The ambulatory transoral endoscopic thyroidectomy vestibular approach is safe and economical for patients with thyroid nodules.

Background: Ambulatory thyroid surgery has been increasingly performed in recent years. However, the feasibility of the ambulatory transoral endoscopic thyroidectomy vestibular approach (TOETVA) has not been evaluated. We aimed to evaluate the safety, economy, and mental health outcomes of ambulatory TOETVA. Methods: We retrospectively reviewed the data of patients who underwent TOETVA between March 2019 and August 2022. The procedure was performed by a skilled surgical team from the Department of Thyroid Surgery of the affiliated Yantai Yuhuangding Hospital of Qingdao University. Patients were enrolled in the ambulatory (n=166) and conventional (n=290) groups, based on their chosen procedure. We analyzed patients' clinical characteristics, surgical outcomes, Hamilton Anxiety Rating Scale (HAM-A) scores, and hospitalization costs. Results: Of 456 patients, 166 underwent ambulatory TOETVA and 290 underwent conventional TOETVA. No significant differences were found in clinical and surgical characteristics between the groups, including sex (P=0.363), age (P=0.077), body mass index (P=0.351), presence of internal diseases (P=0.613), presence of Hashimoto's thyroiditis (P=0.429), pathology (P=0.362), maximum tumor diameter (P=0.520), scope of surgery (P=0.850), or operative time (P=0.351). There were no significant differences in maximum tumor diameter (P=0.349), extrathyroidal tissue invasion (P=0.516), number of retrieved central lymph nodes (P=0.069), or metastatic central lymph nodes (P=0.897) between the groups. No significant differences were found in complications, including transient hypoparathyroidism (P=0.438), transient vocal cord palsy (P=0.876), transient mental nerve injury (P=0.749), permanent mental nerve injury (P=0.926), and other complications (P=1.000). Ambulatory patients had shorter hospital stays (P<0.001) and reduced hospitalization costs (P<0.001). There was no significant difference in HAM-A scores between the groups (P=0.056). Conclusions: Ambulatory TOETVA is a safe, feasible, and cost-effective procedure for selected patients. This procedure resulted in shorter hospital stays, decreased medical costs, and did not increase patient anxiety. To ensure patient safety, surgical teams must inform patients of the indications, when to seek help, and how to receive the fastest medical attention.

GERD after Peroral Endoscopic Myotomy: Assessment of Incidence and Predisposing Factors.

BACKGROUND: Peroral endoscopic myotomy (POEM) is an effective intervention for achalasia, but GERD is a major postoperative adverse event. This study aimed to characterize post-POEM GERD and identify preoperative or technical factors impacting development or severity of GERD. STUDY DESIGN: This is a retrospective review of patients who underwent POEM at our institution. Favorable outcome was defined as postoperative Eckardt score of 3 or less. Subjective GERD was defined as symptoms consistent with reflux. Objective GERD was based on a DeMeester score greater than 14.7 or Los Angeles grade C or D esophagitis. Severe GERD was defined as a DeMeester score greater than 50.0 or Los Angeles grade D esophagitis Preoperative clinical and objective data and technical surgical elements were compared between those with and without GERD. Multivariate logistic analysis was performed to identify factors associated with each GERD definition. RESULTS: A total of 183 patients underwent POEM. At a mean ± SD follow-up of 21.7 ± 20.7 months, 93.4% achieved favorable outcome. Subjective, objective, and severe objective GERD were found in 38.8%, 50.5%, and 19.2% of patients, respectively. Of those with objective GERD, 24.0% had no reflux symptoms. Women were more likely to report GERD symptoms (p = 0.007), but objective GERD rates were similar between sexes (p = 0.606). The independent predictors for objective GERD were normal preoperative diameter of esophagus (odds ratio [OR] 3.4; p = 0.008) and lower esophageal sphincter (LES) pressure less than 45 mmHg (OR 1.86; p = 0.027). The independent predictors for severe objective GERD were LES pressure less than 45 mmHg (OR 6.57; p = 0.007) and obesity (OR 5.03; p = 0.005). The length of esophageal or gastric myotomy or indication of procedure had no impact on the incidence or severity of GERD. CONCLUSION: The rate of pathologic GERD after POEM is higher than symptomatic GERD. A nonhypertensive preoperative LES is a predictor for post-POEM GERD. No modifiable factors impact GERD after POEM.

