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Although inguinal hernia repair in female patients is less common than in male patients, it remains a frequent procedure. The decision to divide or preserve the round ligament has largely been left to surgeon preference, but little data exists about its impact on outcomes. This study aimed to describe current practices for round ligament management and identify the impact of division on surgical and patient-reported outcomes.The 2013 to 2021 Abdominal Core Health Quality Collaborative database was queried for all female patients undergoing inguinal hernia repair with 30-day patient-reported outcome data available. Comparison groups were created based on round ligament management: round ligament division (RLD) or round ligament preservation (RLP).We identified 1365 female patients who underwent open (36.3%), laparoscopic (34.5%), or robotic (28.2%) repair. Most were non-recurrent (93%) and unilateral (82.6%). The round ligament was divided in 868 (63.6%) and preserved in 497 (36.4%) cases. There were no significant differences in overall complications (RLD 7.1%, RLP 5.2%, p = 0.17), reoperation (RLD 0.5%, RLP 0.2%, p = 0.4), or recurrence (RLD 0.1%, RLP 0.4%, p = 0.28). Mean European Registry for Abdominal Wall Hernias quality of life summary scores were not significantly different at 30 days (RLD 27.2, RLP 27.8) or 6 months (RLD 12.8, RLP 17.1). However, a significant difference was found in terms of mean pain-specific scores at 6 months, with lower pain scores in the RLD group (3 vs 4.7, p0.01), which persisted on multivariable analysis (p = 0.02).RLD is a common practice and is not associated with increased complications or recurrence. Although there is some evidence that RLD may result in decreased pain at 6 months, this must be balanced with potential functional complications of division that are not fully studied in this paper.

Background: Per-oral endoscopic myotomy (POEM) is a valuable tool for the treatment of foregut motility disorders. Hands-on courses are often utilized at the initial means of training in POEM. Whether such training is sufficient to allow individuals to launch an independent practice in POEM is unknown. The purpose of this study was to evaluate the successes and barriers of implementing a POEM practice after attending a hands-on course. Methods: We evaluated participants of a 2-day focused POEM training course. All participants of the course were sent a survey to assess their endoscopic practice before and after the course, concentrating on their ability to implement POEM after returning to their home institution. Results: Between 2012 and 2017, 11 POEM courses were held at our institution, with a total of 102 trainees. Fifty-five individuals responded to our survey (53.9%), most of whom were general surgeons who were already doing some therapeutic endoscopy but had not previously performed POEM. More than half (58.2%) were able to institute a POEM practice at their home institution after the course. Those that were successful in starting a POEM practice were more often those with previous advanced endoscopic experience (90.3%). Success was assisted by high rates of additional explant laboratories (43.6%) and in-person proctoring (52.4%) after completing the course. Those that did not start a POEM practice sited lack of institutional support as the main barrier, followed by problems with insurance approval, and lack of referral volume. Conclusion: Despite the complexity of the POEM procedure, a focused hands-on POEM training course is associated with a high rate of implementation of an independent POEM practice, particularly in individuals with previous advanced endoscopic experience. The largest barriers to POEM adoption are not technical factors, but rather are related to institutional and insurance factors.

A key principle of hiatal hernia repair is mitigation of tension. While considerable emphasis is placed on the radial tension of the crural closure itself, of equal importance is assuring that axial tension on the esophagus is appropriately addressed. Because of this, esophageal lengthening procedures such as the transabdominal laparoscopic wedge Collis gastroplasty described here have been proposed. Such esophageal lengthening procedures allow for the creation of additional length of tubularized stomach to create a neo-esophagus that will allow for a tension free and appropriately sized fundoplication to be performed.

