Objective:We aim to describe the long-term follow-up data from our institution's POEM experience.Summary Background Data:Per-oral endoscopic myotomy (POEM) is a well-established endoscopic therapy for achalasia with excellent short-term efficacy, but long-term outcomes data are limited.Methods:Patients older than 4 years removed from POEM for treatment of achalasia were studied. Clinical success was defined as an Eckardt Symptom (ES) score ≤3 and freedom from reintervention for achalasia. Patients underwent esophagogastroduodenoscopy (EGD), high-resolution manometry, impedance planimetry, and timed barium esophagram (TBE) preoperatively and at least 4 years postoperatively. Objective gastroesophageal reflux disease (GERD) was defined LA Grade B or worse esophagitis on EGD.Results:One hundred and nineteen consecutive patients were included. Five patients died or had catastrophic events unrelated to achalasia or POEM. One hundred of the remaining patients (88%, 100/114) had long-term data available. Clinical follow-up for all patients was greater than 4 years postoperatively and the mean was 55 months. Mean current ES was significantly improved from preop (n = 100, 1 ± 1 vs 7 ± 2, P < 0.001). Overall clinical success was 88% and 92%. Five patients had a current ES >3 and 4 patients required procedural reintervention on the lower esophageal sphincter. Reinterventions were successful in 75% of patients (3/4), with current ES ≤3. The rate of objective GERD was 33% (15/45). Esophageal physiology was improved with a decrease in median integrated relaxation pressure (11 ± 4 vs 33 ± 15 mm Hg, P < 0.001), a decrease in median TBE column height (3 ± 3 vs 13 ± 8 cm, P < 0.001), and an increase in median distensibility index (5.1 ± 2 vs 1.1 ± 1 mm2/mm Hg, P < 0.001).Conclusions:POEM provides durable symptom relief and improvement in physiologic esophagogastric junction relaxation parameters over 4.5 years postoperatively. Reinterventions are rare and effective.

Background: Achalasia subtypes on high-resolution manometry (HRM) prognosticate treatment response and help direct management plan. We aimed to utilize parameters of distension-induced contractility and pressurization on functional luminal imaging probe (FLIP) panometry and machine learning to predict HRM achalasia subtypes. Methods: One hundred eighty adult patients with treatment-naïve achalasia defined by HRM per Chicago Classification (40 type I, 99 type II, 41 type III achalasia) who underwent FLIP panometry were included: 140 patients were used as the training cohort and 40 patients as the test cohort. FLIP panometry studies performed with 16-cm FLIP assemblies were retrospectively analyzed to assess distensive pressure and distension-induced esophageal contractility. Correlation analysis, single tree, and random forest were adopted to develop classification trees to identify achalasia subtypes.

No abstract

No abstract

Background: General surgery residencies continue to experience high levels of attrition.Methods: Survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination. Outcomes were consideration of leaving residency, potential alternative career paths, and reasons for staying in residency.Results: Among 7,409 residents, 930 (12.6%) reported considering leaving residency over the last year. Residents were more likely to consider other general surgery programs (46.2%) if PGY 2/3 (OR: 1.93, 95%CI 1.34-2.77) or reporting frequent duty hour violations (OR: 1.58, 95%CI 1.12-2.24). Consideration of other specialties (47.0%) was more likely if dissatisfied with being a surgeon (OR 2.86,.Residents were more likely to consider leaving medicine (49.7%) if female (OR: 1.54, 95%CI 1.16-2.06) or dissatisfied with a surgical career (OR: 2.81, 95%CI 1.85-4.27). Common reasons for remaining in residency included a sense of too much invested to leave (65.3%) and career satisfaction (55.5%). Conclusion:Profiles of trainees considering leaving residency exist based on factors associated with alternative careers. This may be a target for future interventions to reduce attrition.

No abstract

Over the past decade, per-oral endoscopic myotomy has been shown to be a durable minimally invasive approach to the treatment of esophageal achalasia. Patients with suspected achalasia should undergo upper endoscopy, timed barium esophagram, and high-resolution manometry to confirm the diagnosis. The procedure includes several key steps including mucosotomy, submucosal tunneling, selective myotomy of the circular muscle layer, and mucosotomy closure. Specialized endoscopic dissection tools are used during the procedure to access the submucosal space. Common procedural challenges include minor bleeding and capnoperitoneum.

No abstract