Operative vs Nonoperative Management of Acute Cholecystitis During the Different Trimesters of Pregnancy.

Importance: Acute cholecystitis (AC) management during pregnancy requires balancing the risk of pregnancy loss or preterm delivery (adverse pregnancy outcomes [APOs]) with or without surgery. Guidelines recommend cholecystectomy across trimesters; however, trimester-specific evidence on the risks of AC and its management is lacking. Objective: To assess cholecystectomy frequency in pregnant people with AC, compare the rates of APOs in pregnant people with or without AC, and compare the rates of APOs in people with AC who did or did not undergo cholecystectomy. Design, Setting, and Participants: This retrospective, population-based cohort study used data for pregnant people with AC from the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2007, to December 31, 2019, and a propensity score-matched cohort of pregnant people without AC. Trimester status (first [T1], second [T2], and third [T3]), APOs, and cholecystectomy were defined by administrative claims. Data were analyzed from October 2021 to July 2022. Exposures: Pregnant patients with or without AC. Pregnant patients with AC who did or did not receive cholecystectomy. Main Outcomes and Measures: The main outcomes were cholecystectomy during pregnancy and APOs (ie, preterm delivery and pregnancy loss). Pregnant patients with and without AC were compared to assess the association of AC with risk of APOs. Propensity score inverse-probability weighting was used to calculate treatment-associated APO risk among patients with 1-year follow-up. Results: The study included 5759 pregnant patients with AC (mean [SD] age, 30.1 [6.6] years) and 23 036 controls (mean [SD] age, 29.9 [6.7] years) after propensity score matching. Among 3426 pregnant patients with AC and 1-year follow-up, 1182 (34.5%) underwent cholecystectomy during the pregnancy (684 [41.7%] presenting with AC in T1, 404 [40.4%] in T2, and 94 [12.0%] in T3). Acute cholecystitis during pregnancy, irrespective of treatment, was associated with higher odds of APO compared with no AC during pregnancy across all trimesters (odds ratio [OR], 1.69 [95% CI, 1.54-1.85]). Compared with nonoperative management, receipt of surgery was associated with lower odds of APOs across all trimesters (OR, 0.75 [95% CI, 0.63-0.87]), in T1 (OR, 0.81 [95% CI, 0.66-1.00]), in T2 (OR, 0.71 [95% CI, 0.50-1.00]), and in T3 (OR, 0.45 [95% CI, 0.28-0.70]). Conclusions and Relevance: In this study, cholecystectomy was associated with lower risk of APO in patients with AC across all trimesters, with the greatest benefit in T3. However, only 34.5% overall and 12.0% of patients in T3 had a cholecystectomy. These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC.

Laparoscopic Heller myotomy with Toupet fundoplication: revisiting GERD in treated achalasia.

INTRODUCTION: With the advent of the laparoscopic era in the 1990s, laparoscopic Heller myotomy replaced pneumatic dilation as the first-line treatment for achalasia. An advantage of this approach was the addition of a fundoplication to reduce gastroesophageal reflux disease (GERD). More recently, Peroral Endoscopic Myotomy has competed for first-line therapy, but the postoperative GERD may be a weakness. This study leverages our experience to characterize GERD following LHM with Toupet fundoplication (LHM+T ) so that other treatments can be appropriately compared. METHODS: A single-institution retrospective review of adult patients with achalasia who underwent LHM+T from January 2012 to April 2022 was performed. We obtained routine 6-month postoperative pH studies and patient symptom questionnaires. Differences in questionnaires and reflux symptoms in relation to pH study were explored via Kruskal-Wallis test or chi-square tests. RESULTS: Of 170 patients who underwent LHM+T , 51 (30%) had postoperative pH testing and clinical symptoms evaluation. Eleven (22%) had an abnormal pH study; however, upon manual review, 5 of these (45.5%) demonstrated low-frequency, long-duration reflux events, suggesting poor esophageal clearance of gastric refluxate and 6/11 (54.5%) had typical reflux episodes. Of the cohort, 7 (15.6%) patients reported GERD symptoms. The median [IQR] severity was 1/10 [0, 3] and median [IQR] frequency was 0.5/4 [0, 1]. Patients with abnormal pH reported more GERD symptoms than patients with a normal pH study (3/6, 50% vs 5/39, 12.8%, p = 0.033). Those with a poor esophageal clearance pattern (n = 5) reported no concurrent GERD symptoms. CONCLUSION: The incidence of GERD burden after LHM+T is relatively low; however, the nuances relevant to accurate diagnosis in treated achalasia patients must be considered. Symptom correlation to abnormal pH study is unreliable making objective postoperative testing important. Furthermore, manual review of abnormal pH studies is necessary to distinguish GERD from poor esophageal clearance.

