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Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/mThe consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Controversy exists over the use of mesh, its type and configuration in repair of hiatal hernia. We have used biological mesh for large or recurrent hiatal hernias. We have developed a mesh configuration to better enhance the tensile strength of the hiatus by folding the mesh over the edge of the hiatus-entitled the "starburst" configuration. We report our experience with the starburst configuration, comparing it to our results with the keyhole configuration.Medical records of all patients undergoing either the keyhole or starburst mesh configuration hiatal hernia repair were reviewed between 2017 and 2021. Data gathered included age, sex, type of hernia (sliding, paraesophageal, or recurrent), fundoplication type (none, Nissen, Toupet, Dor, Collis-Nissen, Collis-Toupet, or magnetic sphincter augmentation [MSA]), 30-day complications, and long-term outcomes (hiatal hernia recurrence, reflux-symptom recurrence, dysphagia, dilations, reoperations).From 7/2017 to 8/2019, 51 cases using the keyhole mesh were completed. Sliding hiatal hernia comprised 4%, paraesophageal hernia (PEH) 64% and recurrent hiatal hernia (RHH) 34% of cases. Distribution of fundoplication type: 2% none, 41% Nissen, 41% Toupet, 8% Dor, 2% Collis-Nissen, and 6% Collis-Toupet. 30-day complication rate 31%. Long-term outcomes: recurrent hiatal hernia 16%, dysphagia 12%, dysphagia requiring dilation(s) 10%, recurrent GERD symptoms 4%, and reoperation 14%. From 10/2020 to 8/2021, 58 cases using the starburst configuration were completed. PEH comprised 60% and RHH 40%. Distribution of fundoplication type: 10% none, 40% Nissen, 43% Toupet, 5% MSA, 2% Collis-Toupet. 30-day complication rate 16%. Long-term outcomes: recurrent hiatal hernia 19%, dysphagia 14%, dilations 5%, recurrent GERD symptoms 9%, and reoperations 3%.The starburst mesh configuration compares favorably with the keyhole configuration with respect to postoperative dysphagia, need for esophageal dilation, and GERD symptom recurrence, with similar recurrence rates. We are continuing to further refine this technique and study the long-term outcomes.

To determine the accuracy of preoperative modified frailty index (mFI) with or without laboratory values (mFI-labs or labs-continuous) in predicting postoperative discharge destination. Discharge destination is important to providers and patients. The ability to accurately predict discharge destination preoperatively can improve hospital resource utilization and help set patient and family expectations.Cohort analysis of the 2018 American College of Surgeon National Surgical Quality Improvement Project (ACS-NSQIP) Participant Use File of patients undergoing operations with complete data point sets: age, sex, operation work relative-value units; mFI-clinical based on 12 clinical findings, mFI-labs based on seven laboratory values. The nine hierarchical destinations: home, home with assistance, multi-level community, unskilled-care facility, rehabilitation facility, skilled-nursing facility, acute care hospital, hospice, or death, from best to worst outcome. Data were analyzed using univariate analysis, multiple logistic regression and supervised learning artificial neural networks.Univariate and multivariate in general showed that patients with higher mFI-clinical and mFI-lab scores, as well as older age and more complex operations were more likely to be discharged to facilities other than home. However, these statistical techniques could not predict the exact destination. An artificial neural network analysis demonstrated perfect location prediction in 64.9% of cases and within one level of prefect prediction is 87.4%.Using a limited number of preoperative factors, combining the mFI-clinical with laboratory values significantly improves the destination prediction performance significantly better than using the values separately. Preoperative knowledge of the likely discharge destination can benefit postoperative care planning and delivery.

