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Background: Although per oral endoscopic myotomy (POEM) has shown to be beneficial for the treatment of achalasia, it can be difficult to predict who will have a robust and long-lasting response. Historically, it has been shown that higher lower esophageal sphincter pressures have been associated with poorer responses to alternative endoscopic therapies such as Botox therapy and pneumatic dilation. This study was designed to evaluate if modern preoperative manometric data could similarly predict response to therapy after POEM., Methods: This was a retrospective study of 237 patients who underwent POEM at a single institution over a period of 13 years (2011-2023) and who had a high-resolution manometry performed preoperatively and an Eckardt symptom score performed both preoperative and postoperatively. The achalasia type and integrated relaxation pressures (IRP) were tested for potential correlation with the need for any further achalasia interventions postoperatively as well as the degree of Eckardt score reduction using a linear regression model., Results: The Achalasia type on preoperative manometry was not predictive for further interventions or degree of Eckardt score reduction (p = 0.76 and 0.43, respectively). A higher IRP was not predictive of the need for further interventions, however, it was predictive of a greater reduction in postoperative Eckardt scores (p = 0.03) as shown by the non-zero regression slope., Conclusion: In this study, achalasia type was not a predictive factor in the need for further interventions or the degree of symptom relief. Although IRP was not predictive of the need for further interventions, a higher IRP did predict better symptomatic relief postoperatively. This result is opposite that of other endoscopic treatment modalities (Botox and pneumatic dilation). Therefore, patients with higher IRP on preoperative high-resolution manometry would likely benefit from POEM which provides significant symptomatic relief postoperatively., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: It has been reported that higher surgeon experience leads to better patient outcomes. In this study, we look at surgeon experience and its association with postoperative outcomes and variation among the practice of surgeons performing paraesophageal hernia repairs (PEH)., Method: This was a retrospective study of 1155 patients who underwent PEH repair at a single institution (2010-2023). Surgeon experience was defined as the number of surgeries performed per surgeon and was split using the median surgeries (n = 100), with surgeons performing at or above the median categorized as high-experience and below the median as low-experience surgeons. A multivariable logistic regression model was used to test correlation between surgeon experience and variables, including demographics and intra- and post-operative outcomes., Results: High-experience surgeons performed more elective cases (93.4% vs 85.5%), but low-experience surgeons operated more on emergent (2.7% vs 0.9%), semi-elective (2.3% vs 1.4%), and urgent cases (9.5% vs 4.3%). Low-experience surgeons operated more on patients who were older (67.5 vs 63.2 years, p < 0.001) and had an increased risk of CVD (72.9% vs 61.5%, p < 0.001). Intraoperative OR time was considerably less for high-experience surgeons (115.8 vs 172.9 min, p < 0.001). Low-experience surgeons had increased risk of intra-operative complications (4.5% vs 1.8%, p = 0.021) and post-op pneumonia within 30 days (1.8% vs 0.3%). However, long-term outcomes such as hernia recurrence (OR: 1.10, CI: 0.78-1.54) and redo-operations for hiatal hernia (OR: 1.10, CI: 0.65-1.75) were similar for both groups., Conclusion: High-experience surgeons perform more complex revisional surgeries in less time with fewer complications. Low-experience surgeons operated more on patients with higher comorbidities but had significantly higher OR times. Long-term results of recurrence and redo-operations were comparable. These variations suggest that high-experience surgeons are more efficient while operating on more complex cases. These findings have pivotal implications to facilitate mentorship and education among less-experienced surgeons., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The routine use of post-operative esophogram has come under evaluation for multiple upper GI surgeries such as with bariatric surgery and gastric resections. A major complication following Per Oral Endoscopic Myotomy (POEM) is a leak from the myotomy site. A post-operative contrast esophogram is often utilized to evaluate the presence of a leak, however it is not a standardized care practice for all patients. Presently it is selectively performed depending on physician assessment intra-operatively. This project will evaluate the necessity of post-operative contrast esophogram following POEM., Materials and Methods: We retrospectively reviewed 277 patients diagnosed with achalasia who underwent POEM by two surgeons from 2011 to 2022. 173 patients met the inclusion criteria. A post-operative esophogram was used for the evaluation of a leak. Post-operative esophagram were selectively performed on day 1 following surgery using a water-soluble material. Data was evaluated using Stata., Results: There were 3 detected leaks in the group that underwent esophagrams compared to the non-esophagram group in the early post-operative period. The overall complication rate was 5.5% in the non-esophagram versus 7.9% in the esophagram group. Length of stay was 1.48 days in the non-UGI vs 1.76 days in the esophagram group. Readmission rate was 10.9% in non-esophagram versus 8.7% in esophagram group., Conclusion: There was no statistically significant difference in outcomes in patients undergoing POEM who received post-operative esophagram verses patients who did not receive post-operative esophagram. The routine use of a contrast esophogram to detect a leak following POEM may not be justified. This study suggests that esophagrams should be performed depending on the clinical signs/symptoms post-operatively that would warrant imaging and intervention., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Per oral endoscopic myotomy (POEM) is a safe therapy for the treatment of achalasia. Long-term effects of untreated achalasia include worsening dysmotility and disruptions in esophageal anatomy, i.e., tortuosity and dilation. We hypothesize that long-standing achalasia prior to intervention will have worse outcomes following POEM than in patients with symptoms for shorter duration., Methods: We retrospectively analyzed achalasia patients who underwent POEM at our institution from 2011 to 2023, categorizing them into symptom duration cohorts (< 1 year, 1-3 years, 4-10 years, > 10 years). Inclusion criteria comprised patients with documented achalasia diagnosis who received POEM treatment at our facility. Exclusion criteria encompassed individuals lacking data pertaining to achalasia diagnosis, the time frame before intervention, or those missing pre and postoperative Eckardt scores. POEM failure was defined as symptom recurrence, necessity for repeat intervention, or high postoperative Eckardt score. We compared demographic, preoperative, and postoperative outcomes across these cohorts, and employed multivariable logistic regression to explore the link between symptom duration and POEM response., Results: During the study period, in our increased cohort 234 patients met inclusion criteria. 75 patients had symptoms for < 1 year, 78 patients had symptoms from 1 to 3 years, 47 patients had symptoms from 4 to 10 years, and 34 patients had symptoms > 10 years. Patient demographics such as age, sex, BMI, Charleson-Deyo-Comorbidity-Index, and diabetes did not differ amongst cohorts. High-resolution manometry data, including achalasia type, Median IRP, LES residual pressure, and Basal LES pressure did not differ between groups. Preoperative Eckardt scores ranged from 4 to 5 across groups (p 0.24). Patients endorsed an average of three total preoperative symptoms across groups (p 0.13). Patients with symptoms greater than 4 years had significantly more endoscopic interventions prior to POEM (37% vs, 68% p .001). There was no significant difference in post-procedure mean Eckardt scores between cohorts. All cohorts experienced the same number of post-POEM symptoms. Post-POEM manometric measurements remained consistent across cohorts. Similarly, there were no significant differences in terms of symptom recurrence, requirement for repeat interventions, or repeat POEM among the cohorts. Multivariable logistic regression analysis determined achalasia symptoms greater than a decade did not result in increased odds of having a higher postoperative Eckardt score, worse dysphagia, regurgitation, or weight loss., Conclusions: In this increased cohort, this data once again suggests that longer symptom duration is not associated with increased rates of POEM failure., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Gastroparesis can be a debilitating disease process for which durable treatment options are lacking. While dietary changes and pharmacotherapy have some efficacy, symptoms frequently recur and some patients progress to needing supplemental enteral feeding access. Per oral pyloromyotomy (POP) has been shown to be a durable minimally invasive treatment option for refractory gastroparesis with a low side effect profile, and therefore has been performed at this institution for the past 6 years., Methods: This was a retrospective case series of all patients who underwent a POP at a single institution over a 6-year period (2018-2023). Patient demographics, preoperative symptomatology and subsequent workup, postoperative complications, and symptom recurrence were collected and analyzed., Results: There were 56 patients included in the study. There was a 1.8:1 female:male ratio. The average patient age was 56 years old (range 23-85). The average duration of symptoms was 1-3 years. Thirty-eight percent of patients had undergone previous endoscopic therapy for gastroparesis (pyloric botox injection or pyloric dilation) and 16% of patients underwent multiple endoscopic therapies. Twenty-nine percent of patients were on a medication for gastroparesis. Past surgery was the most common gastroparesis etiology for POP (50% of patients). Diabetes (23%) and idiopathic (19%) were the other most common gastroparesis etiologies for POP. Nausea was the most common symptom at first follow-up (30%) but these patients continued to improve with 14% of patients continuing to endorse nausea at 6 months. Twenty-seven percent of patients developed symptom recurrence. Forty percent of patients with symptom recurrence underwent a repeat endoscopic or surgical therapy., Conclusions: In this present study, POP leads to durable results in approximately 75% of patients with minimal complications. Furthermore, the majority of patients who do develop symptom recurrence do not require additional gastroparesis interventions., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Per oral endoscopic myotomy (POEM) is a relatively novel technique to address achalasia; however, little is known about the efficacy of POEM for patients with long-standing achalasia. We hypothesize that patients with long-standing achalasia prior to intervention will be more recalcitrant to POEM than patients with symptoms for a short duration., Methods: We performed a retrospective analysis of patients with achalasia who received a POEM at a single institution from 2012 to 2022. Patients were grouped into cohorts based on the time of symptom duration: < 1 year, 1-3 years, 4-10 years, > 10 years. POEM failure was defined as need for repeat intervention, symptom recurrence, and a high postoperative Eckart score. Demographic and clinical data were compared between cohorts. Measures of failure multivariable logistic regression analyzed the association between symptom duration and response to POEM., Results: During the study period, 132 patients met inclusion criteria. Patient age at surgery, sex, BMI, Charleston-Deyo Comorbidity Index, and patients with diabetes with and without end organ complications, connective tissue diseases, and patients with ulcer diseases did not differ among cohorts. Patients who have had symptoms for greater than 10 years had significantly more endoscopic interventions prior to their POEM (30% vs, 60% p = 0.002). Patients in all cohorts experienced the same number of symptoms post-POEM. Manometric measurements did not vary across cohorts after POEM. Symptom recurrence, need for repeat endoscopic intervention, repeat surgical intervention, or repeat POEM also did not vary across cohorts. Having symptoms of achalasia > 10 years did not increase the odds POEM failure on multivariable logistical regression., Conclusions: These data suggest that longer symptom duration is not associated with increased rates of POEM failure. This is promising as clinicians should not exclude patients for POEM eligibility based on duration of symptoms alone., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Per oral endoscopic myotomy (POEM) has been shown to be an efficacious and safe therapy for the treatment of achalasia. Compared to laparoscopic Heller myotomy however, no antireflux procedure is routinely combined with POEM and therefore the development of symptomatic or silent reflux is of concern. This study was designed to determine if various patient factors and anatomy would predict the development of gastroesophageal reflux disease post-operatively., Methods: This was a retrospective cohort study of all patients who underwent a POEM at a single institution by a single surgeon over an eight-year period (2014-2022). It has been our practice to obtain a postoperative ambulatory pH test on all patients 6 months after POEM off all acid reducing medications. Patients without a postoperative ambulatory esophageal pH monitoring test were excluded. Age, sex, obesity (BMI > 30), achalasia type, presence of a hiatal hernia, history of prior endoscopic achalasia treatments or myotomy were analyzed using univariate analysis as predictive factors for the development of postoperative GERD (DeMeester score > 14.7 on ambulatory pH monitoring)., Results: There were 179 total patients included in the study with 42 patients (23.5%) having undergone postoperative ambulatory pH testing. The majority of patients (137 or 76.5%) were lost to follow up and did not undergo ambulatory pH testing. Twenty-three out of those 42 patients (55%) had evidence of GERD on ambulatory pH testing. Multiple preoperative patient characteristics including demographics, manometric results, EGD findings, and history of prior achalasia interventions did not correlate with the development of post-operative GERD., Conclusions: Despite the high rate of reflux after POEM, there does not appear to be any reliable preoperative indicators of which patients have a higher risk of developing post-operative GERD after POEM., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Studies assessing outcomes of patients undergoing peroral endoscopic myotomy (POEM) after botulinum injection or dilation have had various results with respect to failure, although this has not been differentiated between lack of clinical response and recurrence. We hypothesize that patients with previous endoscopic intervention(s) are more likely to recur than treatment-naïve patients., Methods: This is a retrospective cohort study of patients that underwent POEM for achalasia at a single tertiary care center between 2011 and 2022. Patients were excluded if they had previous myotomy (POEM or Heller). The remaining patients were stratified into treatment-naïve patients (TN), those with previous botulinum injection (BTX), those with previous dilatation (BD), and those with both previous endoscopic interventions (BOTH). Primary outcome was recurrence indicated by clinical symptoms or need for repeat endoscopic intervention or surgery after originally having clinical resolution (Eckardt ≤ 3). Multivariate logistic regression using preoperative and intraoperative factors was completed to assess odds of recurrence., Results: A total of 164 patients were included in the analysis, 90 TN, 34 BD, 28 BTX, and 12 BOTH. There were no other significant differences in demographics or in preoperative Eckardt score (p = 0.53). There was no difference in the proportion of patients that had postoperative manometry (p = 0.74), symptom recurrence (p = 0.59), surgical intervention (p = 0.16). BTX (14.3%) and BOTH (16.7%) patients had a higher rate of repeat endoscopic intervention than BD and TN patients (5.9% and 1.1%). In the logistic regression analysis, there was no association among the BTX, BD, or BOTH groups compared to the TN group. No odds ratios achieved statistical significance., Conclusions: There were no increased likelihood of recurrence with botulinum injection or dilatation prior to POEM, implying that they are similarly good candidates compared to treatment-naïve patients., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: While per oral endoscopic myotomy (POEM) has been shown to be efficacious in the treatment of achalasia, it can be difficult to predict who will have a robust and durable response. Historically, high lower esophageal sphincter pressures have been shown to predict a worse response to endoscopic therapies such as botox therapy. This study was designed to evaluate if modern preoperative manometric data could predict a response to therapy after POEM., Methods: This was a retrospective study of 144 patients who underwent a POEM at a single institution by a single surgeon over an 8-year period (2014-2022) who had high-resolution manometry performed preoperatively and had an Eckardt symptom score performed both preoperatively and postoperatively. The achalasia type and integrated relaxation pressures (IRP) were then tested for potential correlation with need for any further achalasia interventions postoperatively as well as the degree of Eckardt score reduction using univariate analysis., Results: The achalasia type on preoperatively manometry was not predictive of need for further interventions or degree of Eckardt score reduction (p = 0.74 and 0.44, respectively). A higher IRP was not predictive of need for further interventions however it was predictive of a greater reduction in postoperative Eckardt scores (p = 0.03) as shown by a nonzero regression slope., Conclusion: In this study, achalasia type was not a predictive factor in need for further interventions or degree of symptom relief. While IRP was not predictive of need for further interventions, a higher IRP did predict better symptomatic relief postoperatively. This result is opposite that of other endoscopic treatment modalities. Therefore, patients with higher IRP on high-resolution manometry would likely benefit from myotomy which provides significant symptomatic relief postoperatively., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Although obesity is an established risk factor for adverse outcomes after paraesophageal hernia repair (PEHR), many obese patients nonetheless receive PEHR. The purpose of this study was to explore risk factors for adverse outcomes of PEHR among this high-risk cohort. We hypothesized that obese patients may have other risk factors for adverse outcomes following PEHR., Methods: A retrospective study of adult obese patients who underwent minimally invasive PEHR from 2017 to 2019 was performed. Patients were excluded for BMI < 30 or if they had concomitant bariatric surgery at time of PEHR. The primary outcome of interest was a composite adverse outcome (CAO) defined as having any of the four following outcomes after PEHR: persistent GERD > 30 d, persistent dysphagia > 30 d, recurrence, or reoperation. Chi-square and t-test analysis was used to compare demographic and clinical characteristics. Multivariable logistic regression analysis was used to evaluate independent predictors of CAO., Results: In total, 139 patients met inclusion criteria with a median follow-up of 19.7 months (IQR 8.8-81). Among them, 51/139 (36.7%) patients had a CAO: 31/139 (22.4%) had persistent GERD, 20/139 (14.4%) had persistent dysphagia, 24/139 (17.3%) had recurrence, and 6/139 (4.3%) required reoperation. On unadjusted analysis, patients with a CAO were more likely to have a history of prior abdominal surgery (86.3% vs 70.5%, p = 0.04) and were less likely to have undergone a preoperative CT scan (27.5% vs 45.5%, p = 0.04). On multivariable analysis, previous abdominal surgery was independently associated with an increased likelihood of CAO whereas age and preoperative CT scan had a decreased likelihood of CAO., Conclusions: Although there were adverse outcomes among obese patients, minimally invasive PEHR may be feasible in a subset of patients at specialized centers. These findings may help guide the appropriate selection of obese patients for PEHR., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Research presentation has benefits, including CV building, networking, and collaboration. A measurable standard for achievement is publication in a peer-reviewed journal. Expectations regarding the likelihood of publication are unknown for studies presented at a national surgical scientific meeting. This study aims to evaluate predictors of manuscript publication arising from abstracts presented at a national surgical scientific meeting., Methods: Abstracts presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting 2019 were reviewed. Identification of published manuscripts was completed using MedLine, Embase, and Google Scholar 28 months after the presentation to allow for time for publication. Factors evaluated for association with publication included author and abstract measures. Descriptive analyses and multivariable statistics were performed., Results: 724 abstracts (160 podiums, 564 posters) were included. Of the podium presentations, 128 (80%) were published in a median of 4 months after the presentation. On univariable and multivariable analyses, there was no association between publication and abstract topic, gender, degree, number of publications, or H-indices of first and senior authors. 154 (27.3%) poster presentations were published with a median of 13 months. On univariable analysis, there was a statistically significant difference regarding the abstract topic (p = 0.015) and senior author degree (p = 0.01) between published and unpublished posters. Multivariable analysis demonstrated that colorectal surgery (OR 2.52; CI 1.02-6.23) and metabolic/obesity (OR 2.53; CI 1.09-5.84) are associated with an increased odd of publication. There was an inverse association with female senior authors (OR 0.53; CI 0.29-0.98), while additional degrees (e.g., doctorate and/or master's degree) of the senior authors were associated with an increased publication rate (OR 1.80; CI 1.00-3.22)., Conclusion: 80% of podiums but only 27% of posters were ultimately published. While some predictors of poster publication were noted, it is unclear if these are why these projects fail to publish. Future research is warranted to determine if there are effective strategies to increase poster publication rates., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Malignant bowel obstruction (MBO) is a sequela of advanced intraabdominal cancer and has a profound impact on quality of life. Common therapy is endoscopic decompressive gastrostomy tube placement. Standard gastrostomy tubes are poorly designed to completely evacuate the dependent portions of the stomach due to their location on the anterior gastric wall. In our institution we have begun placing the ASPIRE Assist gastrostomy tube (ASPIRE Bariatrics, Exton, PA) which includes a 15 cm long, 30Fr fenestrated gastric tube extension for enhanced gastric decompression. This tube is FDA indicated for gastric decompression and marketed for endoscopic weight loss. The purpose of this study is to review our experience managing MBO utilizing the ASPIRE Assist tube., Methods: This is a retrospective analysis of outcomes at a single institution. All decompressive endoscopic gastrostomy tubes placed by two surgeons between November 2019 and July 2021 were reviewed. Endoscopic placement was performed utilizing standard safe tract and Ponsky pull techniques., Results: Fourteen patients were identified (10F:4 M), mean age 70 (range 35-89). Primary cancer diagnoses included gynecologic (8), colorectal (3), bladder (1), small bowel (1), peritoneal serous (1). During the 12 months before decompressive gastrostomy tube placement, mean number of hospital admissions for MBO was 1.6 (range 1-3). Following tube placement, twelve patients had no further hospital admissions for MBO over their lifespan of mean 270 days (range 8-679 days). One patient had 1 admission for MBO in the 12 months before tube placement and 3 admissions in the 4 months after placement. A second patient had 2 admissions in the 12 months before tube placement and 1 admission in their 54-day lifespan after placement. There were no major complications., Conclusions: Endoscopic placement of the ASPIRE Assist gastrostomy tube is safe for palliation of MBO and may improve gastric decompression compared with standard endoscopic gastrostomy tubes. Enhanced gastric decompression can better manage symptoms, reduce hospital encounters, and improve quality of life. Further study is needed, however, our initial data appears promising., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: 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., Methods: 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/m 2 ) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed., Results: The 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., Conclusion: 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., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Per oral endoscopic myotomy (POEM) is used to treat a variety of esophageal motility disorders and is associated with relatively few complications. However, complications in patients on antithrombotic therapy (AT) is not well-studied. We hypothesize AT patients have a higher risk of post-operative bleeding and 30-day complication rate compared to all other patients, even when these medications are held peri-operatively., Methods: A single-institution retrospective review of a prospectively collected database of patients who underwent POEM procedures January 2011-July 2019 was performed. All 30-day complications were recorded, as well as management of AT medications peri-operatively. Demographic and clinical characteristics were compared using t test, Chi-Square, and Fisher's exact test as appropriate. Multivariate logistic regression was performed to examine factors associated with post-operative complications., Results: A total of 219 POEM procedures were performed. 50.2% of patients were male, and AT patients tended to be older (66.9 vs. 55.4, p = 0.01). The major complication rate was higher among AT patients (36.8% vs. 9.0%, p = 0.01), as was the rate of post-operative bleeding (10.5% vs. 1.0%, p = 0.04). After adjusting for gender and age, the use of antithrombotic therapy was significantly associated with 30-day complications (OR 6.03, p = 0.001)., Conclusions: Patients on AT who undergo POEM are significantly more likely to experience complications, including bleeding, within 30 days of surgery. Safe timing of post-operative resumption of antithrombotic medications remains a difficult decision that must be carefully considered by the endoscopist., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD) OBJECTIVE: These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia., Results: The panel agreed on 4 recommendations for adults and children with achalasia., Conclusions: Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III.

