No abstract

In patients aged 50-65 years undergoing AVR with the Carpentier-Edwards Perimount bioprosthesis, the expected valve durability was 19 years. Age was not a significant risk factor for SVD within this age group. Patient selection and attention to timing of reintervention may be determinants of long-term outcomes.

Background During peroral esophageal myotomy (POEM) for the treatment of achalasia, the optimal distal gastric myotomy length is unknown. In this study we used a functional lumen imaging probe (FLIP) to intraoperatively measure the effect of variable distal myotomy lengths on esophagogastric junction (EGJ) distensibility. Methods EGJ distensibility index (DI) (minimum cross-sectional area divided by intra-bag pressure) was measured with FLIP after each operative step. Each patient's myotomy was performed in four increments from proximal to distal: 1) an esophageal myotomy (from 6cm proximal to the EGJ, to 1cm proximal to it), 2) a myotomy ablating the lower esophageal sphincter (LES) complex (from 1cm proximal to the EGJ, to 1cm distal to it), 3) an initial gastric extension (from 1cm distal to the EGJ, to 2cm distal), and 4) a final gastric extension (from 2cm distal to the EGJ, to 3cm distal). Results Measurements were performed in 16 achalasia patients during POEM. POEM resulted in an overall increase in DI (pre 1.2 vs. post 7.2 mm2/mmHg, p<.001). Initial creation of the submucosal tunnel resulted in a 3-fold increase in DI (1.2 vs. 3.6 mm2/mmHg, p<.001). When the myotomy was then performed in a stepwise fashion from proximal to distal, the initial esophageal myotomy component had no effect on DI. Subsequent myotomy extension across the LES complex resulted in an increase in DI, as did the initial gastric myotomy extension (to 2cm distal to the EGJ). The final gastric myotomy extension (to 3cm distal) had no further effect. Conclusions During POEM, creation of the submucosal tunnel prior to myotomy resulted in a marked improvement in EGJ physiology. Myotomy extension across the LES complex and to 2cm onto the gastric wall resulted in normalization of EGJ distensibility, whereas subsequent extension to 3cm distal to the EGJ did not increase compliance further.

Approximately 10% of all pancreatectomies in the US are for IPMNs. In these patients, treated after the revised international consensus guidelines, only 23% of IPMNs contained invasive or high-grade histology. Resections carried similar morbidity regardless of pathology. Improved biomarkers are needed to aid in surgical selection.