Konstantinos P. Economopoulos

Background: POEM has been shown to have excellent safety and efficacy in adults. We report our experience with the POEM for the treatment of achalasia in elderly patients (65 y or older). Methods: This is a single-institution retrospective cohort study over a span of 4 years. The primary outcome was clinical success, defined as improvement in dysphagia score to ≤1 without need for a reintervention in the first 6 months. Secondary outcomes included technical success, rate of reintervention, and postprocedural complications. Results: A total of 51 patients (male 52.9%, mean age: 72.9±6.2 y; range 65 to 91 y) underwent POEM for treatment of achalasia. Most patients [n=27 (52.9%)] had achalasia type II, while 13 (25.5%) had achalasia type I and 11 (21.6%) had achalasia type III. Technical success was achieved in 100% of patients (n=51), and clinical success was achieved in 96.1% of patients (n=49). The median dysphagia score improved significantly from 3 (IQR=1 to 3) preprocedure to 0 (IQR=0 to 0) at the most recent follow-up ( P P <0.001). Reintervention due to recurrence of symptoms was required in 2 patients (3.9%) during a mean length of follow-up of 9 months (range: 1 to 37 mo). Conclusion: POEM is a safe, effective, and durable treatment for all types of achalasia in elderly patients.

Background Treatment of Zenker’s diverticulum (ZD) has been revolutionized with the introduction of endoscopic techniques. Z-POEM has been shown to have excellent safety and efficacy. We report our experience with the Z-POEM for the treatment of ZD. Methods This is a single-institution retrospective study from 2020 to 2024. The primary outcome was clinical success, defined as improvement in dysphagia score to ≤ 1 without need for a reintervention the first 6 months. Secondary outcomes included technical success, rate of reintervention, and post-procedural complications. Results A total of 32 patients (male 62.5%, mean age 74.2 ± 10.7 years) underwent Z-POEM for treatment of Zenker’s diverticulum. The mean diverticulum size was 26.7 ± 9.9 mm. The American Society of Anesthesiologists (ASA) grade was 3 in 56.3% of patients; the rest of the patients were ASA grade 2. Technical success was achieved in 100% of patients (n = 32) and clinical success was achieved in 96.9% of patients (n = 31). The mean procedure time was 48.6 ± 19.1 min. More than two thirds of the patients (68.8%) were discharged home the same day. One patient developed atrial fibrillation postprocedurally. Mean dysphagia scores improved from 1.5 ± 0.8 before the procedure to 0.09 ± 0.3 after the procedure at most recent follow-up (p < 0.001). Mean regurgitation scores improved from 2.3 ± 1.2 before the procedure to 0.13 ± 0.3 after the procedure at most recent follow-up (p < 0.001). Reintervention due to recurrence of symptoms was required in six patients (18.8%) during a mean length of follow-up of 10.8 months (range 1 to 43 months). Most of the reinterventions (80%) were required after 17 months from the initial Z-POEM. Conclusions Z-POEM is a safe, effective, and durable treatment for Zenker’s diverticulum, but reoperation is needed in 1 out of 5 patients in the short term.

Background Primary bariatric surgery is associated with moderate-to-high risk of venous thromboembolic events (VTE); however, the risk for revisional surgery lacks granularity. Our primary objective was to define the risk of VTE following revisional Roux-en-Y gastric bypass (RYGB) compared to primary RYGB. Methods Adults who underwent primary or revision/conversion RYGB between January 1, 2015, and December 31, 2019, with a BMI ≥ 35 kg/m² were identified in a bariatric specific database. VTE was defined as pulmonary embolus and/or deep venous thrombosis. Thirty-day VTE and transfusion rates were compared between the two groups using propensity score matching of 3:1. Results Primary RYGB was performed in 197,186 (92.4%) patients compared to 16,144 (7.6%) in the revisional group. Patients in the revisional group had fewer comorbidities than those undergoing primary RYGB. In the matched cohort of 64,258 procedures, there were 48,116 (74.9%) primary RYGB cases compared to 16,142 (25.1%) RYGB revisions. The rate of VTE was similar in the revisional surgery group compared to the propensity matched primary RYGB group (0.4% vs. 0.3%, p > 0.580); however, transfusion was more common in the revisional group (1.4% vs. 1.0%, p = 0.005). Revisional group had higher rates of readmission, reoperation, increased length of stay, and operation length ≥ 180 min compared to matched primary RYGB group (p < 0.001). Conclusions VTE rates for both primary and revisional RYGB are similar. Revisional RYGB cases impose increased risk of bleeding among other outcomes. Thus, identifying those at higher risk of complications is critical.