Ventral hernia repair (VHR) has been shown to improve overall quality of life (QOL) by the validated 12-question Hernia-Related Quality-of-Life survey (HerQLes). However, which specific aspects of quality of life are most affected by VHR have not been formally investigated.Through retrospective analysis of the Abdominal Core Health Quality Collaborative national database, we measured the change in each individual component of the HerQLes questionnaire from a pre-operative baseline assessment to one-year postoperatively in VHR patients.In total, 1,875 VHR patients had completed both pre- and post-operative questionnaires from 2014-2018. They were predominately Caucasian (92.3%), 57.9 ± 12.4 Y old, and evenly gender split (50.5% male, 49.5% female, P = 0.31). Most operations were performed open (80.5%) with fewer laparoscopic (7.5%) or robotic cases (12.1%). For each of the 12 individual categories, improvement in QOL from baseline to 1-Y was found to be statistically significant (P0.0001). This held true with subgroup analysis of small (2 cm), medium (2-6 cm), and large (6 cm) hernias (P0.0001), though a larger improvement was seen in 8 of 12 components in hernias6 cm (P0.001). Operative approach did not carry a significant effect except in medium hernias (2-6 cm), where an open approach saw a greater improvement in the "accomplish less at work" item (P = 0.02).VHR is associated with improvement in each of the 12 components of QOL measured in the HerQLes questionnaire, regardless of the size of their hernia. The amount of improvement, however, may be dependent on hernia size and approach.

Background: In-person interviews have traditionally been an integral part of the fellowship application process to allow faculty and applicants to interact and evaluate the intangible aspects of the matching process. COVID-19 has forced a transition away from in-person interviews to a virtual platform. This study sought to track faculty and applicant perspectives on this transition. Study Design: Prospectively collected survey data was obtained from all participants after each of 3 consecutive virtual interview days for minimally invasive surgery fellowship at a single academic institution. Results: One hundred percent (27/27 applicants and 9/9 faculty) of interview participants completed the survey. Cost (100% applicants, 77.8% faculty) was perceived as the greatest barrier to in-person interviews, and “inability to get a feel for the program/applicant” was the largest concern for virtual interviews (66.7% applicants, 88.9% faculty). After interviews, most participants strongly agreed that they were able to assess education (66.7% applicants, 77.8% faculty), clinical experience (70.4% applicants, 77.8% faculty), and research potential (70.4% applicants, 88.9% faculty) through the virtual platform. Only 44.4% of each group strongly agreed that they could assess “overall fit” equally as well. Most faculty (6/9, 66.7%), but fewer applicants (10/27, 37.0%), were willing to completely eliminate in-person interviews. Conclusion: Virtual interviews may be an acceptable alternative to in-person interviews in times of COVID-19 and beyond. Offering a virtual format may help to eliminate costs associated with in-person visits while adequately assessing the fit of a program for both applicants and faculty, though applicants still desire an in-person option.

Per-oral endoscopic myotomy (POEM) has gained widespread enthusiasm amongst foregut specialists since its introduction in the mid 2000s as an effective and less invasive treatment option for achalasia. As more than 6000 POEM procedures have been performed to date throughout the world, we aim to summarize the history and current state of POEM in the treatment of esophageal motility disorders. We performed a comprehensive review of the published literature focusing on the history and development of the POEM procedure, and its most current applications and outcomes. Multiple favorable long-term studies have been published advocating for the use of POEM as a valid and perhaps the most valid treatment option for achalasia. The procedure is also increasingly being applied to a wider spectrum of esophageal motility disorders including type III achalasia, spastic esophageal disease or isolated lower esophageal sphincter (LES) dysfunction, as well as new endoluminal procedures such as submucosal tumor endoscopic resection (STER), endoscopic fundoplications (POEM-F) and peroral pyloromyotomy (POP or G-POEM). While POEM is a proved and valid procedure, its further adoption is being threatened by external factors: challenges related to teaching, institutional support (politics) and insurance reimbursement. While this technique has come an incredible distance in its relatively short lifespan, the future of POEM in the USA will depend on the support from surgical societies to validate it as a valuable tool in the esophageal specialist’s armamentarium, and to encourage a commitment to training in endoluminal surgery.

