Analysis of Pediatric Clinical Practice Guideline Authors by Gender, Race, and Ethnicity.

Background and Objectives: Clinical practice guidelines (CPGs) have significantly influenced medical practice worldwide. Nevertheless, the authorship of CPGs produced by several medical societies has not been representative of the field and population they address, as women and individuals from racial and ethnic minority groups have been underrepresented as authors. We hypothesized that women and individuals from minoritized racial and ethnic groups would also be underrepresented as authors of CPGs produced by the American Academy of Pediatrics (AAP). Methods: In this cross-sectional study, the gender, race, and ethnic composition of authors and subcommittee participants of AAP-produced CPGs published from January 2010 through May 2023 were analyzed and compared to the 2010 and 2021 U.S. population and 2010 and 2022 U.S. medical school pediatric faculty. Results: Women (39.7%, 127/320 of all positions, and 42.5%, 85/200 of named author positions) and women physicians (35.2%, 101/287 of all positions, and 36.4%, 64/176 of named author positions) were significantly underrepresented-while men and men physicians were significantly overrepresented-from their respective composition in the U.S. Census and pediatric faculty. Women and women physicians from all racial and ethnic groups and men and men physicians from minority racial and ethnic groups were significantly underrepresented-from their respective composition in the U.S. Census and pediatric faculty. No Black man was identified as an author. Conclusions: Medical societies that produce CPGs should be cognizant of these inequities and ensure appropriate authorship diversity.

Incorporation of Simulation in Graduate Medical Education: Historical Perspectives, Current Status, and Future Directions.

Technological advancement and improved training strategies have transformed the healthcare practice environment in the last few decades. Simulation has evolved as one of the leading training models for the next generation of healthcare professionals. Simulation-based training enables healthcare professionals to acquire knowledge and skills in a safe and educationally oriented environment and can be a valuable tool for improving clinical practice and patient outcomes. The field of healthcare simulation has been rapidly growing, and various graduate medical education programs around the world have started incorporating this modality into their curricula. In graduate medical education, simulation-based training helps implement an outcome-based curriculum that tests the trainee's actual skill level as the primary factor for the trainee's competency rather than relying on the current model of a predetermined training period. However, the major challenge revolves around developing an educational curriculum incorporating a simulation-based educational model, understanding the value of this new technology, the overall cost factor, and the lack of adequate infrastructure. Hence, embracing the full potential of simulation technology in graduate medical education curricula requires an innovative approach with participation from institutions and stakeholders.

Gender Representation of Editors at Journals Affiliated with Major U.S. Medical Societies.

Objectives: To assess the gender composition of upper-level specialty-specific editor positions among United States (U.S.) medical society-affiliated journals and to evaluate the equitable inclusion of women and women physicians. Materials and Methods: The gender composition of upper-level (e.g., editor-in-chief, deputy) specialty-specific editor positions among 39 U.S. medical society-affiliated journals as of January 5, 2023, was analyzed. Editor positions below the level of associate editor were excluded. Parity (50:50 representation) and equity (compared with the proportion of practicing physicians in each medical specialty) benchmarks were utilized to determine if women are underrepresented in editor positions. Results: A total of 862 editor positions among 39 journals were assessed. Women held 32.9% (284/862) of positions (95% confidence interval [CI]: 29.9%-36.2%), significantly less than expected based on the U.S. population (p < 0.001). Physicians comprised 90.8% (783/862) of positions, of whom 30.4% (238/783) were women physicians (95% CI: 27.3%-33.7%), significantly less than expected (p < 0.001). Thirty-three (84.6%, 95% CI: 70.3%-92.8%) journals were below parity for women overall, whereas 34 (87.2%, 95% CI: 73.3%-94.4%) were below parity for women physicians. Fourteen (35.9%, 95% CI: 22.7%-51.6%) journals were below equity for women physicians. Notably, 13 (33.3%, 95% CI: 20.6%-49.0%) journals were below both parity and equity for women overall and women physicians. Conclusions: This study reveals mixed results in the equitable inclusion of women in editor positions of journals affiliated with U.S. medical societies. Despite the equitable inclusion of women in editorial roles being a remediable issue, approximately one third of journals affiliated with major U.S. medical societies remain inequitable.

