Journal of Gastrointestinal Surgery最新文献

Background: Gastric peroral pyloromyotomy (G-POP) is a minimally invasive endoscopic technique for the treatment of refractory gastroparesis. Functional luminal imaging probe (FLIP) is an endoscopic tool that measures physiologic parameters of GI sphincters. In this study, FLIP was employed to investigate the association between physiologic measurements of the pylorus with clinical outcomes following G-POP using the Gastroparesis Cardinal Symptom Index (GCSI) to monitor clinical response.

Methods: This is a single-center prospective study of forty-eight gastroparetic patients who underwent G-POP for management of refractory gastroparesis. Cross-sectional area (CSA), pressure, and the distensibility index (DI) of the pylorus were evaluated with FLIP at 40mL and 50mL balloon fill volumes pre- and post-procedurally. GCSI scores were used to monitor clinical symptoms both pre-procedurally and at 6-weeks post-G-POP.

Results: Technical success was achieved in 100% of patients. GCSI scores (0-5) decreased by an average of 0.95 +/- 1.45 points at 6 weeks post-op, with the Nausea/Vomiting and Bloating subscales showing the greatest improvement. The change in DI at 50-mL balloon fill volumes was a statistically significant predictor of symptomatic improvement following the procedure, with ∆DI @ 50mL > 1.5mmHg/mm2 strongly correlated with larger improvements in GCSI (Pearson coefficient 0.544, p = 0.036).

Conclusions: EndoFLIP was not found to be a reliable predictor of clinical success prior to G-POP, however measuring changes pre- and post-procedurally can be used to guide management. Additional investigations are needed to elucidate the relationship between physiologic pyloric sphincter measurements and clinical response to G-POP.

Background: Laparoscopic fundoplication remains the gold standard treatment for gastro-esophageal reflux disease (GERD). However, 10% to 20% of patients experience new, persistent or recurrent symptoms warranting further treatment.

Objective: Potential predictors for the best outcome after laparoscopic fundoplication were tested using a mature prospectively maintained database.

Methods: Data from 894 consecutive patients who underwent primary laparoscopic fundoplication from 1998 to 2015, were interrogated using regression and machine learning models. Pre-operative factors were assessed for influence on post-operative outcomes: heartburn, dysphagia, and satisfaction scores at a median follow-up of 5 years.

Results: Accuracy in predicting heartburn score (range 0-10) assessed using the Root-Mean Square Error (RMSE) was similar for a negative binomial regression model (RMSE=2.39) and for the Least Absolute Shrinkage Support Operator (LASSO) machine learning (ML) model (RMSE=2.34). Multivariate analysis using only patients with complete data (n=221) generated lower error than using mean imputation for patients with missing values. The most predictive variables were male sex for heartburn (β=-1.48; 95%CI=-2.37, -0.6, p=0.001) and dysphagia (β=-4.70; 95%CI=-8.02, -1.39, p=0.006), and percentage of esophageal peristalsis for satisfaction (β=0.63; 95%CI=0.16, 1.10, p=0.009) and dysphagia (β=-1.85; 95%CI=-3.43, -0.27, p=0.02).

Conclusion: Although male sex and degree of intact peristalsis are significant predictors for outcomes after laparoscopic fundoplication, prediction of individual patient outcome was relatively poor, and machine learning prediction models provided only marginal improvement in accuracy. Clinical acumen and a discussion with patients to set realistic postoperative expectations cannot be replaced by regression models or standard machine learning prediction algorithms at the present time.

Introduction: Accountable Care Organizations (ACO) have emerged as a value-based care model; however, their impact on gastrointestinal (GI) cancer care remains poorly defined. Therefore, we sought to investigate the impact of hospital ACO participation on surgical and financial outcomes.

Methods: Patients who underwent GI cancer surgery between 2016 and 2020 were identified from the Medicare Standard Analytic Files. Difference-in-Differences (DID) analysis was performed to examine the impact of hospital ACO participation on surgical outcomes and healthcare expenditures.

Results: A total of 23,357 beneficiaries underwent GI cancer surgery at 2,180 hospitals (ACO participating: n=57, 2.7%). Median patient age was 75 years (IQR: 71-81), most patients were female (n=12,207, 52.3%) and had a CCI score of > 2 (n=14,067, 54.3%). On DID analysis, after adjusting for patient and hospital baseline characteristics, ACO participation was not associated with a reduced risk of complications during the index hospitalization (RRR: 1.03, 95% CI 0.90-1.18; p=0.71), extended length of stay (RRR: 1.04, 95% CI 0.92-1.67; p=0.52), 30-day complications (RRR: 1.96, 95% CI 0.72-1.27; p=0.77), 30-day readmission (RRR: 1.07, 95% CI 0.92-1.25; p=0.96), or 30-day mortality (RRR: 0.96, 95% CI 0.77-1.21; p=0.74). Moreover, ACO participation was not associated with reduction in healthcare costs.

Conclusion: Hospital participation in ACOs was not associated with improved surgical outcomes or a reduction in healthcare costs. There is a need for nuanced, targeted interventions within the ACO framework that address the unique needs of complex surgical patients.