Background Recurrence of hiatal hernia after paraesophageal hernia repair (PEHR) affects many patients, and axial tension is thought to be a major factor. A widely accepted guideline is that extensive esophageal mobilization to achieve at least 3 cm of intra-abdominal esophageal length is important, and more length may further reduce recurrence, but there are minimal data to support this. We aimed to analyze the relationship between intra-abdominal esophageal length and recurrence in patients undergoing laparoscopic PEHR. Methods We conducted a retrospective study of adult patients undergoing laparoscopic paraesophageal hernia repair at a tertiary care institution from October 1, 2015, through January 31, 2024. Intra-abdominal esophageal length (EL) was measured prospectively by the operative surgeon after maximal esophageal mobilization. We investigated associations of intra-abdominal EL with radiographic recurrence at 6 months, as well as with postoperative complications, using multivariable logistic regression adjusted for clinical and sociodemographic factors. Results 183 patients were analyzed, with a median age of 68 years and 76% were female. During PEHR, a fundoplication was performed in 99% of cases, mesh was used in 54%, and a relaxing incision was performed in 16%. The median intraabdominal EL was 4.0 cm (IQR 3.5-4.0 cm). Recurrence occurred in 8.2% of patients. Overall, there was no statistically significant association between intra-abdominal EL and recurrence at 6 months (adjusted Odds Ratio aOR 1.48, 95% CI 0.62-3.59, p = 0.38). This finding was robust to sensitivity analyses, including grouping intra-abdominal EL of < = 3 cm compared with > 3 cm and EL of < = 4 cm compared with > 4 cm. Conclusions The common practice to achieve as much intra-abdominal esophageal length as possible during PEHR may be questioned by these findings. Pending further studies, we propose that esophageal mobilization be viewed as more of a continuum than a target, recognizing that more may not be better.

Robotic surgery has been postulated to offer ergonomic benefits, but there is limited research to support this. While ergonomic best practices have been published, adoption among surgeons is also unknown. We aimed to characterize ergonomic experiences and practices of robotic surgeons to identify potential opportunities for optimization. A web-based survey study of self-identified robotic surgeons was conducted, focusing on practice patterns, ergonomic preparation and support, and demographics. Select questions referred to frequency of pain after operating, of achieving best practices, and of supportive ergonomic equipment (5-point Likert). Using a dichotomized outcome of pain, associations with surgeon sex, height, and hand size were evaluated using multivariable logistic regression. Among 292 surgeons, the median age was 42 years, and 63

Most surgeons experience work-related pain and musculoskeletal injuries (WRMSI). Though robotic surgery has been speculated to reduce the risk of WRMSI compared to open and laparoscopic approaches, the majority of robotic surgeons still experience neck, back, and upper extremity discomfort. Despite growing use of robot-assisted surgery (RAS), there is limited research on the ergonomic risks faced by robotic surgeons. This study aims to evaluate ergonomic strain during RAS. Artificial intelligence (AI)-assisted video analysis was used on a convenience sample of experienced faculty-level robotic surgeons to assess their positioning, practice, and pain. Participants completed 3 repetitions of a standardized simulated surgical task on the daVinci Xi robotic surgery console. Video recordings were analyzed using AI-assisted kinematic assessment software (TuMeKe Ergonomics, San Mateo CA). Validated subjective assessment tools and a general ergonomic practices questionnaire were calculated. Spearman’s correlation coefficient evaluated the relationship between the time spent in medium-to-high-risk ergonomic positions and the corresponding reported discomfort. The 5 participants had a mean age of 50.7 years and performed a mean of 3.5 robotic cases weekly. 60

Importance:Acute cholecystitis (AC) management during pregnancy requires balancing the risk of pregnancy loss or preterm delivery (adverse pregnancy outcomes [APOs]) with or without surgery. Guidelines recommend cholecystectomy across trimesters; however, trimester-specific evidence on the risks of AC and its management is lacking. Objective:To assess cholecystectomy frequency in pregnant people with AC, compare the rates of APOs in pregnant people with or without AC, and compare the rates of APOs in people with AC who did or did not undergo cholecystectomy. Design, Setting, and Participants:This retrospective, population-based cohort study used data for pregnant people with AC from the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2007, to December 31, 2019, and a propensity score-matched cohort of pregnant people without AC. Trimester status (first [T1], second [T2], and third [T3]), APOs, and cholecystectomy were defined by administrative claims. Data were analyzed from October 2021 to July 2022. Exposures:Pregnant patients with or without AC. Pregnant patients with AC who did or did not receive cholecystectomy. Main Outcomes and Measures:The main outcomes were cholecystectomy during pregnancy and APOs (ie, preterm delivery and pregnancy loss). Pregnant patients with and without AC were compared to assess the association of AC with risk of APOs. Propensity score inverse-probability weighting was used to calculate treatment-associated APO risk among patients with 1-year follow-up. Results:The study included 5759 pregnant patients with AC (mean [SD] age, 30.1 [6.6] years) and 23 036 controls (mean [SD] age, 29.9 [6.7] years) after propensity score matching. Among 3426 pregnant patients with AC and 1-year follow-up, 1182 (34.5%) underwent cholecystectomy during the pregnancy (684 [41.7%] presenting with AC in T1, 404 [40.4%] in T2, and 94 [12.0%] in T3). Acute cholecystitis during pregnancy, irrespective of treatment, was associated with higher odds of APO compared with no AC during pregnancy across all trimesters (odds ratio [OR], 1.69 [95% CI, 1.54-1.85]). Compared with nonoperative management, receipt of surgery was associated with lower odds of APOs across all trimesters (OR