidity and mortality.

Background: Minimally invasive foregut surgery is increasingly performed for both benign and malignant diseases. We present a retrospective series of patients who underwent minimally invasive Ivor Lewis esophagectomy (MIE) with linear stapled anastomosis performed at two centers in the USA, with a focus on evaluating leak and stricture rates., Methods: Patients treated from 2007 to 2018 were included, and data on demographics, oncologic treatment, pathology, and outcomes were analyzed. The surgical technique utilized laparoscopic and thoracoscopic access, with an intrathoracic esophagogastric anastomosis using a 6-cm linear stapled side-to-side technique., Results: A total of 124 patients were included and 114 resections (91.9%) were completed in a minimally invasive fashion with a 6-cm linear stapled side-to-side anastomosis. Patients were predominantly male (90.7%) with a median age of 66.0 years and body mass index of 28.8 kg/m 2 . Of 121 patients with malignancy, negative margins were obtained in 94.3% and median lymph node yield was 15 (IQR 12-22). In the intention to treat analysis, median operative time was 463 min (IQR 403-515), blood loss was 150 mL (IQR 100-200), and length of stay was 8 days (IQR 7-11). Postoperative complications were experienced by 64 patients (51.6%) including respiratory failure in 14 (11.3%) and pneumonia in 12 (9.7%). In patients who successfully underwent a 6-cm stapled side-to-side anastomosis, anastomotic leaks occurred in 6 patients (5.1%) without need for operative intervention, and anastomotic strictures occurred in 6 patients (5.1%) requiring endoscopic management., Conclusions: Ivor Lewis MIE with a 6-cm linear stapled anastomosis can be completed with a high technical success rate, and low rates of anastomotic leak and stricture.

A 65-year-old Hispanic female presented with a one-year history of anorexia, nausea, early satiety, epigastric discomfort, and a 20 kg weight loss. Computed tomography (CT) demonstrated heterogeneous liver parenchyma. Upper endoscopy revealed large, fungating, infiltrative mass at the lesser gastric curvature incisura, highly suspicious of gastric tumor; however, initial biopsy of the gastric mass was equivocal and an exploratory laparoscopy was performed. Repeated intraoperative biopsies of the gastric mass and of liver parenchyma demonstrated diffuse hyalinized stroma consistent with amyloid deposition, and a bone marrow biopsy confirmed the diagnosis of primary light chain (AL) amyloidosis., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Kathrin Dvir et al.)

Background: Laparoscopic adjustable gastric banding has been a popular bariatric surgery in the United States since the early 2000s. Over the years, various long-term complications have prompted removal of these devices. To avoid subsequent weight gain, explanation of the gastric band is often followed by concomitant or staged conversion to another bariatric procedure., Objective: It is our goal to evaluate the relative leak rate in 1- versus 2-stage adjustable gastric band conversion surgery., Setting: Private teaching hospital, United States., Methods: A search was performed in the PubMed/MEDLINE and Cochrane Library databases to evaluate literature regarding adjustable gastric band conversion procedures. After identification of publications that directly compared 1- and 2-stage laparoscopic adjustable gastric banding conversions, the Newcastle-Ottawa Quality Assessment Scale was used to determine if they would be used in our meta-analysis. The risk ratio for leak in 1- versus 2-stage conversions was then calculated., Results: Our search yielded 483 publications. Twenty-five publications qualified for inclusion. The overall calculated risk ratio for leak in 1- versus 2-stage conversions was .90 (confidence interval [CI] .51-1.61, P = .73). Eight publications were found that discussed conversion from laparoscopic adjustable gastric banding to Roux-en-Y gastric bypass. The risk ratio for 1- versus 2-stage conversions for this subgroup was .82 (CI .35-1.93, P = .65). Eight publications were found that evaluated conversion to sleeve gastrectomy. The risk ratio of leak for 1- versus 2-stage conversions for these patients was 1.61 (CI .55-4.72, P = .39)., Conclusions: Based on the results of this meta-analysis, there does not appear to be a significant difference in the overall leak rate between 1- and 2-stage adjustable gastric band conversions. The findings of our subgroup analysis suggest that there may be a safety advantage for 1-stage procedures when converting to Roux-en-Y gastric bypass and 2-stage procedures when converting to sleeve gastrectomy., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Paraduodenal pancreatitis (PP) is an uncommon abdominal pathology characterized by scarring of the pancreaticoduodenal space. Diagnosis of this inflammatory process is challenging as its clinical presentation is similar to that of pancreatic cancer. Currently, no definitive radiologic or pathologic features have been established to permit diagnosis of PP without surgical resection. However, the presence of eosinophilic concretions has been reported with increasing frequency in the histologic evaluation of PP. To the best of our knowledge, these concretions are distinctive for PP and not reported in neoplasms commonly involving the pancreaticoduodenal space. Herein, we discuss the case of a 60-year-old man who was found to have PP after pancreaticoduodenectomy for a paraduodenal mass with an initially nondiagnostic biopsy. Retrospective review of the preoperative FNA samples revealed eosinophilic concretions like those found in the final surgical specimen. If the identification of eosinophilic concretions in a background of inflammatory changes was to be accepted as a diagnostic criterion for PP, patients such as ours could be spared the morbidity associated with surgical resection., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2020 Jonathan Zadeh et al.)

