Summary: Background: Minimally invasive hiatal hernia (HH) repair is the gold standard for correcting mechanical defects of the crural diaphragm due to its safety and favorable clinical outcomes (i.e., relief of patient symptoms). However, several operative factors, including HH size, may negatively affect the postoperative course. We sought to determine if an increase in HH size was associated with an increased risk of perioperative complications, ICU admission, or hospital readmissions after minimally invasive HH repair. Methods: We conducted a retrospective observational cohort study of patients who underwent primary HH repair by an experienced foregut surgeon between September 2016 and July 2023. Four groups were defined based on the percentage of stomach at the thorax determined during surgery (small-HH: <25%, moderate-HH: 25–49%, large-HH: 50–74%, and intrathoracic stomach [ITS]: ≥75%). Covariates were compared between the groups, and logistic regressions were performed to identify factors associated with postoperative morbidity. Results: A total of 391 patients (73.7% female; mean age, 64.4 ± 12.5 years) comprised the groups: small-HH (n = 160), moderate-HH (n = 63), large-HH (n = 64), and ITS (n = 104). Patients with ITS were older (p < 0.001), had longer operations (p < 0.001), greater blood loss (p < 0.001), longer hospital stays (p < 0.001), and an increased risk of early postoperative complications (aOR 2.59 [CI95: 1.28–5.25], p = 0.009) and ICU admission (aOR 13.3 [CI95: 3.10–57.06], p < 0.001). Conclusion: An increase in HH size was associated with an increased risk of early postoperative complications, ICU admission, and a trend toward higher 30- and 90-day hospital readmissions, likely due to the progressive nature of the disease.

Background: The Johnson–DeMeester composite score (DMS) is the historical gold standard for diagnosing gastroesophageal reflux disease (GERD). The Lyon Consensus outlines criteria for diagnosing GERD by pH monitoring, defining normal acid exposure time (AET) as < 4% and pathological as > 6%, presenting diagnostic uncertainty from 4 to 6%. We aimed to (i) calculate the proportion of borderline studies defined by total AET alone that are reclassified as normal or pathological by the DMS, (ii) determine the importance of supine AET for reclassification, and (iii) propose a new classification system using a composite score that considers positional changes. Methods: This single-center, retrospective, observational study analyzed data from patients with an overall total AET from 2 to 6% on 48-h pH monitoring (Bravo pH capsule). Preselected predictors (supine and upright AET) were included in a model to create a composite score (i.e., pHoenix score) using the regression coefficients. The model was internally validated, and discriminative ability was tested against the DMS and compared to the total AET. Results: We identified 114 patients (80 [70.2%] women; median age, 55 years). Using the total AET, 26 (22.8%) were classified as normal and 88 (77.2%) as borderline; however, using the DMS, 45 (39.5%) were classified as normal and 69 (60.5%) as pathological. The new pHoenix score demonstrated strong discriminative ability (AUC: 0.957 [95% CI 0.917, 0.998]) with high sensitivity and specificity (lower threshold, 94.4% and 79.2%; upper threshold, 87 and 95.8%). Compared to the total AET alone, the pHoenix score significantly decreased the proportion of inconclusive cases (77.2% vs. 13.2%, p < 0.001). Conclusion: Total AET has low sensitivity to identify pathological reflux as it disregards supine versus upright reflux. The pHoenix score improves the distinction between normal and pathological cases and reduces ambiguity, offering an alternative approach to diagnosing GERD that addresses the limitations of using total AET alone or the DMS. Graphical

During the COVID-19 pandemic, weight loss programs rapidly transitioned to a virtual model, replacing in-person clinic visits. We sought to compare the observed weight loss and adherence to treatment between patients referred for intensive behavioral therapy (IBT) who were treated via telemedicine and those treated in person. After IRB approval, we conducted a retrospective observational study of patients referred for clinical bariatric IBT between January 2019 and June 2021 who were followed in person or via telemedicine. The primary endpoint was the percentage of excess BMI loss (EBL%); secondary endpoints included treatment adherence, duration of follow-up, and number of completed visits. During the study period, 139 patients were seen for at least one IBT session for weight management: 62 were followed up in person (IP) and 77 via telemedicine (TM). The mean age, baseline BMI, and follow-up duration between the groups were similar. In the IP and TM groups, the EBL% was -24.7 ± 24.7 and -22.7 ± 19.5 (P = 0.989) and loss to follow-up after the first visit was 27.4% and 19.5% (P = 0.269), respectively. For the management of obesity, weight loss programs delivered via telemedicine can achieve similar outcomes to those provided via classical in-person visits. This study suggests that the integration of telecare into clinical practice in bariatric medicine should be considered in the future. Emerging technologies may allow adequate patient follow-up in multiple scenarios, specifically non-critical chronic disorders, and bring unanticipated benefits for patients and healthcare providers.

Activated pepsin (pepA) in bronchoalveolar lavage (BAL) fluid may be a biomarker of gastric aspiration. We sought to i) evaluate the association of pepA in BAL fluid with acute cellular rejection (ACR) in a cohort of lung transplant recipients (LTRs), ii) assess the association between pepA and isolation of typical gastrointestinal microorganisms from BAL fluid, and iii) explore the accuracy of using pepA concentration as a biomarker of ACR. After IRB approval, we conducted a retrospective observational study analyzing posttransplant BAL fluid samples and concomitant transbronchial biopsies (TBBs) obtained from LTRs who underwent at least two routine surveillance bronchoscopies between March 2020 and August 2022. A total of 349 BAL samples and paired TBBs from 120 LTRs were analyzed. Thirty-five LTRs (29.2%) had at least one episode of ACR during the study period. Most recipients (83.3%) had detectable pepA in at least one BAL sample. LTRs with detection of pepA any time after LTx had a higher likelihood of ACR (OR 9.79 [CI95: 1.26-79.26], P = 0.009). The pepA concentration trended higher as the histological grade of ACR increased, and a cut-off of >2.45 ng/mL provided a sensitivity of 63.3% and specificity of 57.3% to detect ACR. In conclusion, detectable pepA in BAL samples is common among LTRs and was associated with the occurrence of ACR. Furthermore, the BAL pepA concentration trended higher as the histological ACR grade increased; however, this biomarker has several drawbacks if used alone for the detection of ACR, and cautious interpretation is recommended.