Introduction: Per-Oral Endoscopic Myotomy (POEM) is a less invasive alternative to laparoscopic Heller myotomy for patients with achalasia. While a partial fundoplication is often performed concurrently with laparoscopic myotomy, an endoscopic approach does not offer this and leaves patients prone to post-operative reflux. The objectives of this study were to (1) identify patients with post-POEM reflux using BRAVO pH and endoscopic evaluations, and (2) investigate risk factors associated with post-POEM reflux and esophagitis to optimize patient selection for POEM and identify those who will benefit from a proactive approach to post-operative reflux management., Methods: A retrospective review of a prospectively collected database of patients who underwent POEM between January 2011 and July 2017 at a single institution was performed. Demographics along with pre-POEM and post-POEM variables were obtained. Univariate and multivariate analyses were performed, using p values ≤ 0.05 for statistical significance., Results: Forty-six patients were included, with a mean follow-up of 358 days. Mean age was 58 (19.2); 61% were female. Thirty-six patients underwent 48-h BRAVO pH testing after POEM, which revealed abnormal esophageal acid exposure in 15 patients (41.7%). There was a correlation between positive BRAVO results and presence of preoperative esophagitis (p = 0.02). Only 13% of patients had symptom-related reflux episodes based on the Symptom Associated Probability of the BRAVO study. Post-operative endoscopy revealed 6 patients with esophagitis, compared to 4 patients who had esophagitis on preoperative endoscopy. Only higher preoperative Eckardt score was significantly associated with endoscopic evidence of esophagitis post-POEM., Conclusions: Reflux is common after POEM. A majority of patients with a positive BRAVO study are asymptomatic, which is concerning. Objective follow-up is of paramount importance with upper endoscopy and ambulatory pH monitoring being the gold standard. Elevated preoperative Eckardt score and esophagitis are associated with post-POEM reflux. This population warrants close surveillance.