Gender Representation Among Editors of Major Pediatric Journals.

This cross-sectional study analyzes inequities in the gender of editors for 3 major pediatric journals.

Creation of a High-Fidelity, Low-Cost, Intraosseous Line Placement Task Trainer via 3D Printing.

The description of procedural task trainers includes their use as a training tool to hone technical skills through repetition and rehearsal of procedures in a safe environment before ultimately performing the procedure on a patient. Many procedural task trainers available to date suffer from several drawbacks, including unrealistic anatomy and the tendency to develop user-created 'landmarks' after the trainer tissue undergoes repeated manipulations, potentially leading to inappropriate psychomotor skill development. To ameliorate these drawbacks, a process was created to produce a high-fidelity procedural task trainer, created from anatomy obtained from computed tomography (CT) scans, that utilize ubiquitous three-dimensional (3D) printing technology and off-the-shelf commodity supplies. This method includes creating a 3D printed tissue mold capturing the tissue structure surrounding the skeletal element of interest to encase the bony skeletal structure suspended within the tissue, which is also 3D printed. A tissue medium mixture, which approximates tissue in both high-fidelity geometry and tissue density, is then poured into a mold and allowed to set. After a task trainer has been used to practice a procedure, such as intraosseous line placement, the tissue media, molds, and bones are reclaimable and may be reused to create a fresh task trainer, free of puncture sites and manipulation defects, for use in subsequent training sessions.

Gender equity in ergonomics: does muscle effort in laparoscopic surgery differ between men and women?

BACKGROUND: Women surgeons may experience more ergonomic challenges while performing surgery. We aimed to assess ergonomics between men and women surgeons. METHODS: Laparoscopic surgeons from a single institution were enrolled. Demographics and intraoperative data were collected. Muscle groups were evaluated objectively using surface electromyography (EMG; TrignoTM, Delsys, Inc., Natick, MA), and comprised upper trapezius (UT), anterior deltoid, flexor carpi radialis (FCR), and extensor digitorum (ED). Comparisons were made between women (W) and men (M) for each muscle group, assessing maximal voluntary contraction (MVC) and median frequency (MDF). The Piper Fatigue Scale-12 (PFS-12) was used to assess self-perceived fatigue. Statistical analyses were performed using SPSS v26.0, α = 0.05. RESULTS: 18 surgeries were recorded (W:8, M:10). Women had higher activation of UT (32% vs 23%, p < 0.001), FCR (33% vs 16%, p < 0.001), and ED (13% vs 10%, p < 0.001), and increased effort of ED (90.4 ± 18.13 Hz vs 99.1 ± 17.82 Hz). Comparisons were made between W and M for each muscle group, assessing MVC and MDF. CONCLUSIONS: After controlling for surgeon's height and duration of surgery, an increase in muscle activation was seen for women laparoscopic surgeons. Since poor ergonomics could be a major cause of work-related injuries, we must understand differences in ergonomics between men and women and evaluate which factors impact these variations.

Positive association of a women's continuing medical education conference on career advancement and promotion.