Use and Safety of Per-Oral Endoscopic Myotomy for Achalasia in the US.

Importance: Several professional practice guidelines recommend per-oral endoscopic myotomy (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety. Objective: To evaluate the use, safety, health care utilization, and costs associated with the use of POEM for treatment of achalasia relative to laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD). Design, Setting, and Participants: This was a retrospective national cohort study of commercially insured patients, aged 18 to 63 years, who underwent index intervention for achalasia with either LHM, PD, or POEM in the US between July 1, 2010, and December 31, 2017. Patient data were obtained from a national commercial claims database. Included in the study were patients with at least 12 months of enrollment after index treatment and a minimum of 6 months of continuous enrollment before their index procedure. Patients 64 years or older were excluded to avoid underestimation of health care claims from enrollment in Medicare supplemental insurance. Data were analyzed from July 1, 2019, to July 1, 2021. Main Outcomes and Measures: Changes in the proportion of annual procedures performed for achalasia were evaluated over time. The frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, were compared. Negative binomial regression was used to compare the incidence rates of subsequent diagnostic testing, reintervention, and unplanned hospitalization. Generalized linear models were used to compare differences in 1-year health-related expenditures across procedures. Results: This cohort study included a total of 1921 patients (median [IQR] age: LHM group, 48 [37-56] years; 737 men [51%]; PD group, 51 [41-58] years; 168 men [52%]; POEM group, 50 [40-57] years; 80 men [56%]). The use of POEM increased 19-fold over the study period, from 1.1% (95% CI, 0.2%-3.2%) of procedures in 2010 to 18.9% in 2017 (95% CI, 13.6%-25.3%; P = .01). Adverse events were rare and did not differ between procedures. Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR], 2.2; 95% CI, 1.9-2.6) and reinterventions (IRR, 1.9; 95% CI, 1.1-3.3). When compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5; 95% CI, 1.3-1.8) but fewer reinterventions (IRR, 0.4; 95% CI, 0.2-0.6). The total 1-year health care costs were similar between POEM and LHM, but significantly lower for PD (mean cost difference, $7674; 95% CI, $657-$14 692). Conclusions and Relevance: Results of this cohort study suggest that POEM was associated with higher health care utilization compared with LHM and lower subsequent health care utilization but higher costs compared with PD. The use of POEM is increasing rapidly; payers should recognize the totality of evidence and current treatment guidelines as they consider reimbursement for POEM. Patients should be informed of the trade-offs between approaches when considering treatment.

Cost-efficient snare-assisted peroral endoscopic myotomy in comparison of conventional endoscopic knife for treatment of achalasia: results of a randomized controlled trial.

BACKGROUND: To date, the ideal endoscopic knife for peroral endoscopic myotomy (POEM) with good performance and cost-effectiveness is still under investigation. The present study was aimed to evaluate the efficacy, safety, and cost-effectiveness of snare-assisted POEM, compared with the conventional endoscopic knife approach. METHODS: From May 2017 to December 2018, patients with achalasia presenting for POEM without previous endoscopic or surgical therapy were prospectively recruited in this randomized controlled trial. Patients were randomly allocated to receive POEM using either the snare (snare group) or HookKnife (conventional group). The primary outcome was clinical success (Eckardt score ≤ 3) at 12-month follow-up, powered for noninferiority with a margin of -15%. The secondary outcomes included adverse events (AEs), procedure-related parameters, clinical outcomes, and cost-effectiveness. RESULTS: A total of 75 patients with similar baseline characteristics between the snare (N = 37) and conventional (N = 38) groups were included. Clinical success at 12-month follow-up was achieved in 94.6% of patients in the snare group and 92.1% of patients in the conventional group (difference, 2.5% [95% CI, -8.7% to 13.7%]; P < 0.001 for noninferiority). No severe AEs occurred in both groups. The use of snare is associated with comparable procedure time (40.6 minutes vs. 42.5 minutes, P = 0.337), a lower frequency of hemostatic forceps use (27.0% vs. 68.4%, P < 0.001), and lower hospital costs ($4271.1 vs. $5327.3, P < 0.001). The cost-effectiveness plane revealed that 96.9% of snare-assisted POEM procedures offered more cost-savings and health utility benefits. CONCLUSIONS: The snare-assisted POEM was noninferior to the conventional endoscopic knife approach in terms of clinical efficacy, with comparable safety outcomes and cost-effective benefits.