Application of the acquisition of data for outcomes and procedure transfer (ADOPT) method to a hands-on course for teaching extended-view totally extraperitoneal (eTEP) hernia repair to practicing surgeons.

BACKGROUND: After completion of training, practicing surgeons rely on hands-on courses to expand their procedure armamentarium and improve their surgical technique. However, such courses vary in standardized teaching methods. SAGES developed the Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program as a method of longitudinal instruction utilizing standardized teaching techniques, mentorship, and webinars to cover additional techniques. This study examines the adoption of learned techniques and participant confidence before and after an ADOPT course focused on extended-view totally extraperitoneal (eTEP) hernia repair. METHODS: A hands-on course focused on eTEP hernia repair was conducted with enrollment capped at 10 participants. Pre-course and post-course surveys at 3, 6, and 12 months determined implementation of the learned procedure, case volume, and confidence with eTEP skills. A 5-point Likert scale (1 = not confident at all to 5 = completely confident) assessed confidence levels. Survey responses were summarized using descriptive statistics. RESULTS: Of the 10 participants, 10 (100%) completed the pre-course survey, and 7 (70%) completed at least one post-course survey. Median age was 48.5 years (36,56) with a median of 16 years (2,23) in practice, mostly in the community setting (70%). After the course, 50% had performed an eTEP procedure, and 100% reported considering this technique during surgical planning. Participants reported higher confidence in eTEP-specific skills at three months post-course from pre-course levels. The highest change in confidence was seen for the following skills: accessing the retromuscular/extraperitoneal space for ventral hernia and recognizing when the linea alba has been violated, p < 0.05. CONCLUSION: This study shows that rapid incorporation of learned techniques can be achieved through the ADOPT format. Furthermore, through longitudinal mentorship and a structured hands-on course, the ADOPT course supports practicing surgeons to attain autonomy and confidence even when teaching a relatively technically challenging procedure, such as eTEP.

Esophageal Motility Patterns in Paraesophageal Hernia Patients Compared to Sliding Hiatal Hernia: Bigger Is Not Better.

BACKGROUND: In patients with paraesophageal hernias (PEH), the course of the esophagus is often altered, which may affect esophageal motility. High-resolution manometry (HRM) is frequently used to evaluate esophageal motor function prior to PEH repair. This study was performed to characterize esophageal motility disorders in patients with PEH as compared to sliding hiatal hernia and to determine how these findings affect operative decision-making. METHODS: Patients referred for HRM to a single institution from 2015 to 2019 were included in a prospectively maintained database. HRM studies were analyzed for the appearance of any esophageal motility disorder using the Chicago classification. PEH patients had confirmation of their diagnosis at the time of surgery, and the type of fundoplication performed was recorded. They were case-matched based on sex, age, and BMI to patients with sliding hiatal hernia who were referred for HRM in the same period. RESULTS: There were 306 patients diagnosed with a PEH who underwent repair. When compared to case-matched sliding hiatal hernia patients, PEH patients had higher rates of ineffective esophageal motility (IEM) (p<.001) and lower rates of absent peristalsis (p=.048). Of those with ineffective motility (n=70), 41 (59%) had a partial or no fundoplication performed during PEH repair. CONCLUSION: PEH patients had higher rates of IEM compared to controls, possibly due to a chronically distorted esophageal lumen. Offering the appropriate operation hinges on understanding the involved anatomy and esophageal function of each individual. HRM is important to obtain preoperatively for optimizing patient and procedure selection in PEH repair.