Esophagectomy is a fundamental step to achieve long-term disease-free survival in esophageal cancer. While various approaches have been described, there is no consensus on the single best technique to optimize operative and oncologic outcomes. We aim to report the modern experience with laparoscopic transhiatal esophagectomy (LTHE) for invasive adenocarcinoma. We reviewed all patients who underwent LTHE with extended lymph node dissection for distal esophageal adenocarcinoma (EAC) at our institution between 2007 and 2016. Pre-operative characteristics, operative details, postoperative complications, and long-term outcomes were tracked by review of the electronic medical record and patient surveys. Survival rates were calculated with Kaplan-Meier curves. Eighty-two EAC patients underwent LTHE during the study period (84% male, mean age 65, mean BMI 27.8, large). Most patients were clinical stage III (42.7%) and 68.3% had received neoadjuvant chemoradiation (nCRT). Laparoscopy was successful in 93.9%, with five cases requiring conversion to open (6.1%). The median lymph node harvest was 19. Overall complication rate (major and minor) was 45.5% and ninety-day mortality was 4%. Overall 5-year survival was 52% (77% for stage 1, 57% for stage 2, 37% for stage 3). Laparoscopic transhiatal esophagectomy has an important role in current esophageal cancer treatment and can be performed with curative intent in patients with distal esophageal tumors. In addition to the well-known advantages of laparoscopy, the increased mediastinal visibility and a modern focus on oncologic principles seem to have a positive impact on cancer survival compared to the open transhiatal approach.

Laparoscopic magnetic sphincter augmentation (MSA) has emerged as an alternative to laparoscopic Nissen fundoplication (LNF) for the management of symptomatic gastroesophageal reflux disease (GERD). While short-term outcomes of MSA compare favorably to those of LNF, direct comparisons of long-term outcomes are lacking. We hypothesized that the long-term patient-reported outcomes of MSA would be similar to those achieved with LNF.We tested this hypothesis in a retrospective cohort undergoing primary LNF or MSA between March 2013 and July 2015. The primary outcome was GERD-Health Related Quality of Life (GERD-HRQL) score at long-term follow-up relative to baseline. Secondary outcomes included dysphagia and bloating scores, proton-pump inhibitor (PPI) cessation, reoperations, and overall satisfaction with surgery.70 patients (25 MSA, 45 LNF) met criteria for study inclusion. MSA patients had lower baseline BMI (median: 27.1 [IQR: 22.7-29.9] versus 30.4 [26.4-32.8], p = 0.02), lower total GERD-HRQL (26 [19-32] versus 34 [25-40], p = 0.02), and dysphagia (2 [0-3] versus 3 [1-4], p = 0.02) scores. Median follow-up interval exceeded 5 years (MSA: 68 [65-74]; LNF: 65 months [62-69]). Total GERD-HRQL improved from 26 to 9 after MSA (p 0.001) and from 34 to 7.5 after LNF (p 0.01); these scores did not differ between groups (p = 0.68). Dysphagia (MSA: 1 [0-2]; LNF: 0 [0-2], p = 0.96) and bloating (MSA: 1.5 [0.5-3.0]; LNF: 3.0 [1.0-4.0], p = 0.08) scores did not show any statistically significant differences. Device removal was performed in 4 (16%) MSA patients and reoperation in 3 (7%) LNF patients. Eighty-nine percent of LNF patients reported satisfaction with the procedure, compared to 70% of MSA patients (p = 0.09).MSA appears to offer similar long-term improvement in disease-specific quality of life as LNF. For MSA, there was a trend toward reduced long-term bloating compared to LNF, but need for reoperation and device removal may be associated with patient dissatisfaction.

Background: In locally-advanced esophageal cancer (LAEC), providers’ concerns regarding eventual surgical candidacy can persuade physicians to defer to definitive doses of 50 Gy or higher preoperatively. We report the successful completion rate of tri-modality therapy (TMT) (documented at the outset) and reasons for TMT non-adherence at a large multi-disciplinary esophageal program. Methods: LAEC patients diagnosed 2007–2016 from a prospective institutional database were subdivided into CRT/S+ [completed chemoradiation (CRT) and surgery] and CRT/S- (CRT and no subsequent surgery) groups. Chart review provided surgery non-adherence reasons. Results: A total of 283 patients met planned TMT criteria: 164 (58.0%) patients received 50 or 50.4 Gy CRT, 27 patients (9.5%) received greater than 50.4 Gy, and 92 patients received less than 50 Gy (32.5%, only 8 patients received CRT to 41.4 Gy); 221 (78.1%) completed surgery (CRT/S+), while 62 (21.9%) failed to advance to surgery (CRT/S-): 25 of 62 CRT/S- patients (40.3%) evidenced metastatic progression before surgery, 4 (6.5%) were deemed unresectable intraoperatively, 4 (6.5%) expired prior to planned surgery (3 from unknown causes, 1 suicide), 8 (12.9%) experienced significant CRT-related medical decompensation and were withdrawn from surgical consideration, 16 (25.8%) voluntarily declined surgery post-CRT (largely due to long-term quality of life concerns), and 5 (8.1%) failed to advance for unknown reasons. Four of the 16 patients who voluntarily declined surgery after CRT received less than 50 Gy. The 22.2% of CRT/S+ patients achieved pathologic complete response (21.6% for adenocarcinoma and 29.0% for squamous cell carcinoma). Conclusions: Our institution’s 78% surgery completion rate among TMT-indicated patients highlights the benefits of upfront multidisciplinary care. Metastatic disease development most commonly truncated TMT with a low rate failing due to medical decompensation. Given the number of patients who voluntarily declined surgery following CRT, TMT counseling and involvement of a patient advocate are paramount prior to treatment planning.