The impact of socioeconomic and geographic factors on access to transoral robotic/endoscopic surgery for early stage oropharyngeal malignancy.

OBJECTIVE: To evaluate the role of social and geographic factors on the likelihood of receiving transoral robotic surgery (TORS) or non-robotic transoral endoscopic surgery treatment in early stage oropharyngeal squamous cell carcinoma (OPSCC). MATERIALS AND METHODS: The National Cancer Database was queried to form a cohort of patients with T1-T2 N0-N1 M0 OPSCC (AJCC v.7) who underwent treatment from 2010 to 2016. Demographics, tumor characteristics, treatment type, social, and geographic factors were all collected. Univariate analysis and multivariate logistic regression were then performed. RESULTS: Among 9267 identified patients, 1774 (19.1%) received transoral robotic surgery (TORS), 1191 (12.9%) received transoral endoscopic surgery, and 6302 (68%) received radiation therapy. We found that lower cancer stage, lower comorbidity burden and HPV- positive status predicted a statistically significant increased likelihood of receiving surgery. Patients who reside in suburban or small urban areas (>1 million population), were low-to- middle income, or rely on Medicaid were less likely to receive surgery. Patients that reside in Medicaid-expansion states were more likely to receive TORS (p > .0001). Patients that reside in states that expanded Medicaid January 2014 and after were more likely to receive non-robotic transoral endoscopic surgery (p > .0001). CONCLUSIONS: Poorer baseline health, lower socioeconomic status and residence in small urban areas may act as barriers to accessing minimally invasive transoral surgery while residence in a Medicaid-expansion state may improve access. Barriers to accessing robotic surgery may be greater than accessing non-robotic surgery.

Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is becoming the treatment of choice for achalasia. Data beyond 3 years are emerging but are limited. We herein report our 10-year experience, focusing on long-term efficacy and safety including the prevalence, management, and sequelae of postoperative reflux. METHODS: This was a single-center prospective cohort study. RESULTS: Six hundred ten consecutive patients received POEM from October 2009 to October 2019, 160 for type 1 achalasia (26.2%), 307 for type II (50.3%), 93 for type III (15.6%), 25 for untyped achalasia (4.1%), and 23 for nonachalasia disorders (3.8%). Two hundred ninety-two patients (47.9%) had prior treatment(s). There was no aborted POEM. Median operation time was 54 minutes. Accidental mucosotomies occurred in 64 patients (10.5%) and clinically significant adverse events in 21 patients (3.4%). No adverse events led to death, surgery, interventional radiology interventions/drains, or altered functional status. At a median follow-up of 30 months, 29 failures occurred, defined as postoperative Eckardt score >3 or need for additional treatment. The Kaplan-Meier clinical success estimates at years 1, 2, 3, 4, 5, 6, and 7 were 98%, 96%, 96%, 94%, 92%, 91%, and 91%, respectively. These are highly accurate estimates because only 13 patients (2%) were missing follow-up assessments. One hundred twenty-five patients (20.5%) had reflux symptoms more than once per week. At a median of 4 months, the pH study was completed in 406 patients (66.6%) and was positive in 232 (57.1%), and endoscopy was completed in 438 patients (71.8%) and showed reflux esophagitis in 218 (49.8%), mostly mild. CONCLUSIONS: POEM is exceptionally safe and highly effective on long-term follow-up, with >90% clinical success at ≥5 years.