Inguinal hernia repair (IHR) is one of the most common operations in general surgery, with more than 750 000 performed annually in the US.¹ Urinary retention is common following IHR, but the reported incidence in the literature varies extensively from 0.5% to 40%,² making it difficult to quantify the clinical importance of this complication. Furthermore, the data supporting these claims have historically been derived from single-institution, retrospective studies.

Liver transplantation (LT) is the only potentially curative option for children with unresectable hepatocellular carcinoma (HCC). We performed a systematic review of the MEDLINE, Scopus, Cochrane Library, and Web of Science databases (end-of-search date: 31 July 2020). Our outcomes were overall survival (OS) and disease-free survival (DFS). We evaluated the effect of clinically relevant variables on outcomes using the Kaplan–Meier method and log-rank test. Sixty-seven studies reporting on 245 children undergoing LT for HCC were included. DFS data were available for 150 patients and the 1-, 3-, and 5-year DFS rates were 92.3%, 89.1%, and 84.5%, respectively. Sixty of the two hundred and thirty-eight patients (25.2%) died over a mean follow up of 46.8 ± 47.4 months. OS data were available for 222 patients and the 1-, 3-, and 5-year OS rates were 87.9%, 78.8%, and 74.3%, respectively. Although no difference was observed between children transplanted within vs. beyond Milan criteria (p = 0.15), superior OS was observed in children transplanted within vs. beyond UCSF criteria (p = 0.02). LT can yield favorable outcomes for pediatric HCC beyond Milan but not beyond UCSF criteria. Further research is required to determine appropriate LT selection criteria for pediatric HCC.

Background There is currently no consensus regarding the optimal type of peritoneal dialysis catheter (PDC). We compared the outcomes of PDCs according to the number of cuffs, intercuff and intraperitoneal segment shape, and presence of a weighted tip. Methods A systematic review of the literature was performed using the MEDLINE and Cochrane Library databases (end-of-search date: October 16th, 2019). We included studies comparing double-cuff vs. single-cuff, swan-neck vs. straight-neck, coiled-tip vs. straight-tip, and weighted vs. non-weighted PDCs for the outcomes of interest. We performed meta-analyses using the random-effects model. We assessed the risk of bias using the Newcastle–Ottawa scale and the Cochrane Collaboration’s Tool. Results In total, 38 studies were identified, of which 20 were randomized controlled trials (RCTs) and 18 were observational studies. No statistically significant differences were detected between double-cuff vs. single-cuff, swan-neck vs. straight-neck, and coiled-tip vs. straight tip PDCs in any of the outcomes of interest. Weighted catheters were associated with significantly lower rates of tunnel infection (relative risk [RR] 0.52, 95% confidence interval [CI] 0.31–0.95, p = 0.03), migration (RR 0.07, 95% CI 0.03–0.16, p < 0.001), drainage failure (RR 0.62, 95% CI 0.39–0.96, p = 0.03), cuff extrusion (RR 0.40, 95% CI 0.21–0.74, p < 0.001), and complication-related removal (RR 0.53, 95% CI 0.44–0.64, p < 0.001). Discussion Among the different types of PDCs, weighted catheters result in lower complication rates and superior long-term outcomes compared to non-weighted catheters. Other aspects of the catheter design do not significantly affect PDC outcomes. Protocol registration PROSPERO 2020 CRD42020158177. Graphic abstract