Background: Following the success of per-oral endoscopic myotomy (POEM) for achalasia, application of this minimally invasive skillset has broadened to other disease processes. Since 2013, gastric per-oral pyloromyotomy (GPOP) has become an increasingly accepted therapy for refractory gastroparesis. Although it does not treat the underlying etiology of the disease, pyloromyotomy has demonstrated measurable improvements in gastric emptying scintigraphy, nausea, and quality of life. Gastroparesis is a common complication of esophagectomy due to the inherent vagotomy that occurs during creation of the gastric conduit. Fifteen to 30% of post-esophagectomy patients develop gastroparesis with a large portion of them reporting symptoms refractory to medical therapy, botox injection, and endoscopic dilation. Therefore, GPOP may have the potential to offer symptomatic relief to a significant population of debilitated post-esophagectomy patients., Materials and Methods: The procedure was recorded using standard operating room equipment. Materials utilized included high-definition single-channel gastroscope, therapeutic overtube, clear endoscopic cap, triangle tip (TT) knife, ERBE energy source, endoscopic clips, sclerotherapy needle, methylene blue with epinephrine, and CO 2 insufflator., Results: We present a video of GPOP for a 71-year-old male with post-vagotomy-induced gastroparesis after esophagectomy. His pre-operative course was significant for persistent nausea and vomiting, diet intolerance, 20 lb weight loss, and frequent hospitalizations for aspiration pneumonia. Post-operatively, the patient recovered well and was discharged home on post-operative day 1 on a liquid diet. At 3-week follow-up, his nausea, vomiting, and PO intolerance had improved. At 6-month follow-up, he had no recent admissions for aspiration pneumonia and his pylorus remained widely patent on EGD., Conclusions: GPOP status post-esophagectomy presented multiple challenges: difficulty maintaining field of view and insufflation, establishing tension and counter tension for the mucosotomy, and a limited working space. With care and patience, endoscopists trained to perform POEM may apply their skillset to help a large population of patients suffering with post-esophagectomy gastroparesis.