Transnasal endoscopic skull base surgery in the COVID-19 era: Recommendations for increasing the safety of the method.

Transnasal endoscopic skull base surgery (eSBS) has been adopted in recent years, in great part to replace the extended procedures required by external approaches. Though sometimes perceived as "minimally invasive", eSBS still necessitates extensive manipulations within the nose/paranasal sinuses. Furthermore, exposure of susceptible cerebral structures to light and heat emanated by the telescope should be considered to comprehensively evaluate the safety of the method. While the number of studies specifically targeting eSBS safety still remains scarce, the problem has recently expanded with the SARS-CoV-2 pandemic, which also has implications for the safety of the surgical personnel. It must be stressed that eSBS may directly expose the surgeon to potentially high volumes of virus-contaminated aerosol. Thus, the anxiety of both the patient and the surgeon must be taken into account. Consequently, safety requirements must follow the highest standards. This paper summarizes current knowledge on SARS-CoV-2 biology and the peculiarities of human immunology in respect of the host-virus relationship, taking into account the latest information concerning the SARS-CoV-2 worrisome affinity for the nervous system. Based on this information, a workflow proposal is offered for consideration. This could be useful not only for the duration of the pandemic, but also during the unpredictable timeline involving our coexistence with the virus. Recommendations include technical modifications to the operating theatre, personal protective equipment, standards of testing for SARS-CoV-2 infection, prophylactic pretreatment with interferon, anti-IL6 treatment and, last but not least, psychological support for the patient.

Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy.

BACKGROUND: Peroral endoscopic myotomy (POEM) has previously been shown to be equally if not more expensive than laparoscopic Heller myotomy (LHM). We compare perioperative outcomes and charges between POEM and LHM at a single institution. METHODS: Outcomes and charge data of 33 patients who underwent LHM and 126 patients who underwent POEM were analyzed. Patients who did not present electively were excluded. RESULTS: There were no demographic differences between groups. Patients who underwent POEM had a significantly shorter mean operative time and median length of stay (both p < 0.001). Patients who underwent POEM stopped narcotics earlier and had faster return to activities of daily living (both p < 0.05). When adjusted for inflation, POEM incurred less in hospital charges than LHM (35.5 ± 12.8 vs 30.7 ± 10.3 in thousands of US dollars, p = 0.006). CONCLUSIONS: Patients who underwent POEM compared to LHM had significantly better perioperative outcomes. Our results suggest POEM may be the more cost-effective option.

Cost Considerations for Robotic Surgery.

Transoral robotic surgery (TORS) is a rapidly growing diagnostic and therapeutic modality in otolaryngology-head and neck surgery, having already made a large impact in the short time since its inception. Cost-effectiveness analysis is complex, and a thorough cost-effectiveness inquiry should analyze not only financial consequences but also impact on the health state of the patient. The cost-effectiveness of TORS is still under scrutiny, but the early data suggest that TORS is a cost-effective method compared with other available options when used in appropriately selected patients.

[Technological innovation and patent transformation in rectal cancer surgery].