Sigmoid volvulus is a rare condition seen during pregnancy with high maternal and fetal morbidity and mortality. We report a case of a young 26-year-old woman, primipara, in her third trimester who presented with recurrent sigmoid volvulus at both 30 and 32 weeks of gestation. She underwent successful repetitive endoscopic decompression on both admissions with uneventful recovery. Endoscopic evaluation is safe in pregnancy and uncomplicated volvulus. It allows for diagnostic confirmation and assessment of complications; and it has successful outcomes in the presence of a multidisciplinary team.

The Mount Sinai Acute GVHD International Consortium (MAGIC) algorithm probability (MAP), derived from 2 serum biomarkers, measures damage to crypts in the gastrointestinal tract during graft-versus-host disease (GVHD). We hypothesized that changes in MAP after treatment could validate it as a response biomarker. We prospectively collected serum samples and clinical stages of acute GVHD from 615 patients receiving hematopoietic cell transplantation in 20 centers at initiation of first-line systemic treatment and 4 weeks later. We computed MAPs and clinical responses and compared their abilities to predict 6-month nonrelapse mortality (NRM) in the validation cohort (n = 367). After 4 weeks of treatment, MAPs predicted NRM better than the change in clinical symptoms in all patients and identified 2 groups with significantly different NRM in both clinical responders (40% vs 12%, P < .0001) and nonresponders (65% vs 25%, P < .0001). MAPs successfully reclassified patients for NRM risk within every clinical grade of acute GVHD after 4 weeks of treatment. At the beginning of treatment, patients with a low MAP that rose above the threshold of 0.290 after 4 weeks of treatment had a significant increase in NRM, whereas patients with a high MAP at onset that fell below that threshold after treatment had a striking decrease in NRM that translated into clear differences in overall survival. We conclude that a MAP measured before and after treatment of acute GVHD is a response biomarker that predicts long-term outcomes more accurately than change in clinical symptoms. MAPs have the potential to guide therapy for acute GVHD and may function as a useful end point in clinical trials., (© 2019 by The American Society of Hematology.)

Background: Esophagectomies are a notoriously difficult procedure that have undergone drastic changes over the last decade. In particular, the adoption of minimally invasive esophagectomies (MIEs) as the gold standard., Methods: We examine the evolution of the MIE, the support for this method, and our preferred methods for the creation of anastomoses following the resection., Results: The submission of techniques that, after many years of practice, have become our standard methods for anastomosing the Neo-esophagus to the remnant esophagus both at the neck, and within the thorax., Conclusion: No matter which MIE technique is chosen, these anastomotic methods are readily available. Each is provided with step-by-step instructions, performed with standard laparoscopic instruments, and in a safe and reproducible manner.