The environmental impact of surgical telemedicine: life cycle assessment of virtual vs. in-person preoperative evaluations for benign foregut disease.

BACKGROUND: Health care accounts for almost 10% of the United States' greenhouse gas emissions, accounting for a loss of 470,000 disability-adjusted life years based on the health effects of climate change. Telemedicine has the potential to decrease health care's carbon footprint by reducing patient travel and clinic-related emissions. At our institution, telemedicine visits for evaluation of benign foregut disease were implemented for patient care during the COVID-19 pandemic. We aimed to estimate the environmental impact of telemedicine usage for these clinic encounters. METHODS: We used life cycle assessment (LCA) to compare greenhouse gas (GHG) emissions for an in-person and a telemedicine visit. For in-person visits, travel distances to clinic were retrospectively assessed from 2020 visits as a representative sample, and prospective data were gathered on materials and processes related to in-person clinic visits. Prospective data on the length of telemedicine encounters were collected and environmental impact was calculated for equipment and internet usage. Upper and lower bounds scenarios for emissions were generated for each type of visit. RESULTS: For in-person visits, 145 patient travel distances were recorded with a median [IQR] distance travel distance of 29.5 [13.7, 85.1] miles resulting in 38.22-39.61 carbon dioxide equivalents (kgCO2-eq) emitted. For telemedicine visits, the mean (SD) visit time was 40.6 (17.1) min. Telemedicine GHG emissions ranged from 2.26 to 2.99 kgCO2-eq depending on the device used. An in-person visit resulted in 25 times more GHG emissions compared to a telemedicine visit (p < 0.001). CONCLUSION: Telemedicine has the potential to decrease health care's carbon footprint. Policy changes to facilitate telemedicine use are needed, as well as increased awareness of potential disparities of and barriers to telemedicine use. Moving toward telemedicine preoperative evaluations in appropriate surgical populations is a purposeful step toward actively addressing our role in health care's large carbon footprint.

Type II hiatal hernias: do they exist or are they actually parahiatal hernias?

BACKGROUND: Type II hiatal hernias (HH) are characterized by a portion of the gastric fundus located above the esophageal hiatus adjacent to the esophagus while the gastroesophageal junction (GEJ) remains fixed below the esophageal hiatus. This type of HH has been called the "true" paraesophageal hernia (PEH) because the fundus appears to the side of the esophagus. In our experience, Type II HHs are occasionally identified on radiographic testing, however they are rarely, if ever, confirmed intraoperatively. This led to our question: Does Type II HH exist? METHODS: We searched for evidence of type II HH in three locations: 1. Retrospective review of all first-time PEH repairs (excluding Type I HHs and re-operative cases) performed at the University of Washington Medical Center from 1994 to 2021; 2. Operative videos available on YouTube and WebSurg websites; and 3. Abstracts from the SAGES annual meetings from 2005 to 2021. RESULTS: We found no evidence of Type II HH in any of our three searches. We performed 846 PEH repairs: 760 Type III, 75 Type IV, and 11 parahiatal. Upon website video review, we found only one possible type II hernia, though it too was likely a para-hiatal hernia. No video or case presentations of a type II HH were identified within SAGES annual meeting abstracts. CONCLUSION: Type II HHs do not exist as they are currently defined. Although uncommon, parahiatal hernia can easily be misinterpreted as Type II HH. We should consider changing the hiatal hernia classification system to prevent ongoing clinical confusion.