Background: Minimally invasive surgery is now preferred to open in many surgical procedures. This has led to changes in training to ensure skills acquisition and education in minimally invasive technique. There have been limited data regarding the effect of the number of open procedures being performed in training. The aim of this paper is to examine the relationship in trends for open and laparoscopic procedures performed by general surgery residents., Methods: A retrospective review of the Accreditation Council for Graduate Medical Education publicly available resident case log statistical reports for the academic years from 1999-2000 to 2017-2018 was performed for laparoscopic and open anti-reflux surgery, appendectomy, colectomy, splenectomy, and inguinal hernia repair. The data were grouped by time period and compared to evaluate changes in operative patterns., Results: The mean number for all (open and MIS) of the selected procedures increased from 159.1 in 2000 to 223.8 in 2018 (40.7%). The mean number of laparoscopic cases increased from 23.6 to 135.6 (462%), and open decreased from 135.5 to 88.2 (- 34.9%). There was a significant decrease in the average number of open procedures performed in each period among anti-reflux operations (3.4, 1.8, 1.5, 0.7, p < 0.01), appendectomy (30.7, 23.4, 13.6, 6.8, p < 0.01), and splenectomy (3.0, 2.0, 1.6, 1.4, p < 0.05); the number of open colectomies decreased significantly from Period 2 to Period 4 (46.1, 38.5, 33.4, p < 0.02). There was a significant increase in the number of laparoscopic procedures performed in each period among appendectomy (13.1, 28.3, 48.9, 58.4, all p < 0.02), colectomy (2.9, 10.1, 19.1, 23.4, all p < 0.01), and inguinal hernia repair (9.7, 14.9, 25.6, 34.1, all p < 0.01)., Conclusion: The number of open procedures performed by general surgery residents continues to decline despite an increase in total cases reported. The reduction in open surgical experience may result in surgeons who lack technical skills to safely complete open procedures.

Background: Achalasia is a rare motility disorder of the esophagus. Treatment is palliative with the goal of symptom remission and slowing the progression of the disease. Treatment options include per oral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LM) and endoscopic treatments such as pneumatic dilation (PD) and botulinum toxin type A injections (BI). We evaluate the economics and cost-effectiveness of treating achalasia., Methods: We performed cost analysis for POEM, LM, PD and BI at our institution from 2011 to 2015. Cost of LM was set to 1, and other procedures are presented as percentage change. Cost-effectiveness was calculated based on cost, number of interventions required for optimal results for dilations and injections and efficacy reported in the current literature. Incremental cost-effectiveness ratio was calculated by a cost-utility analysis using quality-adjusted life year gained, defined as a symptom-free year in a patient with achalasia., Results: Average number of interventions required was 2.3 dilations or two injections for efficacies of 80 and 61 %, respectively. POEM cost 1.058 times the cost of LM, and PD and BI cost 0.559 and 0.448 times the cost of LM. Annual cost per cure over a period of 4 years for POEM, and LM were consistently equivalent, trending the same as PD although this has a lower initial cost. The cost per cure of BI remains stable over 3 years and then doubles., Conclusion: The cost-effectiveness of POEM and LM is equivalent. Myotomy, either surgical or endoscopic, is more cost-effective than BI due to high failure rates of the economical intervention. When treatment is being considered BI should be utilized in patients with less than 2-year life expectancy. Pneumatic dilations are cost-effective and are an acceptable approach to treatment of achalasia, although myotomy has a lower relapse rate and is cost-effective compared to PD after 2 years.

Introduction: Anastomotic or staple-line leak after foregut surgery presents a formidable management challenge. In recent years, with advancement of endoscopy, self-expanding covered stents have been gaining popularity. In this study, we aimed to determine the safety and effectiveness of self-expanding covered stents in management of leak after foregut surgery., Methods: Consecutive patients who received a fully covered self-expandable metal stent (SEMS) due to an anastomotic leak after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, stent placement and removal, clinical success, time to resolution, and complications were collected. Predictive factors for clinical success rate were assessed., Results: A total of 20 consecutive patients underwent placement of fully covered SEMS for anastomotic leak, following esophagectomy (n = 5), esophageal diverticulectomy (n = 1), gastric sleeve (n = 4), gastric bypass (n = 3), partial gastrectomy (n = 4), and total gastrectomy (n = 3). All the stents were removed successfully, and clinical resolution was achieved in 18 patients (90 %) after a median of two (range 1-3) procedures and a mean of 6.2 weeks (range 0.4-14). Complications presented in 12 patients (60 %), including stent migration (n = 8), mucosal friability (n = 4), tissue integration (n = 2), and bleeding (n = 2). Two (10 %) patients' treatment was complicated by aorto-esophageal fistula formation resulting in one death. Demographic factors, comorbidities, and type of surgery were not predictive of clinical success rate or time to resolution., Conclusion: SEMS are effective tools for the management of leaks after foregut surgery. The biggest challenge with this approach is stent migration. Caution is warranted due to the risk of fatal complications such as aorto-esophageal fistula formation. No type of surgery or particular patient factor, including age, sex, BMI, albumin, history of radiation, malignancy, and comorbid diabetes or coronary artery disease, appeared to be correlated with success rate. Larger studies are needed to determine factors predictive of clinical success.

Background: The purpose of this study was to assess the adequacy of current surgical residency and gastroenterology (GI) fellowship flexible endoscopy training as measured by performance on the FES examination., Methods: Fifth-year general surgery residents and GI fellows across six institutions were invited to participate. All general surgery residents had met ACGME/ABS case volume requirements as well as additional institution-specific requirements for endoscopy. All participants completed FES testing at the end of their respective academic year. Procedure volumes were obtained from ACGME case logs. Curricular components for each specialty and institution were recorded., Results: Forty-eight (28 surgery and 20 GI) trainees completed the examination. Average case numbers for residents were 76 ± 26 colonoscopies and 45 ± 12 EGDs. Among GI fellows, PGY4 s (N = 10) reported 99 ± 64 colonoscopies and 147 ± 79 EGDs. PGY5 s (N = 3) reported 462 ± 307 colonoscopies and 411 ± 260 EGDs. PGY6 GI fellows (N = 7) reported 515 ± 111 colonoscopies and 418 ± 146 EGDs. The overall pass rate for all participants was 75 %, with 68 % of residents and 85 % of fellows passing both the cognitive and skills components. For surgery residents, pass rates were 75 % for manual skills and 85.7 % for cognitive. On the skills examination, Task 2 (loop reduction) was associated with the lowest performance. Skills scores correlated with both colonoscopy (r = 0.46, p < 0.001) and EGD experience (r = 0.46, p < 0.001). Receiver operating characteristics curves were examined among the resident cohort. The minimum number of total cases associated with passing the FES skills component was 103. Significant variability existed in curricular components across institutions., Discussion: These data suggest that current flexible endoscopy training may not be sufficient for all trainees to pass the examination. Implementing additional components of the FEC may prove beneficial in achieving more uniform pass rates on the FES examination.

Background: The purpose of this study was to examine the effectiveness of the SAGES flexible endoscopy course in improving fellows' attitudes, confidence, and skills related to implementing endoscopy in practice., Methods: Fellows participated in a 2-day course consisting of case presentations, expert panels, and hands-on laboratory training. Before and after the course, fellows completed a questionnaire assessing demographics, experiences in residency, practice plans, plans to implement flexible endoscopy in practice, and level of confidence performing 15 endoscopic procedures. Half of the fellows were randomly assigned to complete pre- and post-skills testing using a previously validated endoscopic targeting model., Results: Fifty-four fellows (90 %; age 33.5 ± 2.8; 58 % male) completed the pre- and post-questionnaire. All MIS fellowship types were represented. Almost half (48 %) reported none or very little flexible endoscopy in their current fellowship. The average prior case volume among those completing an ACGME-approved residency (42/54) was 76 upper and 75 lower endoscopies with one-third reporting no experience in therapeutic EGD (33 %) or polypectomy (31 %). Intentions to implement flexible endoscopy in practice significantly improved after the course overall (3.72 ± .85-3.92 ± .69, p < 0.05; 1 = never; 5 = very frequently). Prior to the course, 39 % of fellows reported plans to use endoscopy in practice "occasionally" or "rarely." After, this decreased to 28 with 72 % planning to implement "frequently" or "very frequently." Mean levels of confidence performing all 15 endoscopic tasks improved significantly after the course. Skills performance for the 27 fellows improved significantly as well; participants decreased their time to perform the targeting task by 40 % (222.3 ± 119.8-133.0 ± 70.1 s; p < 0.001) and decreased errors by 49 % (2.9 ± 1.7-1.5 ± 1.5; p < 0.001)., Conclusions: These results indicate that the SAGES flexible endoscopy course increases fellow confidence to implement endoscopic techniques, expands the ways in which they plan to include endoscopy in practice, and enhances their endoscopic skills.

Background: The fundamentals of endoscopic surgery (FES) examination measures the knowledge and skills required to perform safe flexible endoscopy. A potential limitation of the FES skills test is the size and cost of the simulator on which it was developed (GI Mentor II virtual reality endoscopy simulator; Simbionix LTD, Israel). A more compact and lower-cost alternative (GI Mentor Express) was developed to address this issue. The purpose of this study was to obtain evidence for the validity of scores obtained on the Express platform, so that it can be used for testing., Study Design: General surgery residents at various levels of training and practicing endoscopists at five institutions participated. Each completed the five FES tasks on both simulator platforms in random order, with 3-14 days between tests. Scores were calculated using the same standardized computer-generated algorithm and compared using Pearson's correlation coefficient., Results: There were 58 participants (mean age 32; 76% male) with a broad range of endoscopic experience. The mean (95% confidence interval) FES scores were 72 (67:77) on the GI Mentor II and 66 (60:71) on the Express. The correlation between scores on the two platforms was 0.86 (0.77:0.91; p < 0.0001)., Conclusion: There is a high correlation between FES manual skills scores measured on the original platform and the new Express, providing evidence to support the use of the GI Mentor Express for FES testing.

