Ezra N. Teitelbaum

That's like an act of suicide patients' attitudes toward deactivation of implantable defibrillators.

ObjectiveTo understand potential patient barriers to discussions about implantable cardioverter defibrillator (ICD) deactivation in patients with advanced illness.DesignQualitative focus groups.ParticipantsFifteen community-dwelling, ambulatory patients with ICDs assigned to focus groups based on duration of time since implantation and whether they had ever received a shock from their device.ApproachA physician and a social worker used a predetermined discussion guide to moderate the groups, and each session was audiotaped and subsequently transcribed. Transcripts were analyzed using the method of constant comparison.ResultsNo participant had ever discussed deactivation with their physician nor knew that deactivation was an option. Patients expressed a great deal of anxiety about receiving shocks from their device. Participants discussed why they needed the device and expressed desire for more information about the device; however, they would not engage in conversations about deactivating the ICD. One patient described deactivation “like an act of suicide” and all patients believed that the device was exclusively beneficial. Patients also expressed a desire to have their physician make the decision about deactivation.ConclusionsNone of the patients in our study knew that they might need to deactivate their ICD as their health worsens. These community-dwelling outpatients were not willing to discuss the issue of ICD deactivation and their attitudes about deactivation might impede patients from engaging in these conversations. These findings are in contrast to findings in other advance care planning research and may be related to the unique nature of the ICD.

It's Like Crossing a Bridge Complexities Preventing Physicians from Discussing Deactivation of Implantable Defibrillators at the End of Life

OBJECTIVETo understand potential barriers to physician-initiated discussions about Implantable Cardioverter Defibrillator (ICD) deactivation in patients with advanced illness.DESIGNQualitative one-on-one interviews.PARTICIPANTSFour electrophysiologists, 4 cardiologists, and 4 generalists (internists and geriatricians) from 3 states.APPROACHClinicians were interviewed using open-ended questions to elicit their past experiences with discussing deactivating ICDs and to determine what barriers might impede these discussions. Transcripts of these interviews were analyzed using the qualitative method of constant comparison.RESULTSAlthough many physicians believed that conversations about deactivating ICDs should be included in advance care planning discussions, they acknowledged that they rarely did this. Physicians indicated that there was something intrinsic to the nature of these devices that makes it inherently difficult to think of them in the same context as other management decisions at the end of a patient’s life. Other explanations physicians gave as to why they did not engage in conversations included: the small internal nature of these devices and hence absence of a physical reminder to discuss the ICD, the absence of an established relationship with the patient, and their own general concerns relating to withdrawing care.CONCLUSIONWhereas some of the barriers to discussing ICD deactivation are common to all forms of advance care planning, ICDs have unique characteristics that make these conversations more difficult. Future educational interventions will need to be designed to teach physicians how to improve communication with patients about the management of ICDs at the end of life.

International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video)

BACKGROUND Limited data exist on the use of peroral endoscopic myotomy (POEM) for therapy of spastic esophageal disorders (SEDs). OBJECTIVE To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm, jackhammer esophagus, or type III (spastic) achalasia. DESIGN Retrospective study. SETTING International, multicenter, academic institutions. PATIENTS All patients who underwent POEM for treatment of SEDs refractory to medical therapy at 11 centers were included. INTERVENTIONS POEM. MAIN OUTCOME MEASUREMENTS Eckardt score and adverse events. RESULTS A total of 73 patients underwent POEM for treatment of SEDs (diffuse esophageal spasm 9, jackhammer esophagus 10, spastic achalasia 54). POEM was successfully completed in all patients, with a mean procedural time of 118 minutes. The mean length of the submucosal tunnel was 19 cm, and the mean myotomy length was 16 cm. A total of 8 adverse events (11%) occurred, with 5 rated as mild, 3 moderate, and 0 severe. The mean length of hospital stay was 3.4 days. There was a significant decrease in Eckardt scores after POEM (6.71 vs 1.13; P = .0001). Overall, clinical response was observed in 93% of patients during a mean follow-up of 234 days. Chest pain significantly improved in 87% of patients who reported chest pain before POEM. Repeat manometry after POEM was available in 44 patients and showed resolution of initial manometric abnormalities in all cases. LIMITATIONS Retrospective design and selection bias. CONCLUSION POEM offers a logical therapeutic modality for patients with SEDs refractory to medical therapy. Results from this international study suggest POEM as an effective and safe platform for these patients.