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.

The impact of socioeconomic status on telemedicine utilization during the COVID-19 pandemic among surgical clinics at an academic tertiary care center.

BACKGROUND: The COVID-19 pandemic caused many surgical providers to conduct outpatient evaluations using remote audiovisual conferencing technology (i.e., telemedicine) for the first time in 2020. We describe our year-long institutional experience with telemedicine in several general surgery clinics at an academic tertiary care center and examine the relationship between area-based socioeconomic measures and the likelihood of telemedicine participation. METHODS: We performed a retrospective review of our outpatient telemedicine utilization among four subspecialty clinics (including two acute care and two elective surgery clinics). Geocoding was used to link patient visit data to area-based socioeconomic measures and a multivariable analysis was performed to examine the relationship between socioeconomic indicators and patient participation in telemedicine. RESULTS: While total outpatient visits per month reached a nadir in April 2020 (65% decrease in patient visits when compared to January 2020), there was a sharp increase in telemedicine utilization during the same month (38% of all visits compared to 0.8% of all visits in the month prior). Higher rates of telemedicine utilization were observed in the two elective surgery clinics (61% and 54%) compared to the two acute care surgery clinics (14% and 9%). A multivariable analysis demonstrated a borderline-significant linear trend (p = 0.07) between decreasing socioeconomic status and decreasing odds of telemedicine participation among elective surgery visits. A sensitivity analysis to examine the reliability of this trend showed similar results. CONCLUSION: Telemedicine has many patient-centered benefits, and this study demonstrates that for certain elective subspecialty clinics, telemedicine may be utilized as the preferred method for surgical consultations. However, to ensure the equitable adoption and advancement of telemedicine services, healthcare providers will need to focus on mitigating the socioeconomic barriers to telemedicine participation.

Characteristics and outcomes of patients undergoing paraesophageal hernia repair with selective use of biologic mesh.

BACKGROUND: The use of biologic mesh in paraesophageal hernia repair (PEHR) has been associated with decreased short-term recurrence but no statistically significant difference in long-term recurrence. Because of this, we transitioned from routine to selective use of mesh for PEHR. The aim of this study was to examine our indications for selective mesh use and to evaluate patient outcomes in this population. METHODS: We queried a prospectively maintained database for patients who underwent laparoscopic PEHR with biologic mesh from October 2015 to October 2018, then performed a retrospective chart review. The decision to use mesh was made intraoperatively by the surgeon. Recurrence was defined as the presence of > 2 cm intrathoracic stomach on postoperative upper gastrointestinal (UGI) series. RESULTS: Mesh was used in 61/169 (36%) of first-time PEHRs, and in 47/82 (57%) of redo PEHRs. Among first-time PEHRs, the indications for mesh included hiatal tension (85%), poor crural tissue quality (11%), or both (5%). Radiographic recurrence occurred in 15% of first-time patients (symptomatic N = 2, asymptomatic N = 3). There were no reoperations for recurrence. Among redo PEHRs, the indication for mesh was most commonly the redo nature of the repair itself (55%), but also hiatal tension (51%), poor crural tissue quality (13%), or both (4%). Radiographic recurrence occurred in 21% of patients (symptomatic N = 4, asymptomatic N = 1). There was 1 reoperation for recurrence in the redo-repair group. CONCLUSIONS: We selectively use biologic mesh in a third of our first-time repair patients and in over half of our redo-repair patients when there is a perceived high risk of recurrence based on hiatal tension, poor tissue quality, or prior recurrence. Despite the high risk for radiologic recurrence, there was only 1 reoperation for recurrence in the entire cohort.

Controversies in Inguinal Hernia.