Surgery for rectal cancer has obtained quick improvement in techniques and concepts in recent years but still has challenging areas. Colorectal surgeons always seek to make operations clearer and easier, so that surgery can be safer and less time-consuming while guaranteeing surgical goals. With this purpose, our team have explored to make innovations in operations for rectal cancer and translate relevant patents from 2009. We summarize our achievements in this article as follows: (1) Reverse Miles operation (perineal operation first then laparoscopic abdominal operation) with two relevant patents-specialized instruments bag for laparoscopic operations (patent number ZL201520442331.0) and accessory spotlight for ultrasound scalpel (patent number ZL20102 0137689.X). (2) Laparoscopic sphincter-saving surgery for low rectal cancer through marker meeting approach with two patents-vacuum rectal drainage tube with functions of irrigation and ventilation (patent number ZL201520374385.8) and sterile sleeve cover of ultrasound scalpel handle (patent number ZL201920648102.2). (3) Laparoscopic radical resection of colorectal cancer and natural orifice specimen extraction. Different methods were designed according to the location of the tumor that classified as 20-40 cm, 10-20 cm and 5-10 cm to anus. Two relevant patents were specialized instruments for natural orifice specimen extraction (patent application number ZL2017101480141) and plastic film sleeve for natural orifice specimen extraction (patent application number ZL 201921169857.0). Reformation of surgical technique and innovation of surgical instruments should be conducted by surgeons with innovative thinking who always seek the way to translate ideas to patents and then real products to promote surgical treatment.

Impact of Medicaid insurance on outcomes following endoscopic transsphenoidal pituitary surgery.

OBJECTIVE: Despite the rise of studies in the neurosurgical literature suggesting that patients with Medicaid insurance have inferior outcomes, there remains a paucity of data on the impact of insurance on outcomes after endonasal endoscopic transsphenoidal surgery (EETS). Given the increasing importance of complications in quality-based healthcare metrics, the objective of this study was to assess whether Medicaid insurance type influences outcomes in EETS for pituitary adenoma. METHODS: The authors analyzed a prospectively acquired database of EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. All patients with Medicaid insurance were identified. As a control group, the clinical, socioeconomic, and radiographic data of all other patients in the series with non-Medicaid insurance were reviewed. Statistical significance was determined with an alpha < 0.05 using Pearson chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables. RESULTS: Of 584 patients undergoing EETS for pituitary adenoma, 57 (10%) had Medicaid insurance. The maximum tumor diameter was significantly larger for Medicaid patients (26.1 ± 12 vs 23.1 ± 11 mm for controls, p < 0.05). Baseline comorbidities including diabetes mellitus, hypertension, smoking history, and BMI were not significantly different between Medicaid patients and controls. Patients with Medicaid insurance had a significantly higher rate of any complication (14% vs 7% for controls, p < 0.05) and long-term cranial neuropathy (5% vs 1% for controls, p < 0.05). There were no statistically significant differences in endocrine outcome or vision outcome. The mean postoperative length of stay was significantly longer for Medicaid patients compared to the controls (9.4 ± 31 vs 3.6 ± 3 days, p < 0.05). This difference remained significant even when accounting for outliers (5.6 ± 2.5 vs 3.0 ± 2.7 days for controls, p < 0.05). The most common causes of extended length of stay greater than 1 standard deviation for Medicaid patients were management of perioperative complications and disposition challenges. The rate of 30-day readmission was 7% for Medicaid patients and 4.4% for controls, which was not a statistically significant difference. CONCLUSIONS: The authors found that larger tumor diameter, longer postoperative length of stay, higher rate of complications, and long-term cranial neuropathy were significantly associated with Medicaid insurance. There were no statistically significant differences in baseline comorbidities, apoplexy, endocrine outcome, vision outcome, or 30-day readmission.

Comparison of costs and short-term clinical outcomes of per-oral endoscopic myotomy and laparoscopic Heller myotomy.

