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Introduction: The COVID-19 pandemic caused significant decreases in outpatient procedures, many of which are required before to antireflux operation (ARS). The purpose of this study was to add functional luminal imaging probe (FLIP) to esophagogastroduodenoscopy (EGD) and esophageal pH monitoring to assess its utility in decreasing the need for follow up studies in patients being evaluated for ARS. Method(s): Retrospective observational study was performed on 81 patients being evaluated for GERD who underwent EGD, pH monitoring, and FLIP. Data collected included average distensibility index (DI) at 60 mL, presence of repetitive anterograde or retrograde contractions, hiatal hernia dimensions, pathology results, pH data, and need for follow-up testing. Result(s): Based on FLIP results, HRM was recommended in 35 patients (43.2%). This included 14 patients with DI suggestive of significant esophagogastric junction outflow obstruction, eight of whom completed HRM with four confirmed as achalasia. FLIP results were suspicious for eosinophilic esophagitis (EoE) in four patients of which one was confirmed as EoE on biopsy. Gastric emptying study was felt to be necessary for 11 patients before to ARS. Conclusion(s): FLIP identified patients with possible alternative pathologies including achalasia and EoE that would otherwise be a contraindication to ARS. FLIP at the time of EGD and pH monitoring is useful as it guides the clinical decision on need for additional outpatient procedures, which may be difficult to obtain in pandemic conditions. FLIP was effective at reducing the requirements for further follow-up testing in the majority of patients being evaluated for potential ARS.
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Aim: The incidence of paraoesphageal hiatus hernia (PEH) has changed over the last several years. This study aims to ascertain the difference in the presentation of PEH requiring operative intervention at our unit because of the COVID-19 pandemic Material&Methods:We conducted a retrospective review of procedures performed by a single surgeon for PEH in a district general hospital. We compared cases from 2016 to March 2020 and during the initial period of the COVID-19 pandemic in 2020. Result(s): 39 consecutive cases were identified undergoing PEH related procedures. The median age was 66 (IQR 26), with slight female predominance (M:F ratio of 5:6). 28 cases (71.8%) were performed as elective cases. After the 2020 March lockdown, there were 10 cases of PEH repair performed with 78% performed as emergency procedures, compared to 30 cases in the preceding 5 years and 10% performed as emergency cases. Chi-square test to examine the association between COVID-19 pandemic and emergency procedure, X2 (1, N=39)=14.199, p=0.000164. Pre-COVID19 the types of procedures included 76.7% were fundoplication with suture crural closure, 10% were fundoplication with mesh repair, 3.3% biological mesh repair, 3.3% with suture closure of the crural and 6.7% had suture gastropexy. During the COVID-19 period, 44.4% were gastropexy, 33.3% were gastrostomy tube insertion and 22.2% fundoplication performed. Conclusion(s): We have seen significantly more emergency PEH related procedures performed and using a variety of procedures. This leads to the consideration of whether current emergency general surgery training can equip trainees for future independent practice.
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INTRODUCTION: Telehealth visits became a staple in surgical practice in the setting of COVID-19. The objective of this study is to assess benign foregut patient satisfaction and perceived cost savings with use of telehealth visits. METHOD(S): This is a single academic center prospective study of benign foregut patients evaluated for routine postoperative care by a telehealth visit over a 1-year period. Patients who agreed to participate completed a survey assessing their experience with telehealth. RESULT(S): There were 19 patients (13 phone, 6 virtual) ages 21 to 74 years (male:female 5:14) included. A total of 84% underwent hiatal hernia repair, and others underwent operation for achalasia, feeding access, gastric pacemaker, and choledocholithiasis (average length-ofstay 3.5 days, range 0 to 13). The majority (84.2%) reported a high overall satisfaction score (>4/5, range 3 to 5). Of these patients, 94.7% agreed/strongly agreed that their provider was able to adequately assess their problem, that their concerns were addressed, and that they would participate in future telehealth visits. The average time to drive to a hypothetical in-person appointment was 180 minutes (range 20 to 480 minutes). When comparing telehealth with hypothetical in-person visits, no patients had to take time off work for telehealth vs 15.8% would for in-person visits. A total of 21% would need a family member to take time off for in-person visit;of those, 75% would have suffered wage loss;36.8% and 42.1% would require overnight accommodation and meal costs for hypothetical in-person visits, respectively (travel time range 180 to 480 minutes). CONCLUSION(S): Postoperative benign foregut patients were very satisfied with telehealth care with time and cost-saving benefits reported for those traveling long distances for in-person visits.