Reliability, Validity, and Feasibility of the Zwisch Scale for the Assessment of Intraoperative Performance

PURPOSE The existing methods for evaluating resident operative performance interrupt the workflow of the attending physician, are resource intensive, and are often completed well after the end of the procedure in question. These limitations lead to low faculty compliance and potential significant recall bias. In this study, we deployed a smartphone-based system, the Procedural Autonomy and Supervisions System, to facilitate assessment of resident performance according to the Zwisch scale with minimal workflow disruption. We aimed to demonstrate that this is a reliable, valid, and feasible method of measuring resident operative autonomy. METHODS Before implementation, general surgery residents and faculty underwent frame-of-reference training to the Zwisch scale. Immediately after any operation in which a resident participated, the system automatically sent a text message prompting the attending physician to rate the residents level of operative autonomy according to the 4-level Zwisch scale. Of these procedures, 8 were videotaped and independently rated by 2 additional surgeons. The Zwisch ratings of the 3 raters were compared using an intraclass correlation coefficient. Videotaped procedures were also scored using 2 alternative operating room (OR) performance assessment instruments (Operative Performance Rating System and Ottawa Surgical Competency OR Evaluation), against which the item correlations were calculated. RESULTS Between December 2012 and June 2013, 27 faculty used the smartphone system to complete 1490 operative performance assessments on 31 residents. During this period, faculty completed evaluations for 92% of all operations performed with general surgery residents. The Zwisch scores were shown to correlate with postgraduate year (PGY) levels based on sequential pairwise chi-squared tests: PGY 1 vs PGY 2 (χ(2) = 106.9, df = 3, p < 0.001); PGY 2 vs PGY 3 (χ(2) = 22.2, df = 3, p < 0.001); and PGY 3 vs PGY 4 (χ(2) = 56.4, df = 3, p < 0.001). Comparison of PGY 4 to PGY 5 scores were not significantly different (χ(2) = 4.5, df = 3, p = 0.21). For the 8 operations reviewed for interrater reliability, the intraclass correlation coefficient was 0.90 (95% CI: 0.72-0.98, p < 0.01). Correlation of Procedural Autonomy and Supervisions System ratings with both Operative Performance Rating System items (each r > 0.90, all ps < 0.01) and Ottawa Surgical Competency OR Evaluation items (each r > 0.86, all ps < 0.01) was high. CONCLUSIONS The Zwisch scale can be used to make reliable and valid measurements of faculty guidance and resident autonomy. Our data also suggest that Zwisch ratings may be used to infer resident operative performance. Deployed on an automated smartphone-based system, it can be used to feasibly record evaluations for most operations performed by residents. This information can be used to council individual residents, modify programmatic curricula, and potentially inform national training guidelines.

Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study.

Background and study aims: Type III achalasia is characterized by rapidly propagating pressurization attributable to spastic contractions. Although laparoscopic Heller myotomy (LHM) is the current gold standard management for type III achalasia, peroral endoscopic myotomy (POEM) is conceivably superior because it allows for a longer myotomy. Our aims were to compare the efficacy and safety of POEM with LHM for type III achalasia patients. Patients and methods: A retrospective study of 49 patients who underwent POEM for type III achalasia across eight centers were compared to 26 patients who underwent LHM at a single institution. Procedural data were abstracted and pre- and post-procedural symptoms were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤ 1. Secondary outcomes included length of myotomy, procedure duration, length of hospital stay, and rate of adverse events. Results: Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01). Conclusions: POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes. POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia.

Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar short-term anatomic and functional effect.