Background: For cancers of the distal gastroesophageal junction or the proximal stomach, proximal gastrectomy can be performed. It is associated with several perioperative benefits compared with total gastrectomy. The use of laparoscopic proximal gastrectomy (LPG) has become an increasingly popular approach for select tumors., Methods: We describe our method of LPG, including the preoperative work-up, illustrated depictions of the key steps of the surgery, and our postoperative pathway., Results: A total of 6 patients underwent LPG between July, 2013 to June, 2017. Five patients had early-stage adenocarcinoma, and 1 patient had a gastrointestinal stromal tumor. The median age of the cohort was 70, and each patient had significant comorbidities. Conversion to open was required for 1 patient. All patients had negative final margins and an adequate lymph node dissection (median number of nodes examined was 15, range 12-22). The median postoperative length of stay was 7 days (range 4-7). Two patients developed anastomotic strictures requiring intervention, and 1 patient experienced significant reflux. At a median follow-up of 11 months, there was 1 recurrence. Three patients were alive without evidence of disease, and 2 patients died from other causes., Conclusions: For carefully selected patients, LPG is a safe and reasonable alternative to total gastrectomy, which is associated with similar oncologic outcomes and low morbidity., (© 2018 Wiley Periodicals, Inc.)

Background: Surgical enteral access prior to multimodality treatment for esophageal cancer is controversial as dysphagia is often used for feeding tube referral. We hypothesized that enteral access before neoadjuvant chemoradiation for esophageal cancer provides no benefit compared to that placed during definitive esophagectomy., Methods: Patients undergoing esophagectomy for esophageal malignancy from 2007 - 2014 were retrospectively identified. Clinicopathologic factors were recorded including preoperative enteral access, weight change, nutritional laboratory works, and perioperative complications., Results: Of 156 identified patients, 99 (63.5%) received neoadjuvant chemoradiation and comprised the study cohort. Fifty (50.5%) underwent enteral access (gastrostomy [14], jejunostomy [32], other [4]; "Access Group") prior to chemoradiation followed by esophagectomy and were compared to 49 "No-Access" patients who underwent enteral access during esophagectomy. Clinicopathologic variables were similar between cohorts. The Access and No-Access cohorts had similar reported dysphagia (86% vs 75.5%, respectively; P = .2) and mean preesophagectomy serum albumin (3.9 vs 4 gm/dL, respectively; P = .2). Weight loss ± 6-month periesophagectomy was similar between access versus No-Access cohorts (-11.2% vs -15.4%, respectively; P = .1). Weight loss during this period was likewise similar for patients with dysphagia in the Access (-11%) versus No-Access group (-15.2%, P = .1). No difference in complication rates was noted between Access (64%) and No-Access groups (51%, P = .2)., Conclusion: Despite healthcare provider bias, there seems to be no nutritional or perioperative benefit for enteral access before neoadjuvant chemoradiation for esophageal malignancy. Patients with esophageal malignancy should therefore proceed to appropriate neoadjuvant and surgical therapy with enteral access performed during definitive resection or reserved for those with frank obstruction on endoscopy., (Published by Elsevier Inc.)

Gastroesophageal reflux disease (GERD) is a common disorder that has a well-established connection with obesity. To ameliorate the morbidity associated with obesity, bariatric procedures have become an established pathway to accomplish sustained weight loss. In some procedures, such as with the Roux-en-Y gastric bypass surgery, weight loss is also accompanied by the resolution of GERD symptoms. However, other popular bariatric surgeries, such as the sleeve gastrectomy, have a controversial impact on their effect on reflux. Consequently, increased attention has been given to the development of strategies for the management of de novo or recurrent reflux after bariatric surgery. This article aims to discuss medical and surgical strategies for reflux after bariatric surgery, and their outcomes.

Background: There has been an increased utilization of minimally invasive esophagectomy (MIE) in an effort to reduce morbidity, decrease length of stay, and improve quality of life. However, there are limited large series of patients undergoing MIE from the United States and no standardized approach. We reviewed our experience with MIE utilizing a stapled side-to-side anastomosis during a 7.5-year period., Study Design: A retrospective review of prospectively maintained databases for patients undergoing planned esophagectomy were reviewed from 2007 to 2015. Esophagogastric anastomoses were performed via a 6-cm linear stapled side-to-side method. Demographics, comorbidities, surgical approach, pathology data, and postoperative morbidities were recorded and reviewed., Results: A MIE was attempted in 303 of 315 (96 %) patients, and a total minimally invasive approach was completed in 293 of 315 (93 %) patients. Location of anastomosis was predominantly in the neck, with 244 patients (77.5 %) undergoing a total minimally invasive McKeown approach (n = 231). A total, minimally invasive Ivor-Lewis was completed in 60 patients (19.1 %). Anastomotic leak was identified in 24 patients (7.6 %). Rates of anastomotic leak were 4.4 % for Ivor-Lewis and 8.5 % for McKeown resection. Median length of stay was 8 days, and in-hospital mortality occurred in only three patients (n = 1 %). Ninety-day follow-up demonstrated a 4.1 % stricture rate requiring dilatation., Conclusions: In the Western patient population, MIE utilizing a 6-cm stapled side-to-side anastomosis is associated with low rates of anastomotic leak, stricture, and mortality.