Background: Patients, surgeons, and payers are interested in reducing hospital length of stay. Outpatient laparoscopic fundoplication (LF) can be done safely and cost effectively. There is low acceptance of this practice due to fear of readmission and patient dissatisfaction. Our aim was to identify factors predicting failure of same-day discharge after LF. Methods and Procedures: We simulated an outpatient setting for patients who underwent LF from 2017 to 2018 and collected the data prospectively. A perioperative pain and nausea protocol was utilized. Postoperatively, patients were given a liquid diet and oral medications, observed overnight, and then discharged after standard criteria were met. Failure was defined by the need for physician intervention after 3 hours or failure to discharge. Univariate and multivariable logistic regression analyses were performed assessing factors associated with failure. Two-sample t-test and chi-squared tests were used for significance. Results: Ninety-eight patients were included. Twenty patients failed, primarily due to the need for intravenous medications. Seven were discharged on postoperative day 1 but required physician intervention after 3 hours. Thirteen patients stayed >23 hours. Two patients were readmitted within 1 week of discharge. There was one acute recurrence, requiring reoperation, and one conversion to laparotomy. We found no statistically significant patient risk factor, comorbidity, or perioperative variable that could reliably predict failure of same-day discharge. Conclusion: This study suggests that same-day discharge after LF is safe and feasible. However, 20% of patients will unpredictably fail to meet discharge criteria.

Dr. Barbara Bartlett Stimson, AB, MD, MedScD, FACS (1898-1986) was a pioneering orthopedic surgeon from a prominent American family who, in 1940, became the first woman certified by the American Board of Surgery (ABS, certificate number 860). It would be another 7 years and approximately 2500 candidates before the next female surgeon would be certified. A member of the third class to admit women to Columbia Medical School and the second female surgical resident to complete training at Columbia-Presbyterian Medical Center, Dr. Stimson was a confident and exceptionally accomplished trailblazer for women in surgery. In this biographical sketch based upon documents from the ABS, and the archives of Vassar College and the College of Physicians and Surgeons at Columbia-Presbyterian Medical Center, Dr. Stimson's motivations, attitudes, and unique accomplishments emerge as testimony to the exceptional career of this driven, self-possessed woman. Stimson was undaunted by the sex-based conventions of her time, and achieved a notable career as a surgeon in the profession she loved; first honing her skills at a busy urban fracture service in New York, then serving with distinction in the Royal Army Medical Corps during World War II, and finally returning to the states to become a respected leader in her field. Her life story and unprecedented ABS certification affirm her conviction that proven skill and ability can be used as a means of overcoming unfounded biases, and helped pave the way for future generations of board certified female surgeons in the United States.