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Theresa Jackson Sacramento CA1, Gary Grinberg Elk Grove CA1, Aaron Baggs Richmond CA2, Emily Siegler Elk Grove CA3, Panduranga Yenumula Sacramento CA1 Kaiser Permanente South Sacramento1 Kaiser Permanente Richmond2 California Northstate University3 Background: The COVID-19 pandemic impacted healthcare delivery worldwide. Resource limitations prompted a multi-institutional quality initiative to enhance same-day discharge workflow after sleeve gastrectomy to reduce the inpatient hospital burden. This study aims to determine the safety and efficacy of this initiative, as well as potential modifiable and non-modifiable risk factors for inpatient admission. Methods: A retrospective analysis of sleeve gastrectomy patients was conducted from January 2019 to August 2021. Inclusion criteria was discharge on postoperative day zero, one, or two. Patients were divided into same-day discharge (SD) and inpatient cohorts. Demographic, operative, and postoperative variables were compared, as well as monthly trends in same-day and inpatient care. Potential risk factors for inpatient admission were assessed. Results: Analysis included 2,209 sleeve gastrectomy surgeries (462 SD, 1,747 inpatient). Significant differences between cohorts were age, hypertension, obstructive sleep apnea, pre-/post-COVID, facility, and combination procedure (e.g. paraesophageal hernia). Monthly frequency of same-day discharge rose from 13% in June 2020 to 75% in August 2021. There was no difference in rates of inpatient readmission, reoperation, mortality, or 6-month excess weight loss. SD discharge patients had higher rates of 7-day emergency department readmission (9% vs 5%, p=0.004). Potential risk factors for inpatient admission include: age, BMI, diabetes mellitus, hypertension, obstructive sleep apnea, surgery date, facility, and combination case. Conclusion: Same-day discharge after sleeve gastrectomy is safe and efficacious. Administrative support for extended PACU (postanesthesia care unit) recovery was critical to successful protocol implementation for same-day discharge within this large multi-institutional healthcare system demonstrating potential applicability nationwide.
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Daniel Slack Charlotte NC1, Paul Colavita Charlotte NC1, Abdelrahman Nimeri Charlotte NC1 Carolinas Medical Center, Atrium Health1 We present a 55-year-old female with class II obesity and a previous history of sleeve gastrectomy who developed significant gastroesophageal reflux disease refractory to medical management. After a covid infection in fall of 2020 she began to report new symptoms of dysphagia that progressed from solids to liquids. She underwent extensive workup including upper endoscopy, upper GI barium swallow, manometry, pH impedence and EndoFlip leading to a diagnosis of Achalasia type II as well as a paraesophageal hernia. Given these findings she underwent a combined paraesophageal hernia repair with conversion of sleeve gastrectomy to Roux-en-Y gastric diversion and an intra-operative Peroral Endoscopic Myotomy. Intra-operatively she was noted to have significant lower abdominal adhesions leading to performing the Roux-en-Y reconstruction through a supramesocolic defect in a retrocolic fashion. The patient tolerated the procedure well and recovered with improvement of both her reflux and achalasia.
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Background: Optimizing management of gastroesophageal reflux disease (GERD) is important to preserve graft function after lung transplantation as patients with GERD are at higher risk of rejection. Patients with COVID-19 associated respiratory failure undergoing lung transplantation is an emerging subset of patients in which GERD pre- or post-transplant is not well characterized. Aim: To evaluate the prevalence and adverse effects of GERD both pre- and post-transplant in patients undergoing lung transplantation for severe COVID-19 infection. Methods: A retrospective review was conducted at a single academic medical center with a large multi-organ transplant program. All patients undergoing lung transplant due to COVID-19 from 2020-2021 were included in the study, with attention to pre- and post-operative physiological testing for GERD. Results: Seventeen patients were identified who had undergone lung transplant for COVID-19. All patients were male;52.9% (9/17) were Hispanic, 35.3% (6/17) Caucasian and 11.8% (2/17) Black. Median age was 50 (24- 70 years) with median time to transplant from documented infection of 131 days. A prehospitalization GERD diagnosis was found in 29.4% (5/17) patients, and two patients (11.8%) were taking prescribed proton-pump inhibitor (PPI) prior to their COVID-19 associated hospitalization. No patient underwent pre-transplant GERD testing, although three patients did undergo upper endoscopy for GI bleeding prior to transplant. Post-transplant, all patients were immediately treated with PPI per institutional protocol. 70.5% (12/17) patients reported post-transplant foregut symptoms including heartburn, regurgitation, dysphagia, early satiety, abdominal bloating/cramping, nausea and vomiting. All 17 patients had at least one symptomdriven foregut study such as a gastric emptying study, barium esophagram, upper endoscopy, esophageal manometry or pH testing. Three patients were referred for anti-reflux surgery (ARS) based on results of testing, including delayed gastric emptying, abnormal pH testing and bronchoscopy findings concerning for aspiration pneumonia. All three underwent Toupet fundoplication with or without hiatal hernia repair;one was performed early (< 3 mo) posttransplant, two occurred late (> 6 mo), and none had complications or symptom-based recurrence of reflux. Discussion: In this large single-center series of COVID-19 associated respiratory failure and lung transplant, pre-operative reflux testing could not be performed;however, post-transplant GERD symptoms were still routinely assessed and evaluated, prompting management with ARS in a small subset of patients, both early and late posttransplant, with resolution of GERD symptoms. Long-term outcomes of this unique group and comparison with others requiring transplant will necessitate further investigation to assess impact of GERD on allograft dysfunction.