Single-anastomosis duodenoileal bypass with sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) was developed as a bariatric operation with reduced overall morbidity and lasting weight loss results. We performed a systematic review of the literature, including 14 studies reporting on weight loss, comorbidity resolution, postoperative complications, and nutritional deficiencies following SADI-S. Twelve months after SADI-S, the mean total body weight lost ranged from 21.5 to 41.2%, with no weight regain being observed after 24 months. The comorbidity resolution rate was 72.6% for diabetes, 77.2% for dyslipidemia, and 59.0% for hypertension cases. The need for reoperation was the most common postoperative complication. While several patients developed nutrient deficiencies, SADI-S seems to be an overall safe and effective bariatric operation. Graphical abstract

Background: No consensus currently exists regarding the optimal approach for peritoneal dialysis catheter placement. We aimed to compare the outcomes of percutaneous and surgical peritoneal dialysis catheter placement. Methods: A systematic review of the literature was performed using the MEDLINE, Cochrane Library, and Scopus databases (end-of-search date: August 29th, 2020). We included studies comparing percutaneous (blind, under fluoroscopic/ultrasound guidance, and “half-perc”) and surgical peritoneal dialysis catheter placement (open and laparoscopic) in terms of their infectious complications (peritonitis, tunnel/exit-site infections), mechanical complications (leakage, inflow/outflow obstruction, migration, hemorrhage, hernia, bowel perforation) and long-term outcomes (malfunction, removal, replacement, surgery required, and mortality). Results: Thirty-four studies were identified, including thirty-two observational studies (twenty-six retrospective and six prospective) and two randomized controlled trials. Percutaneous placement was associated with significantly lower rates of tunnel/exit-site infection [relative risk (RR) 0.72, 95% confidence interval (CI) 0.56–0.91], catheter migration (RR 0.68, 95% CI 0.49, 0.95), and catheter removal (RR 0.73, 95% CI 0.60–0.88). The 2-week and 4-week rates of early tunnel/exit-site infection were also lower in the percutaneous group (RR 0.45, 95% CI 0.22–0.93 and RR 0.41, 95% CI 0.27–0.63, respectively). No statistically significant difference was observed regarding other outcomes, including catheter survival and mechanical complications. Conclusion: Overall, the quality of published literature on the field of peritoneal dialysis catheter placement is poor, with a small percentage of studies being randomized clinical trials. Percutaneous peritoneal dialysis catheter placement is a safe procedure and may result in fewer complications, such as tunnel/exit-site infections, and catheter migration, compared to surgical placement. Protocol registration: PROSPERO CRD42020154951. Graphic

Purpose To explore whether targeted next generation sequencing (NGS) of liquid biopsy in advanced non-small cell lung cancer (NSCLC) could potentially overcome the innate problems that arise with standard tissue biopsy, like intratumoral heterogeneity and the inability to obtain adequate samples for analysis. Methods The Scopus, Cochrane Library, and MEDLINE (via PubMed) databases were searched for studies with matched tissue and liquid biopsies from advanced NSCLC patients, analyzed with targeted NGS. The number of mutations detected in tissue biopsy only, liquid biopsy only, or both was assessed and the positive percent agreement (PPA) of the two methods was calculated for every clinically relevant gene. Results A total of 644 unique relevant articles were retrieved and data were extracted from 38 studies fulfilling the inclusion criteria. The sample size was composed of 2000 mutations tested in matched tissue and liquid biopsies derived from 1141 patients. No studies analyzed circulating tumor cells. The calculated PPA rates were 53.6% (45/84) for ALK, 53.9% (14/26) for BRAF, 56.5% (13/23) for ERBB2, 67.8% (428/631) for EGFR, 64.2% (122/190) for KRAS, 58.6% (17/29) for MET, 54.6% (12/22) for RET, and 53.3% (8/15) for ROS1. We additionally recorded data for 65 genes that are not recommended by current guidelines for mutational testing. An extra category containing results of unspecified genes was added, with a PPA rate of 55.7% (122/219). Conclusion Despite many advantages, liquid biopsy might be unable to fully substitute its tissue counterpart in detecting clinically relevant mutations in advanced NSCLC patients. However, it may serve as a helpful tool when making therapeutic decisions. More studies are needed to evaluate its role in everyday clinical practice.