Inguinal hernias represent one of the most common pathologic conditions presenting to the general surgeon. In surgical practice, several controversies persist: when to operate, the utility of a laparoscopic versus open approach, the applicability of robotic surgery, the approach to bilateral hernias, management of athletic-related groin pain ("sports hernia"), and the role of tissue-based repairs in modern hernia surgery. Ideally, surgeons should approach each patient individually and tailor their approach based on patient factors and preferences. The informed consent process is critical, especially given increasing recognition of the risk of long-term chronic pain following hernia repair.

Laparoscopic Heller Myotomy and Toupet Fundoplication for Achalasia.

Achalasia manifests as failure of relaxation of the lower esophageal sphincter resulting in dysphagia. Although there are several medical and endoscopic treatment options, laparoscopic Heller myotomy has excellent short- and long-term outcomes. This article describes in detail our surgical approach to this operation. Key steps include extensive esophageal mobilization, division of the short gastric vessels, mobilization of the anterior vagus nerve, an extended gastric myotomy (3 cm as opposed to the conventional 1-2 cm gastric myotomy), a minimum 6 cm esophageal myotomy through circular and longitudinal muscle layers, and a Toupet partial fundoplication. We routinely use intraoperative endoscopy both to check for inadvertent full-thickness injury and to assess completeness of the myotomy and the geometry of the anti-reflux wrap.

Disclosure at #SAGES2018: An analysis of physician-industry relationships of invited speakers at the 2018 SAGES national meeting.

BACKGROUND: Financial conflicts of interest (COI) have been shown to affect the interpretation of scientific findings. Publications with unreported COI tend to be more favorable to industry. Since 2014 industry payments to United States (US) physicians are publicly reported in the Open Payments Database (OPD). Several studies show high levels of unreported COI in medical literature; however, there is no research examining COI reporting at surgical conferences. We hypothesized that compliance with the COI disclosure requirement would be high at the 2018 SAGES meeting. However, we expected to find significant discrepancy between speaker-reported and OPD-reported COI. A secondary aim was to characterize the amount, source, and variation in industry payments to invited speakers. METHODS: We reviewed all available presentations from SAGES 2018 as recorded and publicly available on YouTube™ for the presence of COI disclosure and the disclosed industry relationships. For US physicians we searched the OPD and recorded all industry payments > $500. We compared the self-disclosed COI for each speaker with OPD records. Presentation topics were divided into ten groups to determine which topics received the most funding. RESULTS: Of the 526 invited presentations, 479 (91%) videos were available. Disclosures were reported by 414 presenters (86.4%). There were 420 unique presenters of which 315 were listed in the OPD. Speaker-reported disclosures were fully concordant with the OPD in 38.3% (121/315) of cases with 39% (123/315) under-reporting disclosures. Of presenters listed in OPD, the median payment was $992 ($0-$374,502) with a total of $6,389,097 paid in 2017. SAGES speakers failed to disclose $2,049,535 worth of industry payments with an average undisclosed payment of $16,662.88 (± $40,733.19). The largest financial contributor was Intuitive Surgical with $1,981,169 paid. Among topics, robotics and hernia received the most funding with $2,593,925 (40.6%) and $2,591,671 (40.5%) paid, respectively. CONCLUSIONS: Overall compliance with SAGES disclosure rules is high. There remains a discrepancy between speaker- and industry-reported disclosures, including a number of undisclosed payments, some of which are substantial. Adjustments to disclosure rules to include the relative amount of compensation may be warranted.

Respiratory Failure following Abdominal Wall Reconstruction: An Analysis of the Nationwide Inpatient Sample.