Objective To review management controversies in paraesophageal hernia and options for surgical repair. Background Paraesophageal hernia is an increasingly common problem. There are controversies over whether and when paraesophageal hernias should be surgically repaired. In addition, if these hernias are to be repaired, the method of repair, need for mesh reinforcement, need for fundoplication, and need for gastropexy are not uniformly accepted. Methods Recent literature was reviewed on need for repair, approach (open, laparoscopic or robotic surgery), method of repair (primary suture, use of relaxing incisions, use of mesh reinforcement), materials and configuration of mesh reinforcement, need and type of fundoplication, and need for gastropexy, with emphasis on surgical outcomes. Conclusions The extant literature suggests that paraesophageal hernia should be approached in a patient-centered, precision medicine manner. In general, hernia reduction, sac excision and primary suture approximation of the hiatal crura are mandatory. Use of mesh should be based on individual risk factors; if mesh is used, biological meshes appear to have a more favorable safety profile, with the "reverse C" or keyhole configuration allowing for increase in crural tensile strength at it most vulnerable areas. Use and choice of fundoplication or magnetic sphincter augmentation should be based on individual considerations. Finally, gastropexy is generally ineffective and should be used only in extreme circumstances.

There have been steady innovations in hiatal hernia and anti-reflux surgery. The purpose of this article is to provide a historical perspective on practice-changing innovations in the context a single surgeon experience’s over a career. Patients undergoing anti-reflux surgery or hiatal hernia repair by a single surgeon from 12/1992 to 3/2020 were reviewed. Data collected: sex, age, hiatal hernia type, operation type, adjuncts used, and additional procedure performed during index operation. Superimposed on this experience are the practice-changing innovations that occurred over this timeframe. During the time period, 1200 operations were performed. Distributions: Hernia type: I, 707 (58.9%); II–IV, 325 (27.1%); Recurrent/Failed, 168 (14.0%). Type of operation, including laparoscopic and open: Nissen fundoplication: 889 (74.1%); Toupet fundoplication: 162 (13.5%); Collis-Nissen/Toupet fundoplication: 44 (3.7%); hiatal hernia repair without fundoplication (laparoscopic and open): 38 (3.2%); endoluminal fundoplication: 35 (2.9%); hiatal hernia repair with Heller myotomy/ Dor fundoplication: 10 (0.8%); transthoracic Belsey Mark IV: 2 (0.2%); hiatal hernia repair with magnetic sphincter augmentation: 20 (1.7%). Mesh reinforcement: 185 (15.4%). Additional procedures, 210 (17.5%). During this time, these practice-changing innovations occurred: laparoscopic surgery, 48-h pH monitoring, high-resolution manometry, tailoring of fundoplication, energy sources for tissue division and hemostasis, pyloroplasty for symptomatic gastroparesis, the rise and fall of endoluminal therapies, mesh reinforcement, abandonment of short gastric vessel division, and magnetic sphincter augmentation. Over the last 27 years, a number of practice-changing advances have been made. These have led to changes in technique and operation selection of anti-reflux and hiatal hernia surgery.

PURPOSE: The purpose of this study is to compare the complication rates and recurrence rates of two types of incisional hernia repairs by a single surgeon. MATERIALS AND METHODS: The medical records of all patients undergoing incisional hernia repair by the senior author were reviewed. Patients who underwent the biologic mesh underlay/synthetic mesh overlay (BUSO) “sandwich” repair and separation of components with retrorectus mesh (SOCRM) repair were assessed. Only Grades I, II, and III incisional hernias were included. The two groups were matched for age, sex, hernia size, and body mass index. The groups were compared for any 30-day complication, any adverse event in the follow-up period, and any recurrence as determined by physical examination or imaging. RESULTS: Fifty-six patients were successfully matched. There were no differences in the type of suture used, skin closure, dressing, or drain use. There was no difference in 30-day postoperative complications or discharge status. The BUSO group had a 29% recurrence rate, compared to 4% in the SOCRM group (P = 0.0248). However, the follow-up was longer in the BUSO group. CONCLUSIONS: The results of this study suggest that for incisional hernias not amenable to primary closure, SOCRM repair may be superior to even a two-mesh layer bridging repair.

Predicting patients' surgical transfusion needs preoperatively enables more efficient blood resource management. Identifying the significance of variables to use for transfusion predictions may be accomplished more reliably using machine learning, specifically artificial neural networks (ANN). A logistic regression model and two ANN programs are used to identify the contribution of nine variables selected following a literature review. The first ANN uses a sum of the weights method to identify variable contribution and the second ANN uses a leave one out strategy to identify variable contribution. All models indicated that hematocrit was the most significant variable for predicting perioperative blood transfusions. The weighted averages method indicated wRVU's and ASA score were the next most significant contributors. The leave one out method identified sex and INR as contributing to transfusion prediction. The importance of the variables other than hematocrit varied between techniques and may be dependent on the modeling method used.