Introduction: An optimal method has yet to be established for laparoscopic total gastrectomy with intracorporeal anastomosis., Methods: We aim to describe a simple technique for intracorporeal anastomoses. Technique of laparoscopic total gastrectomy with side-to-side stapled intracorporeal esophagojejunostomy anastomosis and Roux-en-Y jejunojejunostomy is performed on patients with gastric malignancy in an academic community tertiary care center., Results: The anastomotic technique of laparoscopic total gastrectomy with side-to-side stapled esophagojejunostomy is described., Conclusion: Laparoscopic total gastrectomy with D2 lymphadenectomy and side-to-side esophagojejunostomy is safe to perform and has the advantage of a wide lumen with low chance for stricture. A laparoscopic total gastrectomy with stapled side-to-side esophagojejunostomy is feasible and safe in advanced gastric cancer.

Background: There is debate surrounding the use of laparoscopic resection for advanced gastric cancer in the Western population. Here we aim to assess the feasibility and short-term outcomes of laparoscopic gastrectomy in consecutive patients in a Western population., Methods: From 2012 to 2014, retrospective review of 28 patients with clinically staged advanced gastric cancer (≥T3 or ≥N1) treated with laparoscopic resection., Results: Sixty-one percentage of patients were male. Median age was 67 years (range 35-86). Median BMI was 26.5 (range 19.4-46.1). Resection types were proximal (n = 2), distal (n = 14), and total (n = 12). Twenty-six (93 %) patients underwent D2 lymphadenectomy. Four patients underwent conversion to open. Median blood loss was 125 mL (range 30-300). Median LOS was 7 days (range 4-16). Of postoperative complications, five were minor: arrhythmia (n = 1), surgical site infection (n = 3), in-hospital fall (n = 1); and four were major (intra-abdominal abscess, stricture, PE, and anastomotic bleed). T stages were Tx (n = 1), T2 (n = 3), T3 (n = 18), and T4 (n = 6). N stages were N0 (n = 4), N1 (n = 8), N2 (n = 1), and N3 (n = 15). Median tumor size was 5.8 cm (range 0-9.5). Median lymph node yield was 22 (range 6-53). All margins were negative. Median follow-up was 12.8 months (range 2-27). Six patients have died of progressive disease., Conclusion: Following total laparoscopic resection for advanced gastric cancer, oncologic endpoints, postoperative course, and early cancer-specific follow-up are excellent. The results demonstrated here support the routine use of these techniques in the Western patient population.

Adenocarcinoma of the esophagus continues to increase in incidence and has become a significant health problem in Western countries. While mortality rates are slowly improving from this disease, multimodality treatment, including esophagectomy, has remained critical for optimal outcomes. Esophagectomy has been described as an operation with significant morbidity and mortality, but over the last decade, increased utilization of minimally invasive esophagectomy in an effort to reduce the high rates of morbidity and lengthy hospital stays associated with open esophagectomy has been adopted at many medical centers. We review esophageal cancer treatment modalities, considerations in the current context of neoadjuvant therapy, and increased adoption of minimally invasive approaches.