BACKGROUND: Patients undergoing abdominal wall reconstruction are at increased risk of postoperative respiratory failure. Understanding the epidemiology of this complication may guide preventive efforts. METHODS: The authors performed a population-based retrospective cohort study of adults undergoing elective abdominal wall reconstruction (ventral hernia repair with component separation) in the United States from 2004 through 2011 using the Nationwide Inpatient Sample. RESULTS: Of 2283 patients undergoing elective abdominal wall reconstruction, 57 percent were women, with a median age of 57 years, median hospital stay of 5 days, and mean total cost of $23,730. Postoperative respiratory failure occurred in 212 patients (9.3 percent), 164 patients (7.2 percent) were discharged to a skilled nursing facility, and 18 patients (0.8 percent) died. On multivariate analysis, age, male sex, congestive heart failure, lung disease, obesity, and obstructive sleep apnea were independently associated with increased risk of respiratory failure. Respiratory failure was associated with significantly increased risk of death and discharge to a skilled nursing facility as well as significantly increased total cost and hospital length of stay. CONCLUSIONS: Respiratory failure is an uncommon but devastating complication of abdominal wall reconstruction. The authors report clinical risk factors that may facilitate perioperative risk-reduction strategies to improve outcomes of elective abdominal wall reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

SAGES Foregut Surgery Masters Program: a surgeon's social media resource for collaboration, education, and professional development.

BACKGROUND: Facebook is a popular online social networking platform increasingly used for professional collaboration. Literature regarding use of Facebook for surgeon professional development and education is limited. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has established a Facebook group dedicated to discussion of surgery of the esophagus, stomach, and small intestine-the "SAGES Foregut Surgery Masters Program." The aim of this study is to examine how this forum is used for professional development, education, and quality improvement. METHODS: Member and post statistics were obtained from https://grytics.com , a Facebook group analytics service. All posts added to the Foregut forum since its creation in April 2015 through December 2016 were reviewed and categorized for content and topic. Posts were reviewed for potential identifiable protected health information. RESULTS: As of December 2016, there were 649 total members in the group. There have been a total of 411 posts and 4116 comments with a median of 10.1 comments/post (range 0-72). Posts were categorized as operative technique (64%), patient management (52%), continuing education (10%), networking (10%), or other (6%). Video and/or photos were included in 53% of posts with 4% of posts depicting radiologic studies and 13% with intraoperative photos or videos. An additional 40 posts included links to other pages, such as YouTube, journal articles, or the SAGES website. One post (0.2%) contained identifiable protected health information and was deleted once recognized by the moderators of the group. CONCLUSION: Social media is a unique, real-time platform where surgeons can learn, discuss, and collaborate towards the goal of optimal treatment of surgical disease. Active online surgical communities such as the SAGES Foregut Surgery Masters Program have the potential to enhance communication between surgeons and are a potential innovative adjunct to traditional methods of continuing surgical education. Surgical societies should adopt and promote professional and responsible use of social media.

Viewer discretion advised: is YouTube a friend or foe in surgical education?

BACKGROUND: In the current era, trainees frequently use unvetted online resources for their own education, including viewing surgical videos on YouTube. While operative videos are an important resource in surgical education, YouTube content is not selected or organized by quality but instead is ranked by popularity and other factors. This creates a potential for videos that feature poor technique or critical safety violations to become the most viewed for a given procedure. METHODS: A YouTube search for "Laparoscopic cholecystectomy" was performed. Search results were screened to exclude animations and lectures; the top ten operative videos were evaluated. Three reviewers independently analyzed each of the 10 videos. Technical skill was rated using the GOALS score. Establishment of a critical view of safety (CVS) was scored according to CVS "doublet view" score, where a score of ≥5 points (out of 6) is considered satisfactory. Videos were also screened for safety concerns not listed by the previous tools. RESULTS: Median competence score was 8 (±1.76) and difficulty was 2 (±1.8). GOALS score median was 18 (±3.4). Only one video achieved adequate critical view of safety; median CVS score was 2 (range 0-6). Five videos were noted to have other potentially dangerous safety violations, including placing hot ultrasonic shears on the duodenum, non-clipping of the cystic artery, blind dissection in the hepatocystic triangle, and damage to the liver capsule. CONCLUSIONS: Top ranked laparoscopic cholecystectomy videos on YouTube show suboptimal technique with half of videos demonstrating concerning maneuvers and only one in ten having an adequate critical view of safety. While observing operative videos can be an important learning tool, surgical educators should be aware of the low quality of popular videos on YouTube. Dissemination of high-quality content on video sharing platforms should be a priority for surgical societies.