Introduction: Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients who have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients who have undergone POEM and compare outcomes between patients who have or have not received previous treatment for achalasia., Methods and Procedures: We evaluated our prospectively collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and postoperative GERD-Health-Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring., Results: Forty patients received a POEM procedure between 2011 and 2013. Of these, 40% (n = 16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 min for patients with prior procedures (Prior Tx) and 118 min for patients without any prior procedure (No Tx) (p = 0.07). Intraoperative complication rates for the Prior Tx group were 12.5 versus 16.7% for the No Tx group. Mean follow-up was 10 months. Both groups independently demonstrated clinical improvement in both the GERD-HRQL and SF-12 scores following POEM. There were no statistical differences between the two groups for GERD-HRQL reflux and dysphagia subset scores, or SF-12 mental component summary., Conclusion: We found favorable outcomes following POEM in patients who have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no significant differences between these two groups with regards to operative times, GERD-HRQL scores, and mental component SF-12 scores. One complication requiring intervention occurred in a patient that had received multiple prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.

Introduction: Premalignant lesions of the foregut (esophagus and stomach) are common entities usually incidentally identified on either endoscopic or radiographic imaging studies., Symptoms: These lesions are often asymptomatic or associated with vague gastrointestinal symptoms., Treatment: Current management of benign and premalignant lesions of the foregut includes primarily ablative and resective endoscopic techniques as well as thoracoscopic, laparoscopic, and open surgical techniques of enucleation and segmental resections. The appropriate procedure, however, is based on the depth of penetration, lesion location, and suspicion for underlying malignant potential.

Background: Per oral endoscopic myotomy (POEM) has evolved as a novel therapeutic option for the treatment of esophageal motility disorders such as achalasia. The originally described dissection technique involves cutting the inner circular esophageal muscle fibers in an antegrade fashion. We have modified this technique by commencing the muscular division at the most distal aspect of the submucosal tunnel and continuing the dissection in a retrograde fashion. We present our initial series of patients performed using this modified technique., Methods: We retrospectively reviewed our prospectively collected database. Peri- and postoperative data were collected and analyzed. POEM procedures were performed in a near-identical manner as previously published., Results: Retrograde myotomy was performed on five patients with a diagnosis of achalasia. Four had a history of prior treatment including balloon dilation, with one of these having a prior surgical myotomy. Retrograde POEM procedures were performed with trace blood loss and without any complications. Mean operative time was 85 min. All patients had normal esophagram studies, and diets were advanced as per protocol., Conclusion: POEM was developed as a minimally invasive method for the treatment of achalasia. Our retrograde dissection modification allows the most critical portion of the case, namely division of the lower esophageal and upper gastric circular muscle fibers, to be performed earlier in the case. This ensures adequate dissection of the primary site of esophageal dysfunction should problems arise during the procedure. The modification is straightforward, without the need for additional training or equipment, and appears to provide a more rapid myotomy with less charring in this small cohort of patients.

Background: The Fundamentals of Endoscopic Surgery™ (FES) program consists of online materials and didactic and skills-based tests. All components were designed to measure the skills and knowledge required to perform safe flexible endoscopy. The purpose of this multicenter study was to evaluate the reliability and validity of the hands-on component of the FES examination, and to establish the pass score., Methods: Expert endoscopists identified the critical skill set required for flexible endoscopy. They were then modeled in a virtual reality simulator (GI Mentor™ II, Simbionix™ Ltd., Airport City, Israel) to create five tasks and metrics. Scores were designed to measure both speed and precision. Validity evidence was assessed by correlating performance with self-reported endoscopic experience (surgeons and gastroenterologists [GIs]). Internal consistency of each test task was assessed using Cronbach's alpha. Test-retest reliability was determined by having the same participant perform the test a second time and comparing their scores. Passing scores were determined by a contrasting groups methodology and use of receiver operating characteristic curves., Results: A total of 160 participants (17 % GIs) performed the simulator test. Scores on the five tasks showed good internal consistency reliability and all had significant correlations with endoscopic experience. Total FES scores correlated 0.73, with participants' level of endoscopic experience providing evidence of their validity, and their internal consistency reliability (Cronbach's alpha) was 0.82. Test-retest reliability was assessed in 11 participants, and the intraclass correlation was 0.85. The passing score was determined and is estimated to have a sensitivity (true positive rate) of 0.81 and a 1-specificity (false positive rate) of 0.21., Conclusions: The FES hands-on skills test examines the basic procedural components required to perform safe flexible endoscopy. It meets rigorous standards of reliability and validity required for high-stakes examinations, and, together with the knowledge component, may help contribute to the definition and determination of competence in endoscopy.

Background: Flexible endoscopy is an integral part of surgical care. Exposure to endoscopic procedures varies greatly in surgical training. The Society of American Gastrointestinal and Endoscopic Surgeons has developed the Fundamentals of Endoscopic Surgery (FES), which serves to teach and assess the fundamental knowledge and skills required to practice flexible endoscopy of the gastrointestinal tract. This report describes the validity evidence in the development of the FES cognitive examination., Methods: Core areas in the practice of gastrointestinal endoscopy were identified through facilitated expert focus groups to establish validity evidence for the test content. Test items then were developed based on the content areas. Prospective enrollment of participants at various levels of training and experience was used for beta testing. Two FES cognitive test versions then were developed based on beta testing data. The Angoff and contrasting group methods were used to determine the passing score. Validity evidence was established through correlation of experience level with examination score., Results: A total of 220 test items were developed in accordance with the defined test blueprint and formulated into two versions of 120 questions each. The versions were administered randomly to 363 participants. The correlation between test scores and training level was high (r = 0.69), with similar results noted for contrasting groups based on endoscopic rotation and endoscopic procedural experience. Items then were selected for two test forms of 75 items each, and a passing score was established., Conclusions: The FES cognitive examination is the first test with validity evidence to assess the basic knowledge needed to perform flexible endoscopy. Combined with the hands-on skills examination, this assessment tool is a key component for FES certification.

Background: Esophageal endoscopic submucosal dissection (ESD) is an effective minimally invasive therapy for early esophageal cancer and high-grade Barrett dysplasia. However, esophageal stricture formation after circumferential or large ESD has limited its wide adoption. Mitomycin C (MMC), halofuginone (Hal), and transforming growth factor β3 (TGF-β3) exhibits antiscarring effects that may prevent post-ESD stricture formation., Methods: Using endoscopic mucosectomy (EEM) technique, an 8- to 10-cm-long circumferential esophageal mucosal segment was excised in a porcine model. The site was either untreated (control, n = 6) or received 40 evenly distributed injections of antiscarring agent immediately and at weeks 1 and 2. High and low doses were used: MMC 5 mg (n = 2), 0.5 mg (n = 2); Hal 5 mg (n = 2), 1.5 mg (n = 2), 0.5 mg (n = 2); TGF-β3 2 μg (n = 2), 0.5 μg (n = 2). The degree of stricture formation was determined by the percentage reduction of the esophageal lumen on weekly fluoroscopic examination. Animals were euthanized when strictures exceeded 80 % or the animals were unable to maintain weight., Results: The control group had a luminal diameter reduction of 78.2 ± 10.9 % by 2 weeks and were euthanized by week 3. Compared at 2 weeks, the Hal group showed a decrease in mean stricture formation (68.4 % low dose, 57.7 % high dose), while both TGF-β3 dosage groups showed no significant change (65.3 % low dose, 76.2 % high dose). MMC was most effective in stricture prevention (53.6 % low dose, 35 % high dose). Of concern, the esophageal wall treated with high-dose MMC appeared to be necrotic and eventually led to perforation. In contrast, low dose MMC, TGF-β3 and Hal treated areas appeared re-epithelialized and healthy., Conclusions: Preliminary data on MMC and Hal demonstrated promise in reducing esophageal stricture formation after EEM. More animal data are needed to perform adequate statistical analysis in order to determine overall efficacy of antiscarring therapy.