BACKGROUND Peroral esophageal myotomy (POEM) differs from laparoscopic Heller myotomy (LHM) in that only the circular muscle layer of the esophagus is divided, the hiatus is not mobilized, and an antireflux procedure is not performed. The effect of these differences on anatomic and functional outcomes is unknown. METHODS Patients who underwent LHM or POEM and had both a pre- and postoperative timed barium esophagogram were selected for analysis. Timed barium esophagograms were performed with 200 mL of contrast, with radiographs taken at 1, 2, and 5 minutes. RESULTS A total o f 17 LHM and 12 POEM patients had undergone pre- and postoperative timed barium esophagograms. Both groups had decreased column heights postoperatively at 1, 2, and 5 minutes (LHM: pre, 15.6, 12.7, 11.3 cm vs post, 3.6, 2.5, 1.8 cm; P < .001 and POEM: pre, 14.7, 11, 9.4 cm vs post, 4.4, 2.5, 1.2 cm; P < .001). There was no difference between procedures in changes from baseline column height. Both operations resulted in decreased esophageal width and less angulation between the esophageal body and esophagogastric junction. CONCLUSION POEM and LHM produce a similar short-term anatomic and functional result at the esophagogastric junction. POEM results in a similar narrowing and straightening of the esophagus despite the fact that POEM does not involve hiatal mobilization.

A Comparison of Symptom Severity and Bolus Retention With Chicago Classification Esophageal Pressure Topography Metrics in Patients With Achalasia

BACKGROUND & AIMS We compared findings from timed barium esophagrams (TBEs) and esophageal pressure topography studies among achalasia subtypes and in relation to symptom severity. METHODS We analyzed data from 50 patients with achalasia (31 men; age, 20-79 y) who underwent high-resolution manometry (HRM), had TBE after a 200-mL barium swallow, and completed questionnaires that determined Eckardt Scores. Twenty-five patients were not treated, and 25 patients were treated (11 by pneumatic dilation, 14 by myotomy). Nonparametric testing was used to assess differences among groups of treated patients (10 had type 1 achalasia and 15 had type 2 achalasia), and the Pearson correlation was used to assess their relationship. RESULTS There were no significant differences in TBE measurements between patient groups. Of the 25 patients who received treatment, 10 had a manometric pattern consistent with persistent achalasia after treatment (6 patients with type 1 and 4 patients with type 2 achalasia), whereas 15 appeared to have resolved the achalasia pattern (peristalsis was absent in 8 patients and weak in 7 patients). The height of the barium column at 5 minutes and Eckardt Scores were reduced significantly in patients who had resolved their achalasia pattern, based on HRM. The integrated relaxation pressure and the TBE column height correlated at 5 minutes (r = 0.422; P < .05). CONCLUSIONS Patients who resolved their achalasia pattern, based on HRM, showed improved emptying based on TBE measurements and improved symptom scores. There was no significant difference between patients with type 1 or type 2 achalasia in TBEs. These findings indicate that normalization of the integrated relaxation pressure on HRM is a clinically relevant objective of treatment for achalasia.

Assessing Bolus Retention in Achalasia Using High-Resolution Manometry With Impedance: A Comparator Study With Timed Barium Esophagram

OBJECTIVES:The aim of this study was to assess whether high-resolution impedance manometry (HRIM) could be used to assess bolus retention similar to the timed barium esophagram (TBE).METHODS:Twenty achalasia patients (10 males, aged 21–79 years) were prospectively evaluated with HRIM and TBE to determine the correlation between barium column height and the impedance bolus height (IBH). The TBE protocol used a 200-ml barium challenge and the HRIM protocol used a 200-ml saline challenge protocol. Both protocols were performed in an upright position and the heights of the barium and impedance columns were measured at 1 and 5 min. Analysis of IBH was performed with a topographic technique and a spatial impedance variation plot.RESULTS:There was no significant difference between the median IBH and barium column at 1 min (IBH: 12.0 cm (interquartile range (IQR), 8.0–18.0); TBE: 12.0 cm (IQR, 7.0–19.0); P=0.90) or at 5 min (IBH: 11.0 cm (IQR, 1.0–17.0); TBE: 9.0 cm (IQR, 4.0–12.0); P=0.47). In addition, the correlation between the two measurements at 1 and 5 min was 0.60 and 0.86, respectively. Using a barium column or impedance height of >5.0 as a definition of bolus retention was associated with 75% concordance at 1 min and 95% concordance at 5 min.CONCLUSIONS:There was excellent agreement between TBE and high-resolution impedance manometry (HRIM) for assessing bolus retention at 5 min. Thus, HRM with impedance may be used as a single test to assess bolus retention and motor function in the management of achalasia.