Background: Targeting human epidermal growth factor receptor 2 (HER2) with trastuzumab in metastatic esophagogastric adenocarcinoma (EGA) improves survival. The impact of HER2 inhibition in combination with chemoradiotherapy (CRT) in early stage EGA is under investigation. This study analyzed the pattern of HER2 overexpression in matched-pair tumor samples of patients who underwent neoadjuvant CRT followed by surgery., Methods: All patients with EGA who underwent standard neoadjuvant CRT followed by esophagectomy at the University of Florida were included. Demographics, risk factors, tumor features, and outcome data were analyzed. Descriptive statistics, Chi-square exact test, uni- and multivariate analyses, and Kaplan Meier method were used. HER2 expression determined by immunohistochemical (IHC) was scored as negative (0, 1+), indeterminate (2+) or positive (3+)., Results: Among 49 sequential patients (41 M/8 F) with matched-pair tumor samples, 9/49 patients (18%) had pathologic complete response (pCR), 10/49 had near pCR or not enough tumor (NET) to examine in the post- treatment samples. Patients with initial HER2 negativity demonstrated conversion to HER2 positivity after neoadjuvant CRT (7/30 cases; 23%). Baseline HER2 overexpression was more common in lower stage/node negative patients (67% in stages I, IIA vs. 33% in stages IIB, III) and did not correlate with treatment response or survival., Conclusions: Although limited by a relatively small sample size, our study failed to demonstrate that baseline HER2 protein over-expression in EGA predicts response to standard CRT. However, our data suggested that HER2 was up regulated by CRT resulting in unreliable concordance between pre-treatment (pre-tx) and post-treatment (post-tx) samples. Pre-therapy HER2 expression may not reliably reflect the HER2 status of persistent or recurrent disease.

Background: Laparoscopic sleeve gastrectomy (LSG) has gained significant popularity in the USA, and consequently resulted in patients experiencing new-onset gastroesophageal reflux disease (GERD) following this bariatric procedure. Patients with GERD refractory to medical therapy present a more challenging situation limiting the surgical options to further treat the de novo GERD symptoms since the gastric fundus to perform a fundoplication is no longer an option., Objectives: The aim of this study is to determine if the LINX® magnetic sphincter augmentation system is a safe and effective option for patients with new gastroesophageal reflux disease following laparoscopic sleeve gastrectomy., Settings: This study was conducted at the University Medical Center., Methods: This is a retrospective review of seven consecutive patients who had a laparoscopic LINX® magnetic sphincter device placement for patients with refractory gastroesophageal reflux disease after laparoscopic sleeve gastrectomy between July 2014 and April 2015., Results: All patients were noted to have self-reported greatly improved gastroesophageal reflux symptoms 2-4 weeks after their procedure. They were all noted to have statistically significant improved severity and frequency of their reflux, regurgitation, epigastric pain, sensation of fullness, dysphagia, and cough symptoms in their postoperative GERD symptoms compared with their preoperative evaluation., Conclusion: This is the first reported pilot case series, illustrating that the LINX® device is a safe and effective option in patients with de novo refractory gastroesophageal reflux disease after a laparoscopic sleeve gastrectomy despite appropriate weight loss.

Introduction: Pneumonia and tracheal aspiration remain problematic following esophagectomy. We hypothesized that the incidence of postesophagectomy pneumonia occurs in part because of swallowing dysfunction and more importantly silent tracheobronchial aspiration. Therefore, we instituted a routine prospective formal swallowing evaluation to determine if the aspiration rate and its associated morbidity can be decreased by early identification of patients with silent or vocal aspiration., Methods: Patients undergoing minimally invasive McKeown esophagectomy and receiving neoadjuvant chemoradiotherapy (NACR) were prospectively enrolled between December 2013 to January 2015. A standardized cineradiography observation utilizing the Rosenbek penetration-aspiration (RPA) scale was used to rule out anastomotic leak and/or aspiration., Results: Of 27 patients evaluated, twelve patients were noted to have silent (n = 8) or vocal (cough n = 4) aspiration of thin liquid (n = 8) or nectar-thick consistency (n = 4) on their initial study. Three patients were noted to have an anastomotic leak and vocal aspiration on their initial study. Eight of the nine patients who aspirated but did not have an anastomotic leak on their initial study had a repeat RPA study prior to discharge showing improvement from the initial study. Six patients (22 %) had vocal cord paresis and clinical hoarseness, but only two patients who had clinical diagnosis of pneumonia were noted to have vocal cord paresis and silent aspiration., Conclusions: Swallowing dysfunction remains a common problem after minimally invasive esophagectomy (MIE) with cervical anastomosis and can be readily identified. Silent aspiration likely contributes to pneumonia after MIE.