Background: ERCP, especially therapeutic, is difficult in patients with Billroth II surgical reconstruction and is associated with a higher rate of complications. This has led to controversy on the choice between a forward-viewing and side-viewing endoscope for performing the procedure. A previous case series from Asia reported a high rate of success with a cap-fitted ERCP technique. To our knowledge, the utility of cap-assisted ERCP with a forward-viewing gastroscope when other techniques fail has not been reported. We describe and demonstrate a novel rescue approach using a cap-fitted, forward-viewing gastroscope in patients with Billroth II anatomy, when attempts with duodenoscopes, pediatric colonoscopes, and gastroscopes previously failed., Methods: Retrospective case series. Inclusion criteria were: (a) documented Billroth II anatomy; and (b) use of cap-assisted ERCP as a rescue intervention on the first endoscopic encounter after failed attempts to perform ERCP with a duodenoscope. Patients were excluded if they successfully underwent ERCP with a duodenoscope. One advanced endoscopist and one advanced endoscopy fellow performed all but one of the procedures., Results: Five cap-assisted ERCP procedures were performed in three patients with Billroth II anatomy. A wide variety of diagnostic and therapeutic endoscopic maneuvers were technically feasible and successful, including the endoscopic treatment of an afferent limb perforation caused by a duodenoscope., Conclusions: Cap-assisted ERCP is a novel and underutilized technique that adds to the armamentarium of experienced therapeutic endoscopists. This approach may help ensure a successful endoscopic outcome and spare patients with Billroth II anatomy a percutaneous or surgical approach when ERCP with a duodenoscope, pediatric colonoscope or non-cap-fitted gastroscope fails.

Background: Over the last two decades, self-expanding enteral stents have gained popularity and shown therapeutic potential for strictures, obstructions, fistulae, and perforations of the gastrointestinal (GI) tract. Currently available stent delivery systems make deployment in many locations in the GI tract difficult due to the inability to traverse curves or impossible due to the size requirements of the deployment systems., Methods: A 67-year-old male presented to our hospital with severe gallstone pancreatitis, requiring a prolonged intensive care unit course. Two days after discharge to a rehabilitation facility he developed acute abdominal pain and pneumoperitoneum. Operative exploration failed to identify a perforation. Subsequently, a left-upper-quadrant abscess developed that was drained percutaneously, yielding coliform bacteria. The drain produced several hundred milliliters of stool a day. A barium enema demonstrated a perforation in the descending colon from an old colo-colic anastomosis site. We proposed a novel over-the-scope (OTS) stent deployment method. Utilizing a heat-activated polymer sheath, the stent was affixed to the endoscope. A modified speed-banding attachment was created to permit release of the polymer sheath once endoscopic and fluoroscopic confirmation of the correct position was obtained., Results: Utilizing this method of OTS stent deployment, a fully covered 23 × 155 mm self-expanding metal stent (WallFlex, Boston Scientific, Natick, MA) was placed in the colon. Endoscopic and fluoroscopic evaluation following stent placement confirmed stent coverage of the perforation with no ongoing evidence of leak. The patient was discharged to his home state 2 weeks after stent placement in stable condition., Conclusion: We have developed a novel method of OTS stent placement that permits deployment of a variety of enteral stents on any available endoscope. This method permits placement of fully covered stents in locations in the GI tract not reachable with currently available delivery systems.

Background: Advanced esophageal dysplasia and early cancers have been treated traditionally with esophagectomy. Endoscopic esophageal mucosectomy (EEM) offers less-invasive therapy, but high-degree stricture formation limits its applicability. We hypothesized that placement of a biodegradable stent (BD-stent) immediately after circumferential EEM would prevent stricturing., Methods: Ten pigs (five unstented controls, five BD-stent) were utilized. Under anesthesia, a flexible endoscope with a band ligator and snare was used to incise the mucosa approximately 20 cm proximal to the lower esophageal sphincter. A 10-cm, circumferential, mucosal segment was dissected and excised by using snare electrocautery. In the stented group, an 18-×120-mm, self-expanding, woven polydioxanone stent (ELLA-CS, Hradec-Kralove) was deployed. Weekly esophagograms evaluated for percent reduction in esophageal diameter, stricture length, and proximal esophageal dilation. Animals were euthanized when the stricture exceeded 80% and were unable to gain weight (despite high-calorie liquid diet) or at 14 weeks., Results: The control group rapidly developed esophageal strictures; no animal survived beyond the third week of evaluation. At 2 weeks post-EEM, the BD-stent group had a significant reduction in esophageal diameter (77.7 vs. 26.6%, p < 0.001) and degree of proximal dilation (175 vs. 131%, p = 0.04) compared with controls. Survival in the BD-stent group was significantly longer than in the control group (9.2 vs. 2.4 weeks, p = 0.01). However, all BD-stent animals ultimately developed clinically significant strictures (range, 4-14 weeks). Comparison between the maximum reduction in esophageal diameter and stricture length (immediately before euthanasia) demonstrated no differences between the groups., Conclusions: Circumferential EEM results in severe stricture formation and clinical deterioration within 3 weeks. BD-stent placement significantly delays the time of clinical deterioration from 2.4 to 9.2 weeks, but does not affect the maximum reduction in esophageal diameter or proximal esophageal dilatation. The timing of stricture formation in the BD-stent group correlated with the loss radial force and stent disintegration.

Many surgeons attempting Laparo-Endoscopic Single Site (LESS) cholecystectomy have found the operation difficult, which is inconsistent with our experience. This article is an attempt to promote a standardized approach that we feel surgeons with laparoscopic skills can perform safely and efficiently. This is a four-trocar approach consistent with the four incisions utilized in conventional laparoscopic cholecystectomy. After administration of general anesthesia, marcaine is injected at the umbilicus and a 12-mm vertical incision is made through the already existing anatomical scar of the umbilicus. A single four-trocar port is inserted. A 5-mm deflectable-tip laparoscope is placed through the trocar at the 8 o'clock position, a bariatric length rigid grasper is inserted through the trocar at the 4 o'clock position (to grasp the fundus), and a rigid bent grasper is placed through the 10-mm port (to grasp the infundibulum). This arrangement of the instruments promotes minimal internal and external instrument clashing with simultaneous optimization of the operative view. This orientation allows retraction of the gallbladder in a cephalad and lateral direction, development of a window between the gallbladder and the liver which promotes the "critical view" of the cystic duct and artery, and provides triangulation with excellent visualization of the operative field. The operation is concluded with diaphragmatic irrigation of marcaine solution to minimize postoperative pain. Standardization of LESS cholecystectomy will speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach.

Introduction: Laparoscopic Heller myotomy has become the therapy of choice for achalasia. In the last three years, clinical experience with a novel approach to this disease, Per-Oral Endoscopic Myotomy (POEM), has grown., Methods: Herein, we describe the technical steps in the POEM procedure., Conclusion: In our experience, the method appears to be a safe alternative to standard laparoscopic Heller myotomy, but further assessment is needed to understand long-term outcomes.

Background: Minimally invasive techniques have become an integral part of general surgery, with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents a prospective, randomized, multicenter, single-blind trial of SILC compared with four-port cholecystectomy (4PLC) with the goal of assessing safety, feasibility, and factors predicting outcomes., Methods: Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC or 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Pain, cosmesis, and quality-of-life scores were documented. Patients were followed for 12 months., Results: Two hundred patients were randomized to SILC (n = 117) or 4PLC (n = 80) (3 patients chose not to participate after randomization). Patients were similar except for body mass index (BMI), which was lower in the SILC patients (28.9 vs. 31.0, p = 0.011). One SILC patient required conversion to 4PLC. Operative time was longer for SILC (57 vs. 45 min, p < 0.0001), but outcomes, including total adverse events, were similar (34% vs. 38%, p = 0.55). Cosmesis scores favored SILC (p < 0.002), but pain scores were lower for 4PLC (1 point difference in 10-point scale, p < 0.028) despite equal analgesia use. Wound complications were greater after SILC (10% vs. 3%, p = 0.047), but hernia recurrence was equivalent for both procedures (1.3% vs. 3.4%, p = 0.65). Univariate analysis showed female gender, SILC, and younger age to be predictors for increased pain scores, while SILC was associated with improved cosmesis scores., Conclusions: In this multicenter randomized controlled trial of SILC versus 4PLC, SILC appears to be safe with a similar biliary complication profile. Pain scores and wound complication rates are higher for SILC; however, cosmesis scores favored SILC. For patients preferring a better cosmetic outcome and willing to accept possible increased postoperative pain, SILC offers a safe alternative to the standard 4PLC. Further follow-up is needed to detail the long-term risk of wound morbidities, including hernia recurrence.

Background: The advancement of natural orifice translumenal endoscopic surgery (NOTES) into clinical practice is dependent on its safety, efficacy, and efficiency. Access is the obligatory first step in NOTES and serves as a surrogate to technical difficulties associated with this novel surgical approach. This study aimed to compare endoscopic transgastric access techniques in terms of safety, reproducibility, and efficiency., Methods: Seven variations for anterior transgastric NOTES access were evaluated with female domestic swine. After marking of an anterior site, electrocautery was used to create a small gastrotomy, followed by balloon dilation and entry into the peritoneal cavity. Methodologic variations incorporated the use of guidewires, electrocautery and dilation combined within a single device, support tubes, and dilation without electrocautery. Access times were recorded, and tissue injury was evaluated., Results: In 70 access attempts, the most serious complication was bleeding from the gastroepiploic vessel, controlled with electrocautery. High variability in access times was prevalent with almost all the access techniques., Conclusions: This study supports the presumption that an anterior transgastric access technique for NOTES procedures is safe. The use of a wire to mark the site and another wire to retain the gastrotomy provided safe, efficient, and reproducible transgastric access. Comparison with laparoscopy exposed the disparity in technical challenges facing NOTES, suggesting that new technology and further refinement in methodology are required for NOTES to be clinically relevant.