Gastric ischemic conditioning prior to esophagectomy can increase neovascularization of the new conduit. Prior studies of ischemic conditioning have only investigated reductions in anastomotic leaks. Our aim was to analyze the association between gastric conditioning and all anastomotic outcomes as well as overall morbidity in our cohort of esophagectomy patients. We performed a retrospective review of patients undergoing esophagectomy from 2010 to 2015 in a National Cancer Institute designated center. Ischemic conditioning (IC) was performed on morbidly obese patients, those with cardiovascular disease or uncontrolled diabetes, and those requiring feeding jejunostomy and active tobacco users. IC consisted of transection of the short gastric vessels and ligation of the left gastric vessels. Primary outcomes consisted of all postoperative anastomotic complications. Secondary outcomes were overall morbidity. Two-hundred and seven esophagectomies were performed with an average follow-up of 19 months. Thirty-eight patients (18.4%) underwent conditioning (IC). This group was similar to patients not conditioned (NIC) in age, preoperative pathology, and surgical approach. Five patients in the ischemic conditioning group (13.2%) and 57 patients (33.7%) in the NIC experienced anastomotic complications (p = 0.011). Ischemic conditioning significantly reduced the postoperative stricture rate fourfold (5.3 vs. 20.7% p = 0.02). IC patients experienced significantly fewer complications overall (36.8 vs. 56.2% p = 0.03). Gastric ischemic conditioning is associated with fewer overall anastomotic complications, fewer strictures, and less morbidity. Randomized studies may determine optimal selection criteria to determine whom best benefits from ischemic conditioning.

Benign lesions of the esophagus pose a therapeutic challenge as their resection can sometimes involve technically challenging and somewhat morbid operations. Flexible endoscopic approaches offer a less invasive approach and, if approached correctly, even larger esophageal masses can be resected. Here, we describe in detail an advanced endoscopic technique for approaching larger benign esophageal masses, in this case a leiomyoma. This approach entails a submucosal tunneling technique with circumferential and transmural mobilization of the mass and extraction through the submucosal tunnel with endoscopic closure of the mucosotomy. With successful resection, this approach has the potential to save the patient the morbidity of a major thoracic operation while successfully relieving the symptoms of the disease with lower postoperative pain and a shorter length of stay.

Trends in the utilization of Heller myotomy for achalasia in the U.S. over time have not been previously described.Using the Nationwide Inpatient Sample (NIS) database, we analyzed patients undergoing Heller myotomy for achalasia over a 20-year period (1992-2011) to estimate rates of Heller myotomy, locations where the procedures were performed (rural, urban or teaching) and changes in technique (laparoscopic vs open) as well as outcomes of length of stay and in-hospital mortality.Over the last 20 years, the total number of Heller myotomies performed in the U.S. has increased (1576 cases in 1992 to 5046 cases in 2011, p = 0.001). These procedures are now being performed laparoscopically (0.9%-67.0%, p 0.001) and at urban teaching hospitals (45.4%-77.1%, p 0.001). In-hospital mortality has decreased (0.9%-0.3%, p = 0.006). Hospital length of stay has decreased from 7 days to 2 days (p 0.001).These data show a trend of increasing utilization of laparoscopic Heller myotomy at teaching institutions with decreased in-hospital mortality and shorter LOS.

Esophagectomy is a fundamental step to achieve long-term disease-free survival in esophageal cancer. While various approaches have been described, there is no consensus on the single best technique to optimize operative and oncologic outcomes. We aim to report the modern experience with laparoscopic transhiatal esophagectomy (LTHE) for invasive adenocarcinoma.We reviewed all patients who underwent LTHE with extended lymph node dissection for distal esophageal adenocarcinoma (EAC) at our institution between 2007 and 2016. Pre-operative characteristics, operative details, postoperative complications, and long-term outcomes were tracked by review of the electronic medical record and patient surveys. Survival rates were calculated with Kaplan-Meier curves.Eighty-two EAC patients underwent LTHE during the study period (84% male, mean age 65, mean BMI 27.8, large). Most patients were clinical stage III (42.7%) and 68.3% had received neoadjuvant chemoradiation (nCRT). Laparoscopy was successful in 93.9%, with five cases requiring conversion to open (6.1%). The median lymph node harvest was 19. Overall complication rate (major and minor) was 45.5% and ninety-day mortality was 4%. Overall 5-year survival was 52% (77% for stage 1, 57% for stage 2, 37% for stage 3).Laparoscopic transhiatal esophagectomy has an important role in current esophageal cancer treatment and can be performed with curative intent in patients with distal esophageal tumors. In addition to the well-known advantages of laparoscopy, the increased mediastinal visibility and a modern focus on oncologic principles seem to have a positive impact on cancer survival compared to the open transhiatal approach.