Women physicians are underrepresented in leadership positions across medical specialties. Understanding factors that improve women's promotion metrics may lead to career and leadership advancement. This study examined if a woman-centered Continuing Medical Education (CME) conference is associated with differences in productivity metrics toward career advancement. The authors conducted a cross-sectional survey study of women physicians attending a national woman-centered CME conference for professional growth, wellness and networking in September 2019. The survey measured promotion metrics achieved in the year prior to the conference and compared them with previous attendees. Of 425 women attendees of the conference, 389 (91.5%) respondents completed the survey. Respondents were divided into two groups for analysis: first time (FT) attendees, and those that attended the conference previously (PV). In the year preceding the survey, PV attendees were more likely to have published a manuscript as first-author or co-author in a peer-reviewed journal (17.5% vs. 9.7%, p = 0.029), given a talk in their area of practice (48.3% vs. 27.9%, p < 0.001) and to have mentored at least one peer (40.8% vs. 27.5%, p = 0.009) and to have asked for a promotion (15.8% vs. 8.6%, p = 0.033) than FT. As compared to first-time conference attendees, women physicians who previously attended a woman-centered CME conference were more likely to achieve career performance metrics including publications and speaking engagements in the preceding year. This study demonstrated a positive association of Women-centered CME conferences in career advancement metrics for women in medicine and suggests further studies on this and other women-centered CME conferences.

Fertility and Reproductive Health in Women Physicians.

Background: Our aim was to evaluate trends of childbearing during medical training, evaluate issues of infertility, and measure institutionalized barriers to childbearing among women physicians. Materials and Methods: Attendees of a national women physician's leadership conference (Brave Enough Women Physicians Continuing Medical Education Conference) were surveyed during the conference using Qualtrics© (2019 Qualtrics, Provo, UT), in September 2019. Survey data included demographics, training level, and medical specialty. Data related to reproductive health factors, pregnancy status and history, current number of children, medical history related to pregnancy, breastfeeding history, institutional family planning support, and use of previous fertility treatments were collected. Descriptive analyses were done using IBM SPSS v26.0. Results: Three hundred seventy-seven survey participants were included in the study. 10.6% of respondents reported at least one pregnancy during medical school, versus 78.8% as a practicing physician. Of the participants, 25.8% reported having taken off 1 month or less of clinical duties after giving birth, 39.4% reported that their job prevented breastfeeding for the desired length of time, and 52.2% reported significant workplace limitations to breastfeeding. Of them, 25.5% reported having had fertility issues in the past. Fertility drugs (72.9%) was the most common fertility treatment method used, followed by fertility tracking (54.2%). Demands of training (72.9%) and long work hours (61.5%) were the most cited factors in delaying having children as reported by women physicians. Conclusions: This study reported several barriers related to fertility, family planning, and reproductive health among women physicians. Our results highlight the need for a paradigm shift in fertility awareness and institutional support for childbearing during medical training, postgraduate training programs, and in practice for women in medicine.

End-Effector Contact and Force Detection for Miniature Autonomous Robots Performing Lunar and Expeditionary Surgery.

INTRODUCTION: The U.S. Space Force was stood up on December 20, 2019 as an independent branch under the Air Force consisting of about 16,000 active duty and civilian personnel focused singularly on space. In addition to the Space Force, the plans by NASA and private industry for exploration-class long-duration missions to the moon, near-earth asteroids, and Mars makes semi-independent medical capability in space a priority. Current practice for space-based medicine is limited and relies on a "life-raft" scenario for emergencies. Discussions by working groups on military space-based medicine include placing a Role III equivalent facility in a lunar surface station. Surgical capability is a key requirement for that facility. MATERIALS AND METHODS: To prepare for the eventuality of surgery in space, it is necessary to develop low-mass, low power, mini-surgical robots, which could serve as a celestial replacement for existing terrestrial robots. The current study focused on developing semi-autonomous capability in surgical robotics, specifically related to task automation. Two categories for end-effector tissue interaction were developed: Visual feedback from the robot to detect tissue contact, and motor current waveform measurements to detect contact force. RESULTS: Using a pixel-to-pixel deep neural network to train, we were able to achieve an accuracy of nearly 90% for contact/no-contact detection. Large torques were predicted well by a trained long short-term memory recursive network, but the technique did not predict small torques well. CONCLUSION: Surgical capability on long-duration missions will require human/machine teaming with semi-autonomous surgical robots. Our existing small, lightweight, low-power miniature robots perform multiple essential tasks in one design including hemostasis, fluid management, suturing for traumatic wounds, and are fully insertable for internal surgical procedures. To prepare for the inevitable eventuality of an emergency surgery in space, it is essential that automated surgical robot capabilities be developed.