Background: Transgastric endoscopy may represent a viable platform for diagnostic and therapeutic pancreatic interventions with reduced morbidity. In a human cadaver model, we aimed to determine the feasibility of transgastric endoscopic access to the lesser sac, creation of an adequate working space within the lesser sac, and reliable identification of lesser sac anatomic structures., Methods: In six human cadavers, endoscopic guidance was used to determine an appropriate access site to the lesser sac. Subsequently, endosonographic guidance was used to introduce an aspiration needle into the potential space between the stomach and the pancreas. After creating a fluid cushion and dilating the needle tract, an endoscope was advanced through the gastrotomy into the lesser sac and air insufflation was used to create a working space. Predetermined anatomic structures were systematically sought and marked when recognized. In the final two cadavers, endoscopic closure of the access site was performed., Results: All six procedures were successful in achieving access to the lesser sac and establishing an adequate working space. The access sites appeared amenable to endoscopic closure. Reliable organ identification, however, was not achieved in all cases, representing one of the immediate barriers to clinical application., Conclusions: Transgastric endoscopic access to the lesser sac can be achieved reliably and an adequate working space can be established. Additional research addressing endoscopic orientation and organ recognition within the lesser sac is necessary. The immediate potential applications of this approach include differentiating benign from malignant pancreatic pathology.

Background: Endoscopic radiofrequency ablation (RFA) has been used effectively for ablation of foregut disorders and also may have a role in treating colonic pathology. This study aimed to assess the feasibility of delivering RFA to locations within the colon and to determine a range of safe treatment parameters., Methods: Patients undergoing left hemicolectomy or proctocolectomy were evaluated. Focal RFA using a colonoscope-mounted device was delivered to normal segments of the colon and rectum within the planned surgical resection specimen. Endoscopic accessibility and feasibility of delivering heat energy to the colon and rectum were assessed as well as the maximum incurred histologic depth of ablation in relation to the number of applications (2 or 4) and the energy density (12, 15, or 20 J/cm2)., Results: A total of 51 ablation zones in 16 patients had available histopathology. None of the sites receiving two applications demonstrated serosal layer alteration compared with 15% of the sites receiving four applications (p=0.11). Muscularis propria alterations were seen in 25% of the two-application sites and 63% of the four-application sites (p<0.05). Increasing energy density from 12 to 20 J/cm2 did not correlate with a deeper ablation effect., Conclusions: Endoscopic RFA is capable of delivering therapy to the distal colon. Injury is limited to the muscularis propria or less depth when no more than two ablations are applied regardless of the energy density used. Based on these feasibility and dosimetry results, the authors will continue investigation using these and smaller energy doses to initiate trials ultimately with patients who have suitable mucosal and submucosal disorders of the lower gastrointestinal tract including chronic, nonulcerated hemorrhagic radiation proctitis and angiodyplasia.

Background: Evaluation of a potential source for abdominal sepsis in a critically ill patient can be challenging. With flexible endoscopy readily available in this setting, we sought to evaluate the diagnostic efficacy of a transgastric natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy vs. laparoscopic exploration in the identification of intra-abdominal pathology in a porcine model., Methods: In this acute study, 15 pigs were randomized to demonstrate 0 to 4 pathologic lesions: small bowel ischemia (SBI), small bowel perforation (SBP), colon perforation (CP), and gangrenous cholecystitis (GC). Two blinded surgical endoscopists were allowed 60 min to perform NOTES or laparoscopy (LAP) to correctly identify or exclude each lesion. A prototype endoscope (R-scope, Olympus, Inc), which enables independent instrument mobility, was used in the NOTES arm., Results: When considering all lesions, LAP was more sensitive diagnostically than NOTES (77.4% vs. 61.3%) overall. LAP also displayed a slightly higher NPV compared with NOTES (79.4% vs. 70.7%). However, NOTES was 100% specific with 100% positive predictive value (PPV) compared with 93.1% and 92.3% with LAP, respectively. Individually, NOTES was found most sensitive with CP identification (87.5%) and least sensitive with SBP (37.5%). The sensitivity of NOTES for SBI and GC was 62.5% and 57.1%, respectively., Conclusions: The utilization of NOTES as a diagnostic tool may have an important role in the critically ill patient when operative intervention is highly morbid. Although it may be overall inferior diagnostically compared with laparoscopy, a positive identification was highly specific with a strong predictive value. Further investigation addressing an improved small bowel evaluation technique would be beneficial. A human trial of NOTES in the ICU utilizing the current technology would still initially mandate laparoscopic or open surgical confirmation and treatment.

Background: Simulators may improve the efficiency, safety, and quality of endoscopic training. However, no objective, reliable, and valid tool exists to assess clinical endoscopic skills. Such a tool to measure the outcomes of educational strategies is a necessity. This multicenter, multidisciplinary trial aimed to develop instruments for evaluating basic flexible endoscopic skills and to demonstrate their reliability and validity., Methods: The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) Upper Endoscopy (GAGES-UE) and Colonoscopy (GAGES-C) are rating scales developed by expert endoscopists. The GAGES scale was completed by the attending endoscopist (A) and an observer (O) in self-assessment (S) during procedures to establish interrater reliability (IRR, using the intraclass correlation coefficient [ICC]) and internal consistency (IC, using Cronbach's alpha). Instrumentation was evaluated when possible and correlated with total scores. Construct and external validity were examined by comparing novice (NOV) and experienced (EXP) endoscopists (Student's t-test). Correlations were calculated for GAGES-UE and GAGES-C with participants who had performed both., Results: For the 139 completed evaluations (60 NOV, 79 EXP), IRR (A vs. O) was 0.96 for GAGES-UE and 0.97 for GAGES-C. The IRR between S and A was 0.78 for GAGES-UE and 0.89 for GAGES-C. The IC was 0.89 for GAGES-UE, and 0.95 for GAGES-C. There were mean differences between the NOV and the EXP endoscopists for GAGE-UE (14.4 +/- 3.7 vs. 18.5 +/- 1.6; p < 0.001) and GAGE-C (11.8 +/- 3.8 vs. 18.8 +/- 1.3; p < 0.001). Good correlation was found between the scores for the GAGE-UE and the GAGE-C (r = 0.75; n = 37). Instrumentation, when performed, demonstrated correlations with total scores of 0.84 (GAGE-UE; n = 73) and 0.86 (GAGE-C; n = 45)., Conclusions: The GAGES-UE and GAGES-C are easy to administer and consistent and meet high standards of reliability and validity. They can be used to measure the effectiveness of simulator training and to provide specific feedback. The GAGES results can be generalized to North American and European endoscopists and may contribute to the definition of technical proficiency in endoscopy.

Background: Endoscopic full-thickness resection (EFTR) is a less-invasive method of en bloc removal of gastrointestinal tumors. In a previous nonsurvival animal experiment, the feasibility of a novel grasp-and-snare EFTR technique using a prototype tissue-lifting device was demonstrated. The objective of this study was to evaluate the safety and outcomes of this EFTR method in a porcine survival model., Methods: EFTR of model stomach tumors was performed in seven pigs using a double-channel endoscope with a prototype tissue-lifting device through one channel and snare through the other. The lifting device was advanced through the snare loop and anchored to the gastric wall adjacent the model tumor. The lifting device was then partially retracted into the endoscope, causing the target tissue, including tumor, to evert into the gastric lumen. The open snare was then placed beyond the tumor around uninvolved gastric tissue. Resection was performed by delivering an electrosurgical current through the snare. EFTR defects were closed by using tissue anchors. After an intended 10-day observation period, the pigs were euthanized and necropsy was performed., Results: All seven resections were successful with negative gross margins. No immediate complications occurred. Two defect closures failed during the early postoperative period, leading to infectious complications. The remaining intact closures were complicated by adjacent ulcers, one of which resulted in hemorrhage., Conclusions: Endoscopic full-thickness resection of gastric lesions using the grasp-and-snare technique is feasible in pigs. In this experiment, complications related to closure were significant. Further evaluation and modification of closure technique is necessary before studying this method of EFTR in humans.