Locoregional esophageal cancer is currently treated with induction chemoradiotherapy, followed by esophagectomy with reconstruction, using a gastric conduit. In cases of conduit failure, patients are temporized with a cervical esophagostomy and enteral nutrition until gastrointestinal continuity can be established. At our institution, we favor reconstruction, using a colon interposition with a ‘supercharged’ accessory vascular pedicle. Consequently, we sought to examine our technique and outcomes for esophageal reconstruction, using this approach. We performed a retrospective review of all patients who underwent esophagectomy at our center between 2008 and 2018. We identified those patients who had a failed gastric conduit and underwent secondary reconstruction. Patient demographics, perioperative details, and clinical outcomes were analyzed after our clinical care pathway was used to manage and prepare patients for a second major reconstructive surgery. Three hundred and eighty eight patients underwent esophagectomy and reconstruction with a gastric conduit. Seven patients (1.8%) suffered gastric conduit loss and underwent a secondary reconstruction using a colon interposition with a ‘supercharged’ vascular pedicle. Mean age was 70.1 (±7.3) years, and six patients were male. The transverse colon was used in four cases (57.1%), left colon in two cases (28.6%), and right colon in one case (14.3%). There were no deaths or loss of the colon interposition at follow-up. Three patients (42.9%) developed an anastomotic leak, which resolved with conservative management. All patients had resumption of oral intake within 30 days. Utilizing a ‘supercharging’ technique for colon interposition may improve the perfusion to the organ and may decrease morbidity. Secondary reconstruction should occur when the patient’s oncologic, physiologic, and psychosocial condition is optimized. Our outcomes and preoperative strategies may provide guidance for those centers treating this complicated patient population.

This study assesses the value of routine esophagrams in detecting anastomotic leaks after esophagectomy.

A 55 year old male smoker presented with clinical T3N0 esophageal adenocarcinoma of the GE junction. He completed neoadjuvant chemoradiotherapy with carboplatin/paclitaxel and 5040cGy of radiation. He had limited clinical response on restaging but no evidence of metastatic disease and completed a minimally invasive three field esophagectomy. This was complicated by a chyle leak requiring thoracic duct embolization from which he recovered well. Surgical pathology showed no apparent nodal disease or metastases but a poorly differentiated primary tumor with signet-cell features. Approximately 3 months after his surgery, he developed right upper quadrant abdominal pain and elevated liver function tests and was taken for laparoscopic cholecystectomy. Gallbladder pathology demonstrated poorly differentiated adenocarcinoma with extensive lymphovascular invasion with immunohistochemistry analysis and comparison with the original surgical specimen confirming metastatic adenocarcinoma of esophageal origin. Literature review suggests that signet cell features and limited response to neoadjuvant therapy point to a more aggressive biology in esophageal cancer and increase the risk of metastatic disease, even in the setting of node negativity.

Background Post-operative pain control and narcotic over-utilization are challenging issues for surgeons in all fields. While virtual reality (VR) has been increasingly applied in various fields, its feasibility and efficacy in the peri-operative period has not been evaluated. The aim of this study was to examine the experience of an integrated VR protocol in the perioperative setting. Methods Patients undergoing minimally invasive foregut surgery at a single institution were randomized to receive a series of VR meditation/mindfulness sessions (VR) or to standard care after surgery (non-VR). Post-operative pain levels, narcotic utilization and patient satisfaction were tracked. Results Fifty-two patients were enrolled with 26 in each arm. Post-operative pain scores, total narcotic utilization, and overall satisfaction scores were not significantly different between the two groups. For patients in the VR arm, sessions were able to be incorporated into the perioperative routine with little disruption. Most (73.9 %) were able complete all six VR sessions and reported low pain, anxiety, and nausea scores while using the device. A high proportion responded that they would use VR again (76.2 %) or would like a VR program designed for pain (62.0 %). There were no complications from device usage. Conclusion VR is a safe and simple intervention that is associated with high patient satisfaction and is feasible to implement in the perioperative setting. While the current study is underpowered to detect difference in narcotic utilization, this device holds promise as an adjuvant tool in multimodal pain and anxiety control in the peri-operative period.