Achalasia Treatment, Outcomes, Utilization, and Costs: A Population-Based Study from the United States.

BACKGROUND: Randomized trials show that pneumatic dilation (PD) ≥30 mm and laparoscopic myotomy (LM) provide equivalent symptom relief and disease-related quality of life for patients with achalasia. However, questions remain about the safety, burden, and costs of treatment options. STUDY DESIGN: We performed a retrospective cohort study of achalasia patients initially treated with PD or LM (2009 to 2014) using the Truven Health MarketScan Research Databases. All patients had 1 year of follow-up after initial treatment. We compared safety, health care use, and total and out-of-pocket costs using generalized linear models. RESULTS: Among 1,061 patients, 82% were treated with LM. The LM patients were younger (median age 49 vs 52 years; p < 0.01), but were similar in terms of sex (p = 0.80) and prevalence of comorbid conditions (p = 0.11). There were no significant differences in the 1-year cumulative risk of esophageal perforation (LM 0.8% vs PD 1.6%; p = 0.32) or 30-day mortality (LM 0.3% vs PD 0.5%; p = 0.71). Laparoscopic myotomy was associated with an 82% lower rate of reintervention (p < 0.01), a 29% lower rate of subsequent diagnostic testing (p < 0.01), and a 53% lower rate of readmission (p < 0.01). Total and out-of-pocket costs were not significantly different (p > 0.05). CONCLUSIONS: In the US, LM appears to be the preferred treatment for achalasia. Both LM and PD appear to be safe interventions. Along a short time horizon, the costs of LM and PD were not different. Mirroring findings from randomized trials, LM is associated with fewer reinterventions, less diagnostic testing, and fewer hospitalizations.

Wound Morbidity in Minimally Invasive Anterior Component Separation Compared to Transversus Abdominis Release.

BACKGROUND: Transversus abdominis release is a novel approach for myofascial advancement in ventral hernia repair and has been hypothesized to have lower rates of wound complication than anterior component separation. METHODS: Patients who had a ventral hernia repair with either transversus abdominis release or minimally invasive anterior component separation from January of 2010 to January of 2016 were enrolled in this retrospective cohort study. Patient characteristics were collected through chart review. Primary outcomes were operative time and wound complications. Multiple linear/Poisson regression and Fisher's exact test were used to determine statistical significance. RESULTS: Of 142 patients analyzed, 75 subjects underwent Butler minimally invasive anterior component separation and 67 underwent transversus abdominis release. There were no differences in baseline characteristics between groups, except that the anterior component separation group had more immunosuppressed patients (35 percent versus 19 percent). Median operative time for anterior component separation was 6.3 hours versus 6.1 hours for transversus abdominis release (p = 0.6). Overall wound complications did not differ between the groups (p = 0.5). Compared with anterior component separation, transversus abdominis release had a similar incidence of seroma/hematoma (relative risk, 0.9; 95 percent CI, 0.5 to 1.7), wound infection (relative risk, 1.1; 95 percent CI, 0.5 to 2.2), and mesh infection (relative risk, 0.7; 95 percent CI, 0.2 to 3.4). Hernia recurrence was 12 percent for anterior component separation and 6 percent for transversus abdominis release (relative risk, 0.6; 95 percent CI, 0.2 to 1.7). Reoperation was required in 19 percent of anterior component separation and 12 percent of transversus abdominis release subjects (relative risk, 0.5; 95 percent CI, 0.2 to 1.2). CONCLUSIONS: Transversus abdominis release patients had similar operative times, wound complications, reoperations, and hernia recurrences compared with Butler minimally invasive anterior component separation patients. This contemporary comparison helps inform operative decisions for reconstructive surgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.