OBJECTIVE: Per-Oral Endoscopic Myotomy (POEM) has seen increasing application and comparisons to laparoscopic Heller myotomy (LHM). The aim of the present study was to compare perioperative and short-term outcomes, and costs between the two procedures at a single institution. METHODS: Fifty-one consecutive patients documented in a prospective IRB approved database from January 2014 to December 2017 were included. Perioperative data, pre-operative and 3-month postoperative Eckardt Scores, and cost data were compared. RESULTS: Median hospital stay was comparable between POEM and LHM (1 day each). Complications were minor (Clavien-Dindo 1, 2) and rare in both groups. Median Eckardt scores improved significantly after POEM (5 to 0) and LHM (5 to 0). Normalized median costs were comparable: 14 201 USD (POEM) vs. 13 328 USD (LHM) p = 0.45. CONCLUSIONS: POEM demonstrates comparable clinical outcomes and costs to LHM. Long-term issues related to GERD require ongoing assessment in POEM patients. SUMMARY: In patients with achalasia, extended myotomy of the lower esophageal sphincter offers excellent palliation of symptoms. In the last decades, laparoscopic Heller myotomy (LHM) has been the gold standard. Over the past decade, per-oral endoscopic myotomy (POEM) has seen wide application in specialized centers worldwide. In our patient cohort, we demonstrate, that POEM can be introduced with similar outcomes and costs compared to LHM.

A Comparison of Endonasal Dacryocystorhinostomy and External Dacryocystorhinostomy: A Report by the American Academy of Ophthalmology.

PURPOSE: To assess the efficacy of endonasal dacryocystorhinostomy (DCR) compared with external DCR. METHODS: A literature search was conducted in the PubMed database in March 2016 and updated in October 2017 and February 2019. The search strategy was designed to update the first Ophthalmic Technology Assessment on endonasal DCR from 2001 by identifying new peer-reviewed human studies reported since 2000 in the English language that compare results of endonasal DCR with those of external DCR. The searches yielded 169 articles. Of these, 13 met the inclusion criteria and were assigned a level of evidence rating. RESULTS: Six of the 13 studies included in this assessment were rated level II and 7 were rated level III. Three of the 13 studies drew conclusions based on statistically significant results, but all of these were level III evidence. Two of these significant studies demonstrated lesser efficacy of endonasal laser DCR (63%-64%) compared with external DCR (94%; P = 0.0002, 0.024). The third study reported that nonlaser endonasal DCR was superior to external DCR (84% vs. 70%; P = 0.03). The remainder of the studies did not find statistically significant differences in success rates between the 2 techniques. CONCLUSIONS: Limited data suggest that laser endonasal DCR may be less effective than external DCR. Existing data are inadequate to draw conclusions about whether endonasal DCR is superior to, equivalent to, or inferior to the gold standard external DCR.

Preoperative assessment of the risk of cavernous ICA injury in endoscopic transsphenoidal surgery.

In endoscopic endonasal transsphenoidal procedures, ICA injury occurs in up to 3.8% [1]. The highest hazard of injury is in case of contact between the ICA and pituitary gland, during opening of the dura. Preoperative imaging, i.e. CTA, MRA, supports objectively intraoperative techniques of imaging. CTA as well as MRA are essential to access anatomic details in variability of cavernous segments of the ICA (C4 ICA). The aim of the study was to measure the space between Internal Carotid Arteries and distances between the pituitary gland and ICA on both sides. Anatomic relations between left and right ICAs were accessed on CTA (coronal scans) at levels: A - The most concave point of the C4-C5 bend; B - The most convex point of the C4 bend; C - The C4 posterior ascending portion. Distances between pituitary gland and ICAs were measured on both sides on MRA (axial scans): A' - The most concave point of C4-C5 bend; B' - The most convex point of the C4 bend. The Statistica 13 (StatSoft) software was used for the statistical analysis. The Mann-Whitney U test was applied to determine differences between the groups. To analyze the strength of correlations between the quantitative variables, Spearman's rank correlation coefficients were calculated. The results were considered statistically significant at the level of P < 0.05. Distance reduction was shown between pituitary glands and cavernous segment (C4) of ICAs on both sides, which is related to age. This has impact on surgical planning and highlights the risk of intraoperative injury of ICAs.

Canine ovariectomy by hybrid or total natural orifice transluminal endoscopic surgery: technical feasibility study and pain assessment.