The management of symptomatic choledocholithiasis remains a controversial issue. At present, the three most common management options for choledocholithiasis include a preoperative endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction followed by laparoscopic cholecystectomy, then by either an intraoperative endoscopic retrograde cholangiopancreatography with sphincterotomy or a laparoscopic common bile duct exploration. The purpose of this study was to assess the consequences of the decision to pursue each of these three methods.We conducted a review of the existing data comparing these three management options. The literature from 2009 to 2021 pertaining to these three methods was reviewed for data on duct clearance, morbidity, mortality, recurrence rate, length of stay, and operative time. Next, we constructed decision trees for each method using a utility score analysis, and these utility scores were used to create a sensitivity analysis based on stone clearance rate.Laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography had a utility score of 0.9910, a stone clearance rate of 95.5%, a morbidity of 6.3%, and a mortality of 0.2%. Preoperative endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy had a utility score of 0.9629, a stone clearance rate of 85.5%, a morbidity of 13.3%, and a mortality of 0.8%. Laparoscopic cholecystectomy with common bile duct exploration had a utility score of 0.9882, a stone clearance rate of 88.3%, a morbidity of 12.9%, and a mortality of 0.3%.We have shown that a laparoscopic cholecystectomy with an intraoperative endoscopic retrograde cholangiopancreatography is associated with the best overall outcomes.

The GERD-HRQL symptom severity instrument was developed and published 25 years ago. This seems like an apropos time to review how the instrument has been used in the "real-world."Google Scholar, PubMed, and Web of Science websites search was done using the keywords "GERD-HRQL" or its author, "Velanovich." Once articles were identified, the following information was obtained from each article: first author name, country of origin, journal published, year of publications, type of study design, subject of study, category of study, disease type studied, purpose of the study, how the GERD-HRQL scores were reported, how the GERD-HRQL scores were statistically reported, and results of the study. The total and change of scores were analyzed for descriptive statistics based on disease process studied and intervention studied.A total of 767 articles by 562 different first authors were identified in 193 different journals from 53 different countries of study origin. After a period of steady usages, the number of publication employing the GERD-HRQL has rapidly increase over the last 5 years. There have been 8 validated translations into other languages, although there appears to be numerous, non-validated ad hoc translations. Most commonly used or studied: observational cohort study design, surgical treatment study category, GERD disease process, treatment effect study purpose, total GERD-HRQL scores reported as means or medians. However, there were a wide variety of other study designs, study categories, disease processes, and study purposes. In general, GERD and laryngopharyngeal reflux had the high pre-treatment scores (i.e., more severe symptoms), and surgical and endoscopic interventions the lowest post-treatment score (i.e., least severe symptoms) with the largest change in score (i.e., treatment impact.The GERD-HRQL has proven to be a reliable, responsive and versatile symptom severity instrument for studies involving GERD as a subject.

Background Although peroral endoscopic myotomy (POEM) is highly effective for the management of achalasia, clinical failures may occur. The optimal management of patients who fail POEM is not well known. This study aimed to compare the outcomes of different management strategies in patients who had failed POEM. Methods This was an international multicenter retrospective study at 16 tertiary centers between January 2012 and November 2019. All patients who underwent POEM and experienced persistent or recurrent symptoms (Eckardt score > 3) were included. The primary outcome was to compare the rates of clinical success (Eckardt score ≤ 3) between different management strategies. Results 99 patients (50 men [50.5 %]; mean age 51.4 [standard deviation (SD) 16.2]) experienced clinical failure during the study period, with a mean (SD) Eckardt score of 5.4 (0.3). A total of 29 patients (32.2 %) were managed conservatively and 70 (71 %) underwent retreatment (repeat POEM 33 [33 %], pneumatic dilation 30 [30 %], and laparoscopic Heller myotomy (LHM) 7 [7.1 %]). During a median follow-up of 10 (interquartile range 3 – 20) months, clinical success was highest in patients who underwent repeat POEM (25 /33 [76 %]; mean [SD] Eckardt score 2.1 [2.1]), followed by pneumatic dilation (18/30 [60 %]; Eckardt score 2.8 [2.3]), and LHM (2/7 [29 %]; Eckardt score 4 [1.8]; P = 0.12). A total of 11 patients in the conservative group (37.9 %; mean Eckardt score 4 [1.8]) achieved clinical success. Conclusion This study comprehensively assessed an international cohort of patients who underwent management of failed POEM. Repeat POEM and pneumatic dilation achieved acceptable clinical success, with excellent safety profiles.