Background: The immunologic and physiologic effects of natural orifice translumenal endoscopic surgery (NOTES) versus traditional surgical approaches are poorly understood. Previous investigations have shown that NOTES and laparoscopy share similar inflammatory cytokine profiles except for a possible late-phase tissue necrosis factor-alpha (TNF-alpha) depression with NOTES. The local peritoneal reaction and immunomodulatory influence of pneumoperitoneum agents in NOTES also are not known and may play an important role in altering the physiologic insult induced by NOTES., Methods: In this study, 51 animals were divided into four study groups, which respectively underwent abdominal exploration via transgastric NOTES using room air (AIR) or carbon dioxide (CO(2)) or via laparoscopy (LX) using AIR or CO(2) for pneumoperitoneum. Laparotomy and sham surgeries were additionally performed as control conditions. Measurements of TNF-alpha, interleukin-1beta (IL-1beta), and IL-6 were performed for peritoneal fluid collected after 0, 2, 4, and 6 h and on postoperative days (PODs) 1, 2, and 7., Results: Of the 45 animals assessed, 6 were excluded because of technical operative complications. The findings showed that LX-CO(2) generated the most pronounced response with all three inflammatory markers. However, no significant differences were detected between LX-CO(2) and either NOTES group at these peak points. No differences were encountered between NOTES-CO(2) and NOTES-AIR. Subgroup comparisons showed significantly higher levels of TNF-alpha and IL-6 with NOTES-CO(2) than with LX-AIR on POD 1 (p = 0.022) and POD 2 (p = 0.002). The LX-CO(2) subgroup had significantly higher levels of TNF-alpha than the LX-AIR subgroup at 4 h (p = 0.013) and on POD 1 (p = 0.021). No late-phase TNF-alpha depression occurred in the NOTES animals., Conclusion: The local inflammatory reaction to NOTES was similar to that with traditional laparoscopy, and the previously described late-phase systemic TNF-alpha depression in serum was not reproduced. At the peritoneal level, NOTES is no more physiologically stressful than laparoscopy. Furthermore, regardless of which gas was used, the role of the pneumoperitoneum agent did not affect the cytokine profile after NOTES, suggesting that air pneumoperitoneum is adequate for NOTES.

Background: Abdominal procedures have been performed for a long time through the anterior abdominal wall. Since the first reports in the 1980s, laparoscopy has become the standard for cholecystectomy, with many advantages over open procedures. Now a natural-orifice approach to the peritoneal cavity may further reduce the invasiveness of surgery by either diminishing or avoiding abdominal incisions. Several orifice routes to the abdominal cavity have been described: transgastric, transvaginal, transvesical, and transcolonic. Although most experiences with the porcine model showed the possibility of these approaches, few surgeons reported experiences with humans. The authors present their complete early experience with transgastric (TG) and transvaginal (TV) cholecystectomies in human beings., Methods: Thirty-nine patients (4 males and 35 females) underwent hybrid NOTES procedures from January 2007 to January 2009. The mean age was 46 years (range = 19-83). The body mass index ranged from 20 to 41 and ASA was I-II. Transgastric (TG) cholecystectomy was performed in 27 patients and 12 patients had a transvaginal (TV) cholecystectomy., Results: The mean operative time was 140 min. Although operative times were slightly shorter in the TG group 005B137 +/- 34.6 min (range = 75-195)] compared to the TV route [147 +/- 31.5 min (range = 95-220)], there were no significant differences between the two groups (p = 0.5, Mann-Whitney U test). Patients were started on liquids within 1 h and discharged 2 h later, except the last 11 TG patients, who went home 24 h later because of enrollment in a separate protocol. An overall 20% morbidity rate and no mortality were found. The complication rates for the TG and TV groups were 18% (5/27) and 25% (3/12), respectively, which was not statistically significant (p = 0.6, chi(2) test). Seventy-five percent of complications (6/8) occurred the first year and 25% (2/8) during the second year of our experience., Conclusion: Transgastric and transvaginal cholecystectomies are feasible. Although these NOTES procedures were laparoscopically assisted and current flexible endoscopes were used, it seems possible that major intra-abdominal surgeries may one day be performed without skin incisions. However, a learning curve is mandatory and, although there were no major bile duct injuries, there were NOTES-related complications. These trends toward incisionless surgery demand coordinated research in an interdisciplinary setting involving both surgeons and device manufacturers to further define appropriate indications, contraindications, and applications for natural-orifice surgery.

Background: The laparoscopic repair of ventral hernias can result in significant postoperative pain necessitating a prolonged hospital stay, increased narcotic use, and patient dissatisfaction. Elastomeric pain pump devices with local analgesics may significantly reduce postoperative discomfort after laparoscopic ventral hernia repair. This prospective randomized, double-blind, placebo-controlled study evaluated the effect of local anesthetic continuously infused with an elastomeric pain pump device to reduce postoperative pain., Methods: After institutional review board approval of the study, all patients undergoing laparoscopic ventral hernia repair consented to participate. Standardized technique included routine transfascial fixation sutures and titanium spiral tacks. Elastomeric pain pumps were placed percutaneously just above the mesh in the hernia sac. For 48 h postoperatively, 100 ml of continuous 0.5% Marcaine or normal saline was used at 2 ml/h. Postoperatively, the patients were evaluated every 8 h for the first 72 h, then after 2 weeks, 6 weeks, and 3 months for pain scores, narcotic usage (both oral and intravenous), return of flatus, length of hospital stay, and postoperative complications., Results: Of the 73 patients enrolled in the study, 37 received 0.5% Marcaine, and 36 received placebo. Despite randomization, the control group had significantly more obese patients (mean body mass index [BMI], 39 vs. 33 kg/m(2); p = 0.005), and more recurrent hernias (40% vs. 19%; p = 0.05), and also tended to have more prior hernia repairs (0.8 vs. 0.3; p = 0.06). There were no significant differences between the two groups in terms of operative times (p = 0.7), hernia size (p = 0.9), mesh size (p = 0.6), number of transfascial fixation sutures (p = 0.4), or number of spiral tacks (p = 0.13). Postoperative visual analog pain scores, usage of oral or intravenous narcotics, and morphine equivalents were similar between the two groups at all study points (p > 0.05). There were no significant differences between the two groups based on return of bowel function, toleration of a regular diet, or length of hospital stay. No postoperative complications directly related to the catheter were observed., Conclusions: This prospective randomized double-blind, placebo-controlled trial showed no advantage of an elastomeric pain pump device in terms of providing a measurable reduction in postoperative pain scores, narcotic use, time to return of bowel function, or length of hospital stay after laparoscopic ventral hernia repair. Further studies are warranted to determine other alternatives for reducing postoperative pain after laparoscopic ventral hernia repair.

Background: There is increasing interest in the use of virtual-reality simulators in general surgery residency training. Many simulators lack a benchmark against which trainees can measure competence and skill., Methods: Surgeons who had performed over 1,000 colonoscopies were evaluated on module 1, case 5 of the GI Mentor I or II virtual-reality endoscopy simulator (Simbionix, Cleveland). Participants were given 5 min to familiarize themselves with the simulator, and then performed the study case with standardized instructions. Metrics were recorded by using the previously calibrated simulator., Results: Twenty-three surgeons (21 male, 2 female) participated. Mean height was 69.6 +/- 2.6 inches, mean age 51 +/- 9 years, median surgical glove size 7.5, and surgeons had 18.8 +/- 10.1 years of practice, and did 8 +/- 6 colonoscopies weekly. Ten participants had advanced training in endoscopy, laparoscopy or colorectal surgery; eight had used the simulator before, of whom six had used it once. Mean time to complete the study case was 13.6 +/- 5.3 min and time to reach the cecum was 6.5 +/- 4.3 min. Participants examined 92.3 +/- 3.6% of the simulated colonic mucosa with a clear view of the lumen 89.5 +/- 4.2% of the time. Total time the colon was looped was 22 +/- 35 s (range 0-133 s). The overall efficiency of screening was 70.33 +/- 23.45% (range 20-94%). Participants tended to mistake normal simulated colonic structures as pathology., Conclusion: Performance on a virtual-reality endoscopic simulator has a wide amount of variability even among a group of experienced endoscopists. Expert benchmark tests should be performed on simulators that will be used for resident assessment prior to any attempts at certification of competence.

Introduction: Paraesophageal hernia repair is often performed in an elderly population. Few studies have evaluated perioperative mortality in this group. We identified predictors of inpatient mortality using a nationally representative sample., Methods: Patients >/=80 years old undergoing transabdominal paraesophageal hernia repair were identified in the 2005 Nationwide Inpatient Sample. Congenital diaphragmatic defects and traumatic injuries were excluded., Results: One thousand five discharges (73% female) with mean age 84.7 met inclusion criteria. Mean length of stay was 10.1 days (95% confidence interval 8.9-11.3) with a mortality of 8.2%. Non-elective repair was performed in 43%. For these patients, mortality and mean length of stay (16%; 14.3 days) were increased compared to elective repair (2.5%; 7.0 days, p < 0.05). Non-elective repair was the sole predictor of inpatient mortality in adjusted analyses (odds ratio 7.1, 95% confidence interval 1.9-26.3, p < 0.05)., Conclusion: Non-elective repair was associated with a six to sevenfold increase in mortality and longer length of stay. Earlier elective repair of paraesophageal hernia may reduce mortality.