OBJECTIVE: To compare technical feasibility, surgical time, surgical complications, and postoperative pain in ovariectomy (OVE) by hybrid and total natural orifice transluminal endoscopic surgery (NOTES). STUDY DESIGN: Prospective randomized clinical trial. ANIMALS: Sixteen healthy and sexually intact bitches. METHODS: Dogs were randomly assigned to the hybrid NOTES group (HNG; n = 8) and the total NOTES group (TNG; n = 8) to compare surgical time, pain scores and complications. Pain was assessed by using the visual analog scale (VAS) and the Melbourne pain scale (MPS). RESULTS: Surgical time did not differ between the experimental groups (HNG = 46.3 ± 18.5 minutes, TNG = 54.6 ± 31.1 minutes). Exteriorization of the ovaries through the vaginal wound was the major difficulty. Complications were minor in both groups and occurred intraoperatively only in the HNG, and in both groups post operatively. No dogs required rescue analgesia in the intraoperative or postoperative period. There were no differences in VAS or MPS scores between the groups for any surgical times except for the VAS assessment at 72 hours after extubation (HNG = 1.1 ± 0.3, TNG = 0.7 ± 0.4, P = .0221). CONCLUSION: Both NOTES techniques were comparable for canine OVE, with no requirement for additional analgesia in the postoperative periods. It was not possible to determine whether there was a clear advantage of one technique rather than the other. CLINICAL SIGNIFICANCE: The minimally invasive techniques proposed for laparoscopic OVE are feasible for dogs with low pain scores and low rates of complications for both groups.

Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia.

BACKGROUND AND AIMS: Unclear reimbursement for new and innovative endoscopic procedures can limit adoption in clinical practice despite effectiveness in clinical trials. The aim of this study was to determine maximum cost-effective reimbursement for per-oral endoscopic myotomy (POEM) in treating achalasia. METHODS: We constructed a decision-analytic model assessing POEM versus laparoscopic Heller myotomy with Dor fundoplication (LHM) in managing achalasia from a payer perspective over a 1-year time horizon. Reimbursement data were derived from 2017 Medicare data. Responder rates were based on clinically meaningful improvement in validated Eckardt scores. Validated health utility values were assigned to terminal health states based on data previously derived with a standard gamble technique. Contemporary willingness-to-pay (WTP) levels per quality-adjusted life year (QALY) were used to estimate maximum reimbursement for POEM using threshold analysis. RESULTS: Effectiveness of POEM and LHM was similar at 1 year of follow-up (0.91 QALY). Maximum cost-effective reimbursement for POEM was $8033.37 to $8223.14, including all professional and facility fees. This compares favorably with contemporary total reimbursement of 10 to 15 total relative value units for advanced endoscopic procedures. Rates of postprocedural GERD did not affect the preference for POEM compared with LHM, assuming at least 10% cost savings with POEM compared with LHM in cost-minimization analysis, or at least 44% cost savings in cost-effectiveness analysis (WTP = $100,000/QALY). LHM was only preferred over POEM if both procedures were reimbursed similarly, and these findings were primarily driven by lower rates of postprocedural GERD. The rate of conversion to open laparotomy due to perforation or bleeding was infrequent in published clinical practice experience, thus did not significantly affect reimbursement. DISCUSSION: POEM is an example of an innovative and potentially disruptive endoscopic technique offering greater cost-effective value and similar outcomes to the established surgical standard at contemporary reimbursement levels.

Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopy as a day-care procedure: a randomised controlled trial.