Myotomy length for per-oral endoscopic myotomy (POEM) is standardized for type I and II achalasia. However, for type III achalasia, jackhammer esophagus, diffuse esophageal spasms and esophagogastric junction outflow obstruction, there is no standard. Determining myotomy length based on the high-pressure zone found during high-resolution manometry (HRM) and spastic length found during esophagography may be used to determine adequate myotomy length without excess muscle destruction. The records of patients who have undergone POEM procedures at our institution had the following data gleaned: age, sex, esophageal spastic diagnosis, length of high-pressure zone and lower esophageal sphincter (LES) position by HRM, length of spastic esophagus by esophagography, position of the z-line by esophagoscopy and length of myotomy performed. Outcomes were assessed based on patient symptomatic improvement and need for re-intervention. 71 patients were evaluated for POEM, with 67 completing POEM. There was an average difference in LES position by HRM and z-line position by esophagoscopy of 3.9 ± 3.0 cm. There was an average difference in high-pressure zone by HRM and spastic length by esophagography of 4.9 ± 3.2 cm. Overall, with a median of 20 months follow-up, 74% achieved long-term symptomatic improvement, with 17 patients requiring re-intervention. Discordance among HRM, esophagography and esophagoscopy can be significant. Caution should be employed with using these methods to determine myotomy length in POEM.

Background Recurrence after hiatal hernia repair is common. The causes are uncertain. Our observation is the site of recurrence is primarily the nonsutured or nonreinforced anterior-left lateral portion of the hiatus. Our aim was to assess the distribution of hiatal hernia recurrence location as a basis for developing a theory of recurrence. Methods Consecutive patients who underwent repair of recurrent hiatal hernias from March 2012 to December 2019 were reviewed. Data collected included age, sex, date of operation, location of hiatal hernia recurrence, operative approach, method of hiatal hernia repair, fundoplication performed, need for gastrectomy, and additional procedures. Results One hundred and eight consecutive patients were studied. The distribution of recurrence locations was as follows: anterior 67%, posterior 12%, and circumferential 21%. Foreshortened esophagus was a contributing factor in 12%. Median time from the original repair to recurrence was 1.5 years (interquartile range 0.9 to 3.75 years) for posterior recurrences, 2.75 years (interquartile range 1.15 to 8.5 years) for circumferential recurrences, and 3.25 years (interquartile range 1.38 to 10 years) for anterior recurrences. Recurrences were repaired in a variety of techniques, depending on the clinical circumstances. Conclusions Hiatal hernia recurrences due to failure of the crural closure were less common, but early, recurrences. The majority of recurrences were due to stretching of the hiatus anterior and to the left of the esophagus. We theorize that the pathophysiology of late hiatal hernia recurrence is widening of the anterior and left lateral portion of the hiatus secondary to repeated stress from differential pressures that eventually overcomes the tensile strength of the hiatus.

Background and Aims: Laparoscopic Heller's myotomy (LHM), per oral endoscopic myotomy, and pneumatic dilatation are well-established methods to treat achalasia. The ideal treatment algorithm in eld...

Background: Achalasia and other esophageal motility disorders are incurable diseases for which palliation and symptom relief are the goals. One of the many ways these diseases are treated is with either a Heller myotomy or, now more commonly, per-oral endoscopic myotomy (POEM). Unfortunately, symptoms persistence or recurrence is common. This review presents our current approach to these complex patients. Methods: Review of the literature pertaining to approaches to recurrent or persistent symptoms after myotomy for esophageal motility disorders and elucidation of our multidisciplinary approach to this patient group. Results: There are a myriad of causes of recurrent or persistent symptoms. These include incomplete myotomy, periesophageal scarring, reflux-induced stricture, obstructing fundoplication, functional dysphagia, and end-stage achalasia. Therapeutic options include redo myotomy (either Heller or POEM), botulinum toxin injection, pneumatic, balloon or Savary dilation, adhesiolysis, and fundoplication reversal or esophagectomy. Choice of approach is best done through multidisciplinary consensus. Conclusions: A multidisciplinary approach to patients with persistent and recurrent symptoms after myotomy can best tailor the therapeutic approach based on symptom causation.