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Background: Excessive testing is extremely common in the US, with an estimated $760 - 935 billion wasted in healthcare costs, 8 - 13% of this due to overtreatment or low-value care (i.e., duplicate tests). We present a case where an older adult patient was correctly diagnosed by a geriatrics team diligently gathering data and conversing with specialists, thereby avoiding unnecessary tests and interventions. Case Presentation: A 79yr old woman in long-term care with past medical history significant for a hiatal hernia presented with cough, shortness of breath and rhinorrhea. Evaluation was notable for mild hypoxia (88 - 90% on RA) and tachypnea (26). Physical exam revealed rhonchi which cleared with coughing. She had mild leukocytosis, testing was negative for COVID-19, Influenza A and B, and RSV. Chest x-ray (CXR) showed complete opacification of the left hemithorax concerning for a mucous plug and/or infection. She was started on inhalers/antibiotics. Her nursing home team obtained a second CXR (similar to the first), then compared the CXR with a prior abdominal CT. In discussion with the reading radiologist, the CT revealed a loop of air-filled bowel in the left thorax. They concluded that the likely etiology of respiratory compromise and opacification seen on CXR was bowel herniation into the thorax via her hiatal hernia, causing compression of the left lung. Thoracic surgery was consulted, and did not recommend surgery of the hiatal hernia. Antibiotics were discontinued and the patient was managed conservatively in the nursing home. Discussion: This case details a situation where complete lung opacity on CXR did not match the clinical situation and required further investigation. The nursing home team uncovered the etiology through looking at old imaging and conferring with a radiologist. These methods allowed for proper triage of this problem, including informed discussion with her family. The patient successfully avoided a hospitalization, which would have been a natural impulse upon seeing the lung opacity on CXR. Incentives for this type of diligent, resource-mindful care are largely missing in the US healthcare system, resulting in unnecessary or duplicated testing and treatment. Despite these barriers, practitioners for older adults should be mindful that diligence and tailoring service to each patient can potentially avoid excessive testing and unnecessary interventions.
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Background and aim: Hiatal Hernia (HH) is a common condition in obese patients undergoing bariatric surgery (BS). HH can be preoperatively diagnosed by upper GI endoscopy and it may influence the operation strategy. AIM: to assess the diagnostic accuracy of endoscopic HH detection, in comparison to intraoperative diagnosis assumed as a standard of reference. Materials and methods: A retrospective analysis was performed on a prospective database of consecutive patients who underwent bariatric surgery after the first peak of Covid-19 pandemic from May 2020 to February 2021 in a single bariatric center. All included patients underwent a preoperative gastroscopy by the same dedicated endoscopist (RP). All the surgical procedures have been performed by a single surgeon (LA). In case of intraoperative finding of HH, it was repaired contextually by performing a posterior cruroplasty. HH was defined as a distance between the gastro-esophageal junction and the diaphragmatic hiatus ≥2 cm and using Hill's classification (Hill grade III-IV). The intraoperative finding was assumed as gold standard for the HH diagnosis. Results: 247 patients underwent BS from May 2020 to February 2021. HH was intraoperatively diagnosed and repaired (HHR) in 118/247 patients (47,7%). The distribution of the surgical procedures is represented in Table 1. When compared to intraoperative evaluation, the sensitivity of the UGIE was 65% and the specificity 97%, with a positive predictive value of 96% and a negative predictive value of 74%. The preoperative diagnostic accuracy of UGIE was 81%.(table presented) Conclusions: Hiatal hernia is a common condition in obese population possibly understimated by the bariatric community. UGIE when performed by a dedicated endoscopist has a high accuracy of HH detection assuming the intraoperative diagnosis as reference standard.