Our emerging recognition of the chronic and relapsing nature of the metabolic dysfunction that contributes to obesity, as well as the numerous life-threatening comorbidities related to excess weight, dictates the importance of long-term follow-up in obese populations. This tenet cannot be overstated in the success of bariatric surgery patients. While follow-up has frequently been relegated to primary care personnel in the past, recent investigations have shown the benefit of longitudinal monitoring by a multidisciplinary bariatric team. Such support is associated with greater improvements in sustained weight loss, prevention of vitamin deficiencies, and better maintenance of comorbidities. Establishing a successful long-term follow-up protocol is vital for bariatric practitioners in order to optimize patient outcomes. This should include but is not limited to a standard clinic visit schedule, periodic laboratory monitoring, ongoing dietary counseling, and bariatric support groups. In addition, specialty providers such as psychologists and physical therapists should be available to help guide patients successfully through the myriad changes that accompany extreme weight loss.

Early-stage esophageal cancer (stages 0–1) has been shown to have relatively good outcomes after local endoscopic or surgical resection. For this reason, neoadjuvant chemoradiation usually is reserved for higher-stage disease. Some early tumors, however, are found after resection to be more advanced than predicted based on initial clinical staging, termed pathologic upstaging. Such tumors may have benefited from alternate treatment models had their true stage been known preoperatively. This study aimed to identify high-risk features in early esophageal cancers that might predict tumor upstaging and guide more individualized treatment algorithms. Through retrospective review of a single-institution foregut disease registry, we evaluated patients who underwent esophagectomy for high-grade dysplasia (Tis) or stage 1 esophageal cancer, searching for factors associated with pathologic upstaging. The review included 110 patients (88% male, median age at diagnosis, 64.5 years) treated between January 2000 and June 2016. Upstaging occurred for 20.9% of the patients, and was more common for patients with angiolymphatic invasion (odds ratio [OR], 11.07; 95% confidence interval [CI], 2.96–41.44; P

Trimodal therapy consisting of neoadjuvant chemoradiation followed by esophagectomy has become the standard of care in North America for locally advanced esophageal cancer. While cisplatin/5-fluorouracil has been a common concurrent chemotherapy regimen since the 1980s, its utilization has declined in recent years as the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial regimen of carboplatin/paclitaxel has become widely adopted. The efficacy of the CROSS regimen compared to alternate chemotherapy choices, however, has rarely been evaluated when each is used as a component of a trimodal treatment approach. The aim of this study is to report our institutional experience with these two concurrent chemotherapy regimens at a specialized esophageal cancer center.We performed an Institutional Review Board-approved retrospective review of a prospectively maintained institutional foregut registry from a single National Cancer Institute-designated cancer center. Esophageal cancer patients who completed trimodal therapy with a chemotherapy regimen of either carboplatin/paclitaxel or cisplatin/5-fluorouracil were identified and divided into groups based on their chemotherapy regimens. Multivariable logistic regression was used to analyze pathologic complete response rates, while the Kaplan-Meier and Cox proportional hazards models were utilized to evaluate recurrence-free and overall survival. Analytical models were adjusted for age, clinical stage, radiation dose, histologic subtype (adenocarcinoma vs. squamous cell carcinoma), and time interval from completion of neoadjuvant therapy to surgery.One hundred and forty-two patients treated between January of 2000 and July of 2015 were identified as meeting inclusion criteria. Of this group, 87 had received the CROSS regimen of carboplatin/paclitaxel, while 55 had completed cisplatin/5-fluorouracil. Multivariable analysis demonstrated that the cisplatin/5-fluorouracil.group had an increased odds of pathologic complete response (odds ratio = 2.68, 95% confidence interval, P = 0.032), as well as significantly improved recurrence-free survival (hazard ratio = 0.39, 95% confidence interval 0.21-0.73, P = 0.003) and overall survival (hazard ratio = 0.46, 95% confidence interval 0.24-0.87, P = 0.016), compared to the carboplatin/paclitaxel group.Concurrent chemotherapy with cisplatin/5-fluorouracil in locally advanced esophageal cancer is associated with higher rates of pathologic complete response and improved recurrence-free and overall survival compared to the CROSS regimen of carboplatin/paclitaxel. This suggests that, for select patients, alternate neoadjuvant chemotherapy approaches, such as cisplatin/5-fluorouracil, merit reconsideration as potential primary treatment choices in the management of this highly morbid disease.