Surgical and clinical outcomes comparison of mesh usage in laparoscopic hiatal hernia repair.

PURPOSE: Use of absorbable mesh in hiatal hernia (HH) repair has been shown to decrease recurrence rates. Our aim was to compare the efficiency of three meshes in relation to the surgical outcomes of patients undergoing HH repair. METHODS: A single-institution retrospective review was done for adult patients who underwent HH repair with mesh between 2004 and 2016. Demographics, intra-operative, and cost data were collected. Esophageal symptoms and medication use were assessed pre- and postoperatively. Surgical outcomes were evaluated at 6-, 12-months, and long-term follow-up. Three groups were created based on type of mesh: human tissue matrix (HTM), biosynthetic mesh (BIOS), or porcine tissue matrix (PTM). Comparisons were performed between groups using SPSS v.26.0 and PC SAS v9.4, α = 0.05. RESULTS: 292 patients were included (HTM:N = 162, BIOS:N = 83, PTM:N = 47). Majority were male (60.4%), Caucasian (93.2%), median age, and BMI of 59 years [25-90 years] and 29.19 kg/m2 [18.9-58.0 kg/m2], respectively. 69% had a large HH. Median follow-up time was 27 months [1-166 months]. Overall recurrence rate was 39%, being significantly lower in BIOS at long-term (HTM: 31%, BIOS: 17%, PTM: 19%, p = 0.038). All groups had a significant postoperative improvement of esophageal symptoms, all p < 0.001. 65-70% of the cost difference between the groups was incurred by the cost of mesh alone (HTM: $1072, BIOS: $548, PTM: $1295), with the remainder attributable to the surgery itself. CONCLUSION: While outcomes of the three mesh groups were similar in our data, there was a significant difference in mesh cost. Surgeon and hospital preference still play a role in choosing the type of mesh used; however, knowledge of the individual mesh cost will help surgeons make better informed decisions.

How high is too high? Extensive mediastinal dissection in patients with hiatal hernia repair.

BACKGROUND: Approximately 10% of patients receiving anti-reflux procedures present with shortened esophagus. Collis gastroplasty (CG) is the current gold standard for esophageal lengthening, but mediastinal esophageal mobilization without gastroplasty may be an alternative approach. This study assesses preoperative and intraoperative hernia characteristics and mediastinal dissection impact in patients with large hiatal hernia repair (HHR). METHODS: A single-institution, prospectively collected database was reviewed for adults who underwent laparoscopic HHR with mesh and anti-reflux surgery between 2005 and 2016, hernia ≥ 5 cm. Preoperative hernia and follow-up were assessed using upper endoscopy and barium swallow. Intraoperative hernia characteristics were collected from the operative note. Esophageal symptom scores were collected pre- and postoperatively. Analyses were conducted using SPSS v26.0. RESULTS: Among 662 patients who had anti-reflux surgery in this period, a total of 205 patients who underwent HHR with mesh met the inclusion criteria and were included in study. Mean age was 61.7 ± 13.6 years, and majority of patients were female and Caucasian. Mean BMI was 29.9 ± 6.0 kg/m2. Median hernia size was 6.5 cm [5.0-12.0 cm], and intra-thoracic stomach had a prevalence of 21.9%. Analysis of preoperative barium swallow revealed an average of elevated gastroesophageal junction above the diaphragm of 4.10 ± 1.67 cm. Radiographically, average hernia size was 6.34 ± 1.93 cm and 6.38 ± 1.92 cm in the anterior-posterior and obliquus view, respectively. Median follow-up time was 2.7 years [1-9 years]. Esophageal symptoms improved in all patients (p < 0.05). 45% of patients had radiographic recurrence, but only four presented symptomatic or were on PPI. CONCLUSIONS: CG has been the standard for ensuring adequate esophageal length prior to anti-reflux surgery. Our results support that CG is unnecessary in the majority of cases, and extensive mediastinal dissection was successfully used instead of CG with durable, long-term outcomes. Extended mediastinal dissection may mitigate CG risks in patients requiring additional intra-abdominal esophagus.

Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis.

BACKGROUND: We aimed to examine the outcomes and utilization of different hiatal hernia repair (HHR) approaches in elective and emergent/urgent settings. METHODS: Vizient 2015-2017 database was queried for adult patients who underwent HHR. Patients were grouped into open (OHHR), laparoscopic (LHHR), or robotic-assisted (RHHR), and further stratified by elective or urgent status and severity of illness at admission. Surgical outcomes and costs were compared across all groups. Statistical analysis were done using SPSS v.25.0. RESULTS: 9171 adults were included (OHHR N = 1534;LHHR N = 6796;RHHR N = 841). LHHR was the most utilized approach (74.1%), followed by OHRR (16.7%) and RHHR (9.2%). OHHR was employed three times as frequently in U settings, compared to elective. Overall, OHHR had longer mean length of stay (LOS; 9.41 vs. < 4 days) and higher postoperative complication rates (8.8% vs < 3.8%), mortality (2.7% vs < 0.5%) and mean direct cost ($27,842 vs < $10,407), when compared to both LHHR and RHHR, all p < 0.05. Analysis of mild to severely ill elective cases demonstrated LHHR and RHHR to be better than OHHR regarding complications (p < 0.05), cost (p < 0.001) and LOS (p < 0.013); there were insufficient extremely ill elective patients for meaningful analysis. In the urgent setting, minimally invasive approaches predominate, overtaken by OHHR only for the extremely ill. Despite the urgent setting, for mild-moderately ill patients, OHHR was statistically inferior to both LHHR and RHHR for LOS (p = 0.002, p < 0.0001) and cost (p = 0.0133, p < 0.001). In severe-extremely ill patients, despite being more utilized, OHHR was not superior to LHHR; in fact, complication, cost, and mortality trends (all p > 0.05) favored LHHR. CONCLUSION: Our analysis demonstrated LHHR to currently be the most employed approach overall. LHHR and RHHR were associated with lower cost, decreased LOS, complications, and mortality compared to OHHR, in all but the sickest of patients. Patients should be offered minimally invasive HHR, even in urgent/emergent settings, if technically feasible.

Citizenship Tasks and Women Physicians: Additional Woman Tax in Academic Medicine?

Background: Our aim was to evaluate differences in reported citizenship tasks among women physicians due to personal or demographic factors and time spent performing those tasks for work. Materials and Methods: Attendees of a national women physician's leadership conference (Brave Enough Women Physicians Continuing Medical Education Conference) replied to a survey using Qualtrics© (2019 Qualtrics, Provo, UT), in September 2019. Data collected included age, race, ethnicity, training level, medical practice, specialty, current annual total compensation, educational debt, and number of children. We asked about employment-related citizenship tasks, including time spent on those activities, and perceived obligation to volunteer for citizenship tasks. Descriptive and impact of demographic factors on those opinions were evaluated using IBM SPSS v26.0. Results: Three hundred eighty-nine women physicians replied. When compared with their younger counterparts, women physicians older than 49 years stated they feel obligated to volunteer for these tasks because of their gender (p = 0.049), and were less likely able to decide which citizenship tasks they were assigned to (p = 0.021). Furthermore, a higher proportion of women of color physicians perceived race as a factor in feeling obligated to volunteer for work-related citizenship tasks, when compared with White women physicians (p < 0.001). Additionally, nearly 50% of women physicians reported spending more time on citizenship tasks than their male counterparts. Conclusion: Our findings suggest that gender, race, and age may play a role in the decision of women physicians to participate in work-related citizenship tasks. To our knowledge, this is the first study to report on work-related citizenship tasks as described by women physicians. Still, an in-depth assessment on the role citizenship tasks play in the culture of healthcare is warranted.