Intraductal papillary mucinous neoplasms (IPMN) are a type of mucinous pancreatic cyst. IPMN have been shown to be pre-malignant precursors to pancreatic cancer, which has an extremely high mortality rate with average survival less than 1 year. The purpose of this analysis is to utilize methodological triangulation using artificial neural networks and regression to examine the impact and effectiveness of a collection of variables believed to be predictive of malignant IPMN pathology. Results indicate that the triangulation is effective in both finding a new predictive variable and possibly reducing the number of variables needed for predicting if an IPMN is malignant or benign.

Hiatal hernias are at high risk of recurrence. Mesh reinforcement after primary approximation of the hiatal crura has been advocated to reduce this risk of recurrence, analogous to mesh repair of abdominal wall hernias. However, the results of such repairs have been mixed, at best. In addition, repairs using some type of mesh have led to significant complications, such as erosion and esophageal stricture. At present, there is no consensus as to (1) whether mesh should be used, (2) indications for use, (3) the type of mesh, and (4) in what configuration. This lack of consensus is likely secondary to the notion that recurrence occurs at the site of crural approximation. We have explored the theory that many, if not most, “recurrences” occur in the anterior and left lateral aspects of the hiatus, normally where the mesh is not placed. We theorized that “recurrence” actually represents progression of the hernia, rather than a true recurrence. This has led to our development of a new mesh configuration to enhance the tensile strength of the hiatus and counteract continued stresses from intra-abdominal pressure. RESUMO As hérnias hiatais têm alto risco de recidiva. O reforço com tela após a aproximação primária dos pilares hiatais tem sido defendido, para reduzir esse risco de recidiva, análogo ao reparo com tela de hérnias da parede abdominal. No entanto, os resultados de tais reparos foram variados, na melhor das hipóteses. Além disso, os reparos com algum tipo de tela levaram a complicações importantes, como erosão e estenose esofágica. Atualmente, não há consenso sobre 1) se a tela deve ser usada, 2) indicações para uso, 3) o tipo de tela e 4) em qual configuração. Essa falta de consenso provavelmente é secundária à noção de que a recidiva ocorre no local da aproximação crural. Exploramos a teoria de que muitas, se não a maioria, das recidivas ocorrem nas faces anterior e lateral esquerda do hiato, normalmente onde a tela não é colocada. Nós teorizamos que a “recidiva” na verdade representa a progressão da hérnia, em vez de uma verdadeira recidiva, levando ao desenvolvimento de uma nova configuração da tela, para aumentar a resistência à tração do hiato e neutralizar as tensões contínuas da pressão intra-abdominal.

Background Assessing the value of a treatment is of great importance. Typical methods are directed toward policy decisions. However, individual stakeholders will have different valuation based on their interests. Methods Formulas were developed to quantify the value of a treatment from the patient, surgeon, hospital, and private third-party payer. These formulas are based on observed factors that go into treatment decision-making for each stakeholder. Using the example of four surgical treatment options for gastroesophageal reflux disease, values for each factor were obtained from publically available documents or were arbitrarily estimated. Results From the patient perspective, the laparoscopic Nissen fundoplication (LNF) provided the best value at 2.99 quality-adjusted life years per $1,000 spent. From the surgeon perspective, it provided the best value at $752.20 earned per hour effort. From the hospital perspective, LNP provided the best value at $3,446 earned per episode of care. Lastly, from the third-party payer perspective, total incisionless fundoplication provided the best value at $13,336 per year. Conclusions Because value is measured differently for each stakeholder, there will be conflicts as to how treatment options are valued.