Sponge cytology is a novel screening tool for esophageal cancer but has been unable to be validated for widespread use. Our aim was to apply fluorescent in situ hybridization to sponge cytology samples in order to evaluate the safety and efficacy of this modality in screening for esophageal cancer.At a single, multidisciplinary, NCI-designated cancer center, patients completed sponge cytology sampling prior to upper endoscopy. Samples were analyzed by p53 fluorescent in situ hybridization, and results were compared to the endoscopic diagnosis.Fifty patients were enrolled (96 % Caucasian, 68 % male, median age of 67). All patients successfully swallowed the capsule. No complications (string breakage, bleeding, mucosal injury) occurred. Endoscopy revealed that 38 % had normal esophageal mucosa and 62 % had an esophageal mucosal abnormality. In total, six samples demonstrated p53 loss (94 % specificity for any abnormality). The sensitivity of the p53 fluorescent in situ hybridization probe was13.3 % for any abnormality, 10 % for intestinal metaplasia, and 0 % for dysplasia or esophageal cancer.Esophageal sponge cytology is a promising, safe, and tolerable method for collecting esophageal cell samples. However, our data suggest that p53 fluorescent in situ hybridization does not improve the sensitivity for detecting cancer in these samples.

While first-line therapy for uncomplicated gastroesophageal reflux disease (GERD) continues to be medical management with proton pump inhibitors (PPIs), anti-reflux surgery remains an important tool in the stepwise management of the disease. In general, surgery is justified in patients with GERD symptoms that have been present for an extended period of time (typically greater than 1 year), who have objectively documented reflux, and who have failed medical therapy, either through an inability to tolerate medications, or by suffering from persistent symptoms despite adequate medical therapy. Because surgical approaches vary depending on esophageal function and anatomy, patients must be carefully evaluated prior to operative intervention. Given the complex physiology of GERD and its multitude of potential effects on the esophagus, there is no single test that can provide all the essential information needed to plan a safe and appropriate operation. Thus, a thorough, multimodal preoperative evaluation is necessary. This should include a detailed history and physical, as well as objective, evaluation of the degree and severity of reflux through upper endoscopy and/or pH monitoring. Additionally, it is vital to document esophageal anatomy and function with upper GI series and esophageal manometry prior to embarking on surgery. On completion of this evaluation, the surgeon should be able to discern whether or not the patient’s symptoms are compatible with and correlate to the presence of objectively documented pathological reflux, and whether there is any indication of abnormal anatomy or function that would require alterations of surgical approach. Armed with this information, patients can be selected and managed appropriately, allowing us to optimize surgical outcomes in anti-reflux procedures.

Importance Pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) may be a clinical prognostic marker of superior outcomes. In patients with esophageal cancer, pCR is associated with increased survival. While mechanisms for increasing the likelihood of pCR remain unknown, in other solid tumors, higher rates of pCR have been associated with longer time intervals between CRT completion and surgical procedures. Objective To determine the association between time intervals from the completion of CRT to surgical procedure with rates of pCR in patients with esophageal cancer. Design, Setting, and Participants A prospectively maintained multidisciplinary foregut database was reviewed for consecutively enrolled patients with esophageal cancer from January 2000 to July 2015 presenting for surgical evaluation at a single National Cancer Institute–designated cancer center within a quaternary academic medical center. Interventions Included patients successfully completed neoadjuvant CRT followed by esophagectomy. Main Outcomes and Measures Rate of pCR by logistic regression based on a categorized time interval (ie, 0 to 42, 43 to 56, 57 to 70, 71 to 84, 85 to 98, and 99 or more days) from the completion of CRT to surgical resection, adjusted for clinical stage, demographic information, and CRT regimen. Results Of the 234 patients who met inclusion criteria, 191 (81.6%) were male, and the median (range) age was 64 (58-70) years; 206 (88.0%) were diagnosed as having adenocarcinoma, and 65 (27.9%) had a pCR. Patients in the 85 to 98–day group had significantly increased odds of a pCR compared with other groups (odds ratio, 5.46; 95% CI, 1.16-25.68; P = .03). No significant differences in survival were seen between time groups overall or among patients with residual tumor. Conclusions and Relevance This study suggests that a time interval of 85 to 98 days between CRT completion and surgical resection is associated with significantly increased odds of a pCR in patients with esophageal cancer. No adverse association with survival was detected as a result of delaying resection, even in patients with residual tumor.