3D printing of face shields to meet the immediate need for PPE in an anesthesiology department during the COVID-19 pandemic.

BACKGROUND: Anesthesia providers are at risk for contracting COVID-19 due to close patient contact, especially during shortages of personal protective equipment. We present an easy to follow and detailed protocol for producing 3D printed face shields and an effective decontamination protocol, allowing their reuse. METHODS: The University of Nebraska Medical Center (UNMC) produced face shields using a combination of 3D printing and assembly with commonly available products, and produced a simple decontamination protocol to allow their reuse. To evaluate the effectiveness of the decontamination protocol, we inoculated bacterial suspensions of E. coli and S. aureus on to the face shield components, performed the decontamination procedure, and finally swabbed and enumerated organisms onto plates that were incubated for 12-24 hours. Decontamination effectiveness was evaluated using the average log10 reduction in colony counts. RESULTS: Approximately 112 face shields were constructed and made available for use in 72 hours. These methods were successfully implemented for in-house production at UNMC and at Tripler Army Medical Center (Honolulu, Hawaii). Overall, the decontamination protocol was highly effective against both E. coli and S. aureus, achieving a ≥4 log10 (99.99%) reduction in colony counts for every replicate from each component of the face shield unit. DISCUSSION: Face shields not only act as a barrier against the soiling of N95 face masks, they also serve as more effective eye protection from respiratory droplets over standard eye shields. Implementation of decontamination protocols successfully allowed face shield and N95 mask reuse, offering a higher level of protection for anesthesiology providers at the onset of the COVID-19 pandemic. CONCLUSIONS: In a time of urgent need, our protocol enabled the rapid production of face shields by individuals with little to no 3D printing experience, and provided a simple and effective decontamination protocol allowing reuse of the face shields.

Elective robotic-assisted bariatric surgery: Is it worth the money? A national database analysis.

BACKGROUND: This study sought to evaluate surgical outcomes, cost, and opiate utilization between patients who underwent either laparoscopic or robotic-assisted bariatric procedures, including sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). METHODS: The Vizient administrative database was queried for patients admitted with mild to moderate severity of illness scores who underwent elective laparoscopic (L) and robotic-assisted (R) SG or RYGB from October 2015 through December 2018. Patients were grouped according to surgical approach for each bariatric procedure. Rates of overall complications, mortality, 30-day readmission, LOS, total direct cost, and opiate utilization were collected. Comparisons were performed within each bariatric procedure, between laparoscopic and robotic approaches, using IBM SPSS v.25.0, α = 0.05. RESULTS: For SG, a total of 84,034 patients were included (LSG:N = 78,405; RSG:N = 5639). There was no significant difference in rates of overall complications (LSG:0.5%, RSG:0.4%; p = 0.872), mortality (LSG:<0.01%, RSG:<0.01%; p = 0.660), and 30-day readmissions (LSG: 0.5%, RSG:0.5%; p = 0.524). Average LOS was 1.65 ± 1.07 days for LSG and 1.77 ± 1.29 days for RSG (p=<0.001). Robotic approach had a significantly higher direct cost (LSG: $6505 ± 3,200, RSG: $8018 ± 3849; p=<0.001). Rate of opiate use was 97.3% for both groups (p=>0.05). For RYGB, 36,039 patients met the inclusion criteria (LRYGB:N = 33,053; RRYGB:N = 2986). There was no significant difference in rates of overall complications (LRYGB: 1.4%, RRYGB:1.3%; p = 0.414) or mortality (LRGYB:<0.01%, RRYGB: <0.01%; p = 0.646). Robotic approach was associated with a lower 30-day readmission rate (LRYGB: 1.3%, RRYGB:<0.01%; p=<0.001). Average LOS was 2.1 ± 2.18 days for LRYGB and 2.18 ± 3.78 days for RRYGB (p = 0.075). Robotic approach had a significantly higher direct cost (LRYGB:$8564 ± 5,350, RRYGB: $10,325 ± 7689; p=<0.001) and rate of opiate use (LRYG:95.75%, RRYGB:96.85%; p = 0.005). CONCLUSION: Our study found the direct cost of RSG to be significantly higher than LSG with no added clinical benefit, therefore, universal use of the robotic platform for routine SG cases remains difficult to justify. While the direct cost of RRYGB was also higher than LRYGB, the significantly lower readmission rate associated with robotic approach may help to offset the financial discrepancy and warrant its use.