Intraductal papillary mucinous neoplasms (IPMN) are a type of mucinous pancreatic cyst. IPMN have been shown to be pre-malignant precursors to pancreatic cancer, which has an extremely high mortality rate with average survival less than 1 year. The purpose of this analysis is to utilize methodological triangulation using artificial neural networks and regression to examine the impact and effectiveness of a collection of variables believed to be predictive of malignant IPMN pathology. Results indicate that the triangulation is effective in both finding a new predictive variable and possibly reducing the number of variables needed for predicting if an IPMN is malignant or benign.

Introduction Paraesophageal hernia repairs are prone to recurrence and mesh reinforcement is common. Both biologic and prosthetic meshes have been used. We report a comparison of a new type of biologically derived graft, Gentrix Surgical Urinary Bladder Matrix (UBM). Methods The medical records of 65 patients who underwent paraesophageal hernia repair (PEHR) were reviewed. Primary data points included demographics, first-time or recurrent hernia, operative approach, graft or primary repair, operative time, and postoperative complications. Patients then underwent upper gastrointestinal series, completed the GERD-HRQL symptom severity questionnaire, and the SF-36 generic quality of life instrument. Results A total of 32 patients underwent graft-reinforced repair, 33 underwent primary repair. More patients in the UBM group were being treated for recurrent PEH. Demographic data and postoperative complications were similar. There was no difference in recurrence rates, size of recurrence, postoperative symptomatic or quality of life improvement. Patients who suffered recurrence in the primary repair group had more severe symptoms and a higher rate of dissatisfaction. Of the 3 patients with recurrences after Gentrix placement, reoperation demonstrated anterior failure where no reinforcement had occurred because of the posteriorly placed U-shaped graft. Conclusions The use of UBM was not associated with an increased complications despite use in more difficult patients. Although there appeared to be no difference in recurrence rate or size, it was associated with less severe symptomatic recurrences. The U-shape configuration is prone to recurrence at the site of the repair not covered by the graft, suggesting that a keyhole configuration may be superior.

Recurrent/persistent symptoms of achalasia occur in 10–20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population. All patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively. Data collected: demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes. A total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance. There are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.

Symptoms may be unreliable to diagnose gastroesophageal reflux disease (GERD) in patients with minor psychiatric disorders (MPD). This study aims to evaluate the influence of MPD in the diagnosis of GERD. We prospectively studied 245 patients (based on a sample size calculation) with suspected GERD. All patients underwent manometry and pH monitoring and MPD evaluation based on the Hospital Anxiety and Depression Scale (HADS). Based on the results of the pH monitoring, patients were classified as GERD + (n = 136, 55% of the total, mean age 46 years, 47% females) or GERD − (n = 109, 45% of the total, mean age 43 years, 60% females). The mean HADS score for GERD + and GERD − for anxiety was 7.8 and 8.5, respectively (p = 0.8) and for depression was 5.4 and 6.1, respectively (p = 0.1). DeMeester score (DS) did not correlate with total HADS score (p = 0.08) or depression domain (p = 0.9) but there was a negative correlation between DS and anxiety level (p

Background: Well-annotated, high-quality biorepositories provide a valuable platform to support translational research. However, most biorepositories have poor representation of minority groups, limiting the ability to address health disparities. Methods: We describe the establishment of the Florida Pancreas Collaborative (FPC), the first state-wide prospective cohort study and biorepository designed to address the higher burden of pancreatic cancer (PaCa) in African Americans (AA) compared to Non-Hispanic Whites (NHW) and Hispanic/Latinx (H/L). We provide an overview of stakeholders, study eligibility and design, recruitment strategies, standard operating procedures to collect, process, store, and transfer biospecimens, medical images, and data, our cloud-based data management platform, and progress regarding recruitment and biobanking. Results: The FPC consists of multidisciplinary teams from fifteen Florida medical institutions. From March 2019 through August 2020, 350 patients were assessed for eligibility, 323 met inclusion/exclusion criteria, and 305 (94%) enrolled, including 228 NHW, 30 AA, and 47 H/L, with 94%, 100%, and 94% participation rates, respectively. A high percentage of participants have donated blood (87%), pancreatic tumor tissue (41%), computed tomography scans (76%), and questionnaires (62%). Conclusions: This biorepository addresses a critical gap in PaCa research and has potential to advance translational studies intended to minimize disparities and reduce PaCa-related morbidity and mortality.