OBJECTIVE: To compare hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus total laparoscopic hysterectomy (TLH) as a day-care procedure. DESIGN: Parallel group, 1:1 randomised single-centre single-blinded trial, designed as a non-inferiority study with a margin of 15%. SETTING: Belgian teaching hospital. POPULATION: Women aged 18-70 years scheduled to undergo hysterectomy for benign indications. METHODS: Randomisation to TLH (control group) or vNOTES (experimental group). Stratification according to uterine volume. Blinding of participants and outcome assessors. MAIN OUTCOME MEASURES: The primary outcome was hysterectomy by the allocated technique. We measured the proportion of women leaving within 12 hours after hysterectomy and the length of hospital stay as secondary outcomes. RESULTS: We randomly assigned 70 women to vNOTES (n = 35) or TLH (n = 35). The primary endpoint was always reached in both groups: there were no conversions. We performed a sensitivity analysis for the primary outcome, assuming one conversion in the vNOTES group and no conversions in the TLH group: the one-sided 95% upper limit for the differences in proportions of conversion was estimated as 7.5%, which is below the predefined non-inferiority margin. More women left the hospital within 12 hours after surgery after vNOTES: 77 versus 43%, difference 34% (95% CI 13-56%), P = 0.007. The hospital stay was shorter after vNOTES: 0.8 versus 1.3 days, mean difference -0.5 days, (95% CI -0.98 to -0.02), P = 0.004. CONCLUSIONS: vNOTES is non-inferior to TLH for successfully performing hysterectomy without conversion. Compared with TLH, vNOTES may allow more women to be treated in a day-care setting. TWEETABLE ABSTRACT: RCT: vNOTES is just as good as laparoscopy for successful hysterectomy without conversion but allows more day-care surgery.

New insertion method of transnasal ileus tube for small bowel obstruction: Anterior balloon method.

BACKGROUND: Small bowel obstruction (SBO) is usually caused by postoperative adhesions and malignant disease, and decompression is effective for SBO. Our previous case report suggested that a new transnasal ileus tube insertion method, the anterior balloon method (ABM), could achieve decompression for adhesive SBO. AIMS: The study aimed to investigate the effectiveness of a new method for inserting transnasal ileus tubes in patients with SBO. METHODS: Altogether, 134 patients with small bowel obstruction treated from January 2011 to December 2017 were reviewed. The patients were categorized into two groups: those with the new method that inserts an anterior balloon (ABM group: 52 patients, 2014-2017) versus those with the ordinary insertion method (OIM group: 82 patients, 2011-2014). RESULTS: The patients' characteristics and symptoms on admission were similar in the ABM and OIM groups. Adhesions were the main cause of ileus in the two groups. The insertion time duration was significantly shorter in the ABM group than in OIM group (28.4 ± 9.1 vs. 33.5 ± 13.0 min; p = 0.01). The ABM group also had significantly longer tubes than OIM group (222.4 ± 32.2 vs. 157.4 ± 31.7 cm; p < 0.001), which resulted in a significantly shorter time until clinical symptoms were relieved in ABM group. There were no significant differences in adverse events between the two groups. CONCLUSIONS: The ABM group had shorter insertion duration and longer tubes than those of OIM group. The ABM might become a preferred therapeutic choice to achieve decompression in patients with SBO.

The Impact of Resident and Fellow Participation in Transsphenoidal Pituitary Surgery.

OBJECTIVES/HYPOTHESIS: Postoperative complications is an important marker of healthcare quality. The aim of this study was to analyze the impact of resident and fellow participation on postoperative complications in transsphenoidal pituitary surgery in a multi-institutional setting. STUDY DESIGN: Retrospective analysis of population-based surgical registry. SETTING: Academic medical center. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to generate transsphenoidal pituitary surgery patient cohorts. The attending with resident and/or fellow group was compared to the attending alone based on demographics and preoperative and postoperative variables. RESULTS: A total of 469 cases were included in the analysis, with 315 performed with resident participation and 154 by attendings alone. The attending group had higher rates of diabetics (20.1% vs. 11.7%, P = 0.015) and patients with a history of previous percutaneous coronary intervention (6.0 vs. 1.6%, P = 0.009). Although the attending group demonstrated higher rates of surgical complications, and the resident/fellow group showed increased incidence in medical and overall complication rates, there was no statistical difference between the two groups. Multivariate analysis further demonstrated lack of significance in complication rates between attendings and residents/fellows. CONCLUSION: Resident and fellow participation in transsphenoidal surgery is not associated with significant differences in surgical complications, medical complications, mortality, operating time, reoperation rates, or readmission rates when compared to attendings. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2707-2713, 2018.