Although infrequent, esophageal leiomyomas are the most common benign intramural tumors of the esophagus. As malignant potential is not a concern in these lesions, they represent ideal candidates for an organ-preserving approach. Due to their well-circumscribed growth, a minimally invasive approach should be pursued in almost all patients. We present our recent techniques and results associated with totally minimally invasive thoracoscopic and laparoscopic approaches to resection of esophageal leiomyomas. These approaches require technical expertise but can be accomplished with a short learning curve.

Importance: Predicting complete pathologic response (CPR) preoperatively can significantly affect surgical decision making. There are conflicting data regarding positron emission tomography computed tomography (PET CT) characteristics and the ability of PET CT to predict pathologic response following neoadjuvant chemoradiotherapy in esophageal adenocarcinoma because most existing studies that include squamous histology have limited numbers and use nonstandardized PET CT imaging., Objective: To determine if PET CT characteristics are associated with CPR in patients undergoing trimodality treatment for esophageal adenocarcinoma., Design, Setting, and Participants: A retrospective medical record review was conducted at a large tertiary cancer center from a prospectively maintained database from January 1, 2005, to December 31, 2012. Inclusion criteria were patients undergoing esophagectomy for locally advanced esophageal adenocarcinoma post-neoadjuvant chemoradiotherapy with 2 standardized PET CT studies done at our institution (pre-neoadjuvant chemoradiotherapy and post-neoadjuvant chemoradiotherapy) for review. Data collected included clinical, pathologic, imaging, and treatment characteristics., Main Outcome and Measure: The primary study outcome was the association of PET CT characteristics with histologic confirmed pathologic response., Results: Of the total participants, 77 patients met the inclusion criteria. Twenty-two patients (28.6%) had CPR vs 55 patients (71.4%) who had incomplete pathologic response. The 2 groups were similar in age, sex, race/ethnicity, comorbid conditions, Eastern Cooperative Oncology Group status, tumor grade, chemotherapy, and radiation regimen and days between the 2 PET CTs. The mean prestandardized uptake variable (SUV; 14.5 vs 11.2; P = .05), δ SUV (10.3 vs 5.4; P = .02), and relative δ SUV (0.6 vs 0.4; P = .02) were significantly higher in those with CPR vs incomplete pathologic response. Using the Youden Index, a δ SUV value less than 45% was predictive of residual disease with a positive predictive value of 91.7% (95% CI, 73-99; P < .05)., Conclusions and Relevance: To our knowledge, this is the largest study examining the role of PET CT characteristics in esophageal adenocarcinoma for patients undergoing neoadjuvant chemoradiotherapy that demonstrates that δ SUV of less than 45% is associated with patients with residual disease but not CPR. Based on the findings from our study, the current recommendation is still surgical resection regardless of the posttherapy PET SUV in the primary tumor. However, our study highlights the ability to detect patients with residual disease and the need to critically evaluate these patients for consideration of additional therapies.