Current state of robotic use in inguinal hernia repair: a survey of minimally invasive hernia surgeons.

Little is known about how robot technology is employed by surgeons in minimally invasive surgery (MIS). We evaluated the needs of established robotic surgeons and of those who are new to this technology. A survey was designed and sent electronically to MIS surgeons. Questions included fellowship training, area of expertise, experience with robotic simulation and in clinical use, mentorship, likelihood of switching to a different approach, and expectations for the robot. Descriptive analysis was conducted using STATA/MP 15.1. 189 interviewees self-identified as hernia surgeons. 73.8% had additional fellowship, with majority practicing for 3-6 years (54%). Nearly 40% were MIS surgeons (N = 73), followed by general surgery (34.4%), and bariatrics (13.8%). 146 interviewees (77.7%) have used the daVinci® in clinical scenarios. Among robotic surgeons, majority were performing less than ten robotic cases per month. Inguinal hernia repairs were the leading procedures (49%), followed by foregut-related (19.5%), and colorectal-related surgeries (17.5%). Nearly 40% of surgeons stated inguinal hernia repairs to be the most often performed procedure using the robot. Nearly 40% of open and laparoscopic hernia surgeons are willing to adopt robotic-assisted procedures for their inguinal hernia repairs. Level 1 evidence (47.9%) and cost (24.1%) were the most pressing needs for robotic research. Majority of interviewees have used the daVinci® in clinical settings. Hernia repair remains the primary application of the robot in general surgery, among specialized surgeons. Over 40% of hernia surgeons are interested in switching to robotic technology over its open or laparoscopic counterparts.

Achalasia Treatment in Patients over 80 Years of Age: A Multicenter Survey.

Background and Aims: Laparoscopic Heller's myotomy (LHM), per oral endoscopic myotomy, and pneumatic dilatation are well-established methods to treat achalasia. The ideal treatment algorithm in elderly patients is, however, still elusive. This multicenter study aims to evaluate outcomes and changes in routine therapeutic options in patients >80 years of age. Methods: Worldwide high-volume centers for the treatment of achalasia were surveyed. Therapeutic options and outcomes in patients >80 years of age were reviewed. Results: Eighty-five (54% men, mean age 84 ± 4 years) patients were studied. Primary treatment was endoscopic in 43 (51%) patients, surgical in 39 (46%) patients (30 LHM, 9 cardioplasty + gastrectomy), and medical in 3 (4%) patients. Four centers tailored treatment based on age (14% of the patients). Secondary treatment was necessary in 34 (40%) patients: 30 of them with endoscopic treatment as primary treatment. LHM was performed in 20 patients and endoscopic treatment in 14 patients. A total of 11 (13%) patients had complications after LHM. Seven had LHM or cardioplasty + gastrectomy as primary treatment. Four had LHM as secondary treatment. The mean time of hospitalization was 4 ± 2 days for those who did not have complications, and 7 ± 6 days for those who had complications. Conclusions: Most specialized centers do not tailor treatment based on advanced age. Treatment of the oldest-old patients should be based solely on their physiologic and mental health, not their age. Endoscopic treatment has a high rate of recurrence and gastrectomy a high rate of complications in his population. LHM seems to be a safe option with good outcomes in this population.