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Objective: During COVID-19 pandemic, the access to skeleton investigations for osteoporosis was in many cases postponed, thus consequences on fracture risk (FR) might be expected in terms of not continuing the antiosteoporotic medication or not initiating it if needed. Reduced physical activity might reduce the risk of fall, on one hand, but associated sarcopenia and inhibition of bone formation due to lack of physical exercise increase the FR, on the other hand (1-5). This is a case report of a female with severe osteoporosis who delayed the presentation for diagnostic during first 15 months of pandemic. Case report: This is a 73-year-old female, known with a history of osteoporosis since 2005. She also associates FR: chronic therapy with different SSRIs for depression, multinodular goiter-related hyperthyroidism (which was treated with radioiodine therapy). She has chronic therapy for arteria hypertension, hyperlipemia and hiatal hernia. At diagnostic, after initial lumbar T-score=-3.5 SD, she refused therapy until 2015 (when T-score decreased to -4 SD), thus she began therapy with intravenous ibandronate until 2017 when she experienced a vertebral fracture and daily 20 μg of teriparatide was initiated, starting from a DXA-BMD of 0.783 g/cm2, T-score of 3.1 SD. After 8 months, the treatment was stopped because of her lack of compliance, so she continued with annual zolendronic acid 5 mg until of T-score of -2.6 SD, BMD=0.856 g/cm2. In March 2020, when lockdown pandemic were initiated, she had to come to reassessment, but delayed it, and refused medication based on telemedicine recommendations, except for daily 1000 UI vitamin D. 14 months later, central DXA showed lumbar L1-3 BMD of 0.824 g/cm2, T-score of -2.9 SD, Z-score of -0.7 SD, hip BMD of 0.682 g/cm2, T-score of -2.6 SD, Z-score of -0.4 SD;25-hydroxyvitamin D of 29 ng/mL, PTH of 55 pg/mL, suppressed CrossLaps of 0.287 ng/mL (normal: 0.33-0.782 ng/mL), osteocalcin of 17 ng/mL (normal: 15-46 ng/ mL), P1NP of 27 pg/mL (normal: 15-45 pg/mL);an additional T4 thoracic fracture. Zolendronic acid was further recommended. Conclusion: During pandemic lockdown, the usual serial assays and decision of therapy were less adequate based on telemedicine.
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Introduction: The coronavirus disease 2019 (COVID-19) is a global respiratory disease outbreak caused by a novel coronavirus called severe acute respiratory system coronavirus 2 (SARS-CoV-2). A slew of adverse events related to chronic proton pump inhibitors (PPIs) treatment have been documented in the past decade. However, the risk of infection with the novel coronavirus in patients with gastro-esophageal reflux disease (GERD) using PPI still remains to be elucidated. Aim: To determine the incidence of COVID-19 in GERD patients on chronic PPI treatment. Methods: We reviewed data from a large commercial database (Explorys IBM) that aggregates electronic health records from 26 large nationwide healthcare systems. Using systemized nomenclature of clinical medical terms (SNOMED CT), we identified adults with GERD (November 1999-November 2020) and COVID-19(January 2020 – November 2020). Comorbidities known to be associated with GERD and COVID-19 such as obesity, diabetes mellitus (DM), Barrett’s esophagus (BE), gender, smoking, advance age were also collected. Incidence of COVID-19 was compared among different risk groups. Univariable and multivariable logistic regression analyses were performed to investigate the strongest association. Results: Out of 61.4 million active adult patients in the database, 6,173,950 patients (9.85%) had documented GERD. In univariate analysis in GERD cohort, there was a higher incidence of COVID-19 in patients who are on PPIs (0.11% vs 0.03 % OR 3.28 [95% CI: 3.03 – 3.55]), females (0.11% vs 0.05%;OR 2.05 [95%CI: 1.94–2.17]), younger than 65 years (0.10% vs 0.07%, OR 1.50 [95%CI: 1.41 - 1.59]) diabetic (0.13% vs 0.07%, OR 1.93 [95%CI: 1.83–2.04]), or have BE (0.32% vs 0.08%, OR 4.00 [95%CI: 3.39–4.72]). Incidence of COVID-19 was also higher among smokers (0.09% vs 0.08%, OR 1.12 [95%CI: 1.05–1.20]), those with hiatal hernia (0.11% vs 0.08% OR 1.31 [95%CI: 0.98–1.76]) and obese (0.13% vs 0.07%, OR 1.91;95%CI: 1.81–2.02]). In multivariable model, the incidence of COVID with PPI use was modified with gender after adjusting for other risk factors for COVID -19 from the univariate model. Female patients using PPIs had higher risk of COVID-19 (OR 9.94, 95%CI: 8.91-11.09) than their male counterparts using PPI (OR 1.20, 95%CI: 1.04–1.36). This interaction was found to be statistically significant (P < 0.05). Conclusion: PPI use in patients with GERD is associated with higher risk of COVID-19, especially among female patients and those with Barrett’s esophagus. (Table Presented) (Table Presented)