Background: Enteral feeding via gastrostomy or jejunostomy tube is often required to adequately treat patients with cancer, gastrointestinal disorders, and cerebral vascular accident. Although sufficient to provide adequate caloric intake, the present design of a gastrostomy tube is inadequate. Leakage of gastric contents onto the skin is commonplace prompting emergency department visits and skin damage that requires costly nonoperative and operative intervention. We introduce a new gastrostomy tube design and prototype that inhibits leakage by using an adjustable external retaining member, which compresses against the feeding tube shaft thereby preventing dynamic friction., Methods: A conventional external retaining member of a 22 French gastrostomy tube was tested against a novel compression-fitting external retaining member. Each gastrostomy tube was clamped to a scale and the external retaining member moved to slide along the tubing at a constant rate, and the applied frictional force was recorded. Thirty repetitions were performed., Results: The experimental prototype generated ×2.5-3 the frictional force preventing tube excursion. Mean (standard deviation) forces were 18 (3) versus 46 (4) ounces (n = 10, P = 2.57E-13) and 15 (4) versus 48 (4) ounces (n = 10, P = 1.90E-13) for conventional and experimental designs, respectively. Simulated in situ environment mean forces were 19 (3) versus 39 (3) ounces (n = 10, P = 3.30E-11) for conventional and experimental designs, respectively., Conclusions: The experimental design created an increased static frictional force that inhibited the movement of the external retaining member against the gastrostomy tube. Clinical implementation is the next step to evaluate for reduced feeding tube morbidity and healthcare expenses by preventing leakage of gastric contents., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Athletic pubalgia is a syndrome of chronic lower abdomen and groin pain that occurs in athletes. It is the direct result of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor., Methods: Under IRB approval, we conducted a retrospective review of our prospectively competitive athlete patients with athletic pubalgia from 2007 to 2013., Results: A cohort of 54 patients was examined. Mean age was 22.4 years. Most patients were football players (n = 23), triathlon (n = 11), track and field (n = 6), soccer players (n = 5), baseball players (n = 4), swimmers (n = 3), golfer (n = 1), and tennis player (n = 1). Fifty one were males and three were females. All patients failed medical therapy with physiotherapy prior to surgery. 76 % of patients had an MRI performed with 26 % having a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7 % of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Twenty patients had no findings on their preoperative MRI, and only one patient was noted to have an inguinal hernia on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients were able to return to full sports-related activity in 24 days (range 21-28 days). One patient experienced urinary retention and another sustained an adductor brevis hematoma 3 months after completion of rehabilitation and surgical intervention. Mean follow up was 18 months., Conclusion: Athletic pubalgia is a disease with a multifactorial etiology that can be treated surgically by a laparoscopic totally extraperitoneal hernia repair with synthetic mesh accompanied with an ipsilateral adductor longus tenotomy allowing patients to return to sports-related activity early with minimal complications.

The objective of this study was to show laparoscopic subtotal, distal gastrectomy with D2 lymphadenectomy as a safe and appropriate method for the resection of advanced gastric cancer. This study was conducted at a designated NCI Cancer Center. Subjects of the study were patients with advanced gastric malignancy, including transmural penetration of the tumor and/or nodal disease, requiring subtotal, distal gastrectomy. The main outcome measure is a description of the technique of a laparoscopic subtotal, distal gastrectomy for antral and distal body tumors. In conclusion, the laparoscopic approach to advanced gastric malignancy with a subtotal, distal gastrectomy and D2 lymphadenectomy is a safe, oncologically appropriate procedure which provides excellent outcomes.

Importance: Nearly 1400 medical students enter preliminary surgical residency each year; placing some of these students into categorical surgical training is an important component of building the future surgical workforce., Objectives: To examine the training outcomes of preliminary residents in a university and Veterans Affairs surgical residency and to test the hypothesis that characteristics of these residents could be identified that would predict successful placement into categorical general surgical residency., Design, Setting, and Participants: A retrospective cohort of 66 nondesignated preliminary surgical residents who entered a research-intensive, university-based surgical training program with significant Veterans Affairs hospital experience between 2004 and 2012., Main Outcomes and Measures: Placement of preliminary residents into a categorical general surgical residency., Results: Of 66 nondesignated preliminary residents enrolled in our program during the study period, 57 completed a postgraduate year (PGY) 1 and 22 completed a PGY-2. A total of 21 residents (32%) secured categorical general surgical positions, 8 of 57 (14%) after PGY-1 and 13 of 22 (59%) after PGY-2, a significantly different rate (P < .001). Predictors of success in obtaining a categorical position included a PGY-2, United States Medical Licensing Examination step 2 score, year 1 American Board of Surgery In-Training Examination score, class rank, and prior graduate medical education. By multivariable analysis, only the PGY-2 was significant (P < .03). Residents who obtained categorical surgical positions after 1 preliminary year had significantly higher United States Medical Licensing Examination scores (mean [SD] step 1 score, 235.4 [23.5] vs 206.3 [16.2]; P < .02; step 2 score, 239.3 [21.2] vs 218.5 [16.1]; P < .05) but did not have higher year 1 American Board of Surgery In-Training Examination percentiles (mean [SD], 63.3 [33.3] vs 47.3 [30.8]; P < .34)., Conclusions and Relevance: Performing a PGY-2 preliminary year increases the chance for a preliminary surgical resident to obtain a place in a categorical surgical residency. Programs that offer preliminary positions should consider offering both PGY-1 and PGY-2 positions, because the PGY-2 increases the categorical surgical placement rate, especially for residents with lower test scores.