Per-oral Endoscopic Myotomy (POEM) After the Learning Curve: Durable Long-term Results With a Low Complication Rate.

Objective: We aimed to report long-term outcomes for patients undergoing per-oral endoscopic myotomy (POEM) after our initial 15-case learning curve. Background: POEM has become an established, natural-orifice surgical approach for treating esophageal motility disorders. To date, published outcomes and comparative-effectiveness studies have included patients from the early POEM experience. Methods: Consecutive patients undergoing POEM after our initial 15 cases, with a minimum of 1-year postoperative follow-up, were included. Treatment success was defined as an Eckardt score ⩽3 without reintervention. Gastroesophageal reflux was defined by abnormal pH-testing or reflux esophagitis >Los Angeles grade A. Results: Between January 2012 and March 2015, 115 patients underwent POEM at a single, high-volume center. Operative time was 101 ± 29 minutes, with 95% (109/115) of patients discharged on postoperative day 1. Clavien-Dindo grade III complications occurred in 2.7%, one of which required diagnostic laparoscopy to rule out Veress needle injury to the gall bladder. The rate of grade I complications was 15.2%. At an average of 2.4 years post-POEM (range 12–52 months), the overall success rate was 92%. Objective evidence of reflux was present in 40% for all patients and 33% for patients with a body mass index <35 kg/m2 and no hiatal hernia. Conclusions: POEM performed by experienced surgeons provided durable symptomatic relief in 94% of patients with nonspastic achalasia and 90% of patients with type 3 achalasia/spastic esophageal motility disorders, with a low rate of complications. The rate of gastroesophageal reflux was comparable with prior studies of both POEM and laparoscopic Heller myotomy.

Duration of Faculty Training Needed to Ensure Reliable OR Performance Ratings

OBJECTIVES The American Board of Surgery has mandated intraoperative assessment of general surgery residents, yet the time required to train faculty to accurately and reliably complete operating room performance evaluation forms is unknown. Outside of surgical education, frame-of-reference (FOR) training has been shown to be an effective training modality to teach raters the specific performance indicators associated with each point on a rating scale. Little is known, however, about what form and duration of FOR training is needed to accomplish reliable ratings among surgical faculty. DESIGN Two groups of surgical faculty separately underwent either an accelerated 1-hour (n = 10) or immersive four-hour (n = 34) FOR faculty development program. Both programs included a formal presentation and a facilitated discussion of sample behaviors for each point on the Zwisch operating room performance rating scale (see DaRosa et al.(8)). The immersive group additionally participated in a small group exercise that included additional practice. After training, both groups were tested using 10 video clips of trainees at various levels. Responses were scored against expert consensus ratings. The 2-sided Mann-Whitney U test was used to compare between group means. SETTING AND PARTICIPANTS All trainees were faculty members in the Department of Surgery of a large midwestern private medical school. RESULTS Faculty undergoing the 1-hour FOR training program did not have a statistically different mean correct response rate on the video test when compared with those undergoing the 4-hour training program (88% vs 80%; p = 0.07). CONCLUSIONS One-hour FOR training sessions are likely sufficient to train surgical faculty to reliably use a simple evaluation instrument for the assessment of intraoperative performance. Additional research is needed to determine how these results generalize to different assessment instruments.