In this trial, a magnetic device to augment the lower esophageal sphincter was implanted in 100 patients with gastroesophageal reflux disease. At 1 year, esophageal acid exposure had decreased and ...symptoms had improved. Six patients had serious adverse events.
The fundamental pathologic abnormality in gastroesophageal reflux disease is an incompetent lower esophageal sphincter.
1
–
3
First-line therapy for gastroesophageal reflux disease is acid suppression, usually with proton-pump inhibitors. Although effective, proton-pump inhibitors provide incomplete control of reflux symptoms in up to 40% of patients.
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6
A partial response can occur because these drugs do not address an incompetent sphincter or prevent reflux; consequently, some patients have only partial relief from symptoms and seek alternative treatment if their quality of life is compromised. At present, the only established option for these patients is antireflux surgery, typically Nissen fundoplication. However, the acceptance . . .
Background
Transoral incisionless fundoplication (TIF) offers an endoscopic approach to the treatment of gastroesophageal reflux disease (GERD). Controlled trials have demonstrated the short-term ...efficacy of this procedure, but long-term follow-up studies are lacking. The objective of this study was to evaluate the long-term impact of TIF on disease-specific quality of life and antisecretory medication use.
Methods
We performed retrospective cohort study of all patients undergoing TIF between 2007 and 2014 in a large academic medical center. Reflux symptoms and quality of life were assessed using the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) questionnaire at baseline, short-term, and long-term follow-up.
Results
Fifty-seven patients with a median age of 46 (37–59) years and an average BMI of 28.8 ± 4.9 kg/m
2
underwent TIF during the study period. Sixty percent of the patients were female, and all were taking a PPI at least daily. At a median follow-up interval of 97 months, twelve patients had undergone subsequent laparoscopic antireflux surgery (LARS). Of those who had not, 23 had complete long-term follow-up data for analysis and were included in the study. Seventy-three percent reported daily acid-reducing medication use, and the median GERD-HRQL score was 10 (6–14) compared to 24 (15–28) at baseline (
p
< 0.01). Seventy-eight percent of these patients expressed satisfaction or neutral feelings about their GERD management. There were no significant differences in the baseline characteristics of patients who underwent LARS during the study period and those who did not.
Conclusions
This study demonstrates that TIF can produce durable improvements in disease-specific quality of life in some patients with symptomatic GERD. The majority of patients resumed daily PPI therapy during the study period, but with significantly improved GERD-HRQL scores compared to baseline and increased satisfaction with their medical condition.
Background The incidence of pancreatic cancer is age related; patients older than the age of 65 represent 60% of all cases. We assessed our institution's experience and outcomes with pancreatic ...resection for malignancy in patients in their ninth decade. Study Design We reviewed records of patients undergoing pancreatic resection for malignancy at our institution between 1990 and 2007. Demographics, laboratory, treatment, and outcomes data were gathered. Comparisons were made between patients older and younger than the age of 80. Survival was analyzed using the Kaplan-Meier method and comparisons between groups were performed using the log-rank test. Regression methods were used to evaluate predictors of outcomes. Results There were 517 pancreatic resections for cancer reviewed. Of these, 27 patients were 80 years or older (age range 80 to 91 years), compared with 490 patients less than 80 (range 20 to 79 years). The distribution of clinical characteristics was similar between the 2 groups. The majority of patients undergoing pancreatic resection harbored a mass in the head of the pancreas, so the most common procedure was pancreaticoduodenectomy (n = 398, 78%). There were no significant differences in complication rates for younger and older groups (59% vs 52%, respectively, p = 0.4), median length of stay (11 vs 12 days, p = 0.33), or perioperative mortality rates (3.7% vs 3.7%, p = 1.0). Overall survival between the 2 groups was similar (21.9 vs 33.3 months, p = 0.18). Conclusions Pancreatectomy for malignancy is a safe option for the elderly. Patients older than age 80 achieved similar results, with similar rates of perioperative complications and mortality. Pancreatectomy for cancer offers a similar survival benefit in both groups.
Background
The proportion of population older than 60 years is rapidly increasing. The majority of this older population suffers from multiple comorbid conditions including obesity. Non-surgical ...means of weight loss do not offer a predictable solution. Surgical interventions seem to be the most promising solution for the obesity problem, but there is a relative lack of data in literature regarding bariatric procedures in older populations.
Objectives
Our study aims to evaluate the safety and efficacy of bariatric surgery in patients older than 60 years of age, to determine the weight loss, rate of operation-related complications, and impacts of surgery on comorbid conditions, and to compare the effectiveness of bariatric surgery in older patients to the effectiveness of bariatric surgery for the general population at Montefiore Medical Center.
Methods
A retrospective review of patients’ medical records were used to collect data to create databases to identify patients older than 60 years age who underwent bariatric surgery procedures spanning a 4-year period between January 2009 and October 2013. Data reviewed included age, sex, height, pre-operative weight, and body mass index (BMI), presence of obesity-related comorbid conditions, procedures performed, mortality, immediate or delayed complications, length of follow-up, excess weight lost, BMI points lost, percent of excess weight loss (%EWL), hemoglobin Alc (HgbA1c), and effects on obesity-related comorbid conditions. The percent of excess weight loss and number of complications within the older patient group were compared to the general population, which consists of patients between the ages of 22 and 59.
Results
Ninety-eight patients were identified. Seven patients did not follow up at any time period, and the eight patients who had laparoscopic adjustable gastric band (LAGB) were also excluded due to insufficient data. Overall, 83 patients who were above the age of 60 were examined; 30 patients had laparoscopic sleeve gastrectomy (LSG), and 53 patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). The average patient age was 63.4 years, the average pre-operative weight was 122.3 kg, and the average excess body weight was 54.8 kg. The pre-existing comorbid conditions included 90.4 % hypertension (HTN), 63.9 % diabetes mellitus (DM), 50.6 % hyperlipidemia (HL), 34.9 % obstructive sleep apnea (OSA), and 30.1 % asthma. The average %EWL at 3 months, 6 months, and 12 months was 37.0, 51.3, and 65.2 %, respectively. A significant proportion of patients reported resolution or improvement in comorbid conditions. When results were compared to the general, population there was no significant difference in the number of complications that occurred within each of the two groups. The difference in %EWL at the 12-month follow-up was not statistically significant between the general population and the older patients, which suggests that both groups lost a similar amount of weight and that bariatric surgery on patients who are above the age of 60 is effective.
Conclusions
Bariatric surgery can be safe and effective for patients older than 60 years of age with a low morbidity and mortality; the weight loss and improvement in comorbidities in older patients were clinically significant. When compared to the general population, there was no statistically significant difference in the average %EWL at 12 months or the number of complications due to surgery. Long-term effects of such interventions will need further studies and investigations.
Background
Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared ...fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC.
Methods
Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot’s triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected.
Results
Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m
2
, respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min,
p
< 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C.
Conclusions
NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.
Background
Cancers of the ampulla of Vater, distal common bile duct, and pancreas are known to have dismal prognosis. It is often reported that ampullary cancers are less aggressive relative to the ...other periampullary carcinomas. We sought to evaluate predictors of survival for periampullary cancers following pancreaticoduodenectomy to identify biologic behavior.
Methods
We reviewed the records of all patients who underwent pancreaticoduodenectomy for periampullary carcinoma between 1992 and 2007 at the Ohio State University Medical Center. Demographics, treatment, and outcome/survival data were analyzed. Kaplan–Meier survival curves were created and compared by log-rank analysis. Multivariate analysis was undertaken using Cox proportional-hazards method.
Results
346 consecutive periampullary malignancies (249 pancreatic cancers, 79 ampullary carcinomas, 18 extrahepatic cholangiocarcinomas) treated by pancreaticoduodenectomy were identified. Pancreatic cancer histology correlated with the shortest median survival (17.1 months), followed by cholangiocarcinoma (17.9 months) and ampullary carcinoma (44.3 months) (
P
< 0.001). Potential predictors of decreased survival on univariate analysis included site of origin, preoperative jaundice, microscopic positive margin, nodal metastasis, lymphovascular invasion, neural invasion, and poor differentiation. Only nodal metastasis (median 16.2 versus 29.9 months,
P
< 0.001) and neural invasion (median 17.7 versus 47.9 months,
P
< 0.00001) significantly predicted outcome on multivariate analysis.
Conclusions
Although ampullary cancers have the best prognosis overall, when controlled for tumor stage, only presence of neural invasion and nodal metastasis predict poor survival following pancreaticoduodenectomy. Biological behavior remains the most important prognostic indicator in periampullary cancers amenable to resection, regardless of site of origin.
Background
Bariatric surgery has been established as the most effective long-term treatment for morbid obesity.
Methods
We performed a retrospective review of SSO patients treated at our institute ...between 2008 and 2013 who underwent a laparoscopic gastric bypass (LGBP) or sleeve gastrectomy (LSG). The primary end point for this study was excess weight loss (EWL) at 1, 3, 6, and 12 months. Secondary end points included procedure length (PL), length of stay (LOS), diabetes management and postoperative complications.
Results
We identified 135 SSO patients who underwent bariatric surgery (93 LGBP, 42 LSG) at our institute from 2008 to 2013 with a median follow-up of 49 months. The incidence of EWL > 30 % for patients in the LGBP group was 3.9, 29.0, 72.2 and 94.6 % at 1, 3, 6 and 12 months, respectively, while the incidence of EWL > 30 % in patients in the LSG group was 4.2, 25.0, 59.1 and 100 % at 1, 3, 6 and 12 months, respectively. PL was 124 ± 49 min for the LGBP group and 98
+
51 min for the LSG group (
p
< 0.005). LOS was on average 3.0 days (range 1–21) for the LGBP group and 3.4 days (range 1–13) for the LSG group (
p
= 0.41). Patients experienced a decrease in their hemoglobin A1C level by 10 % for the LGBP group and 9 % for the LSG group at 1 year (
p
= 0.89). Postoperative complications were seen in 15.1 % of LGBP patients and 4.8 % of LSG patients.
Conclusions
Bariatric surgery is feasible in the SSO patients with comparable EWL outcomes and postoperative complications to historical non-SSO patients.
Comprehensive studies evaluating the efficacy of team-based competition (“Gamification”) in surgery have not been performed. Board pass rates and resident satisfaction may improve if surgical ...residents are involved in competition.
Residents at Montefiore Medical Center (Bronx, New York) were surveyed and separated into teams during a draft. Each resident’s performance was converted into a point system. Resident scores were combined into a team score and presented as a leaderboard. Awards were given. ABSITE, ACGME residency satisfaction, and ABS qualifying exam pass rates were compared.
Sixty percent of residents are inspired to improve their performance during gamification. ABSITE average percentile score improved from 28 to 43. ABS qualifying exam pass rates improved from 73% to 100%. Resident satisfaction improved from 65% to 88%. The point system allowed for establishing “growth curves” for each resident enabling enhanced assessment of residents.
A comprehensive team-based competition inspires performance, is feasible, and seems to improve ABSITE scores, ABS pass rates, and satisfaction while being a tool for assessment of performance.
•Most surgery residents consider themselves competitive and work well on teams.•Most of residents queried state that surgical teams inspire improved performance.•ABSITE and ABS exam outcomes improve during gamification of residency.•Resident program satisfaction improves during gamification of residency.•Points collected during gamification allow for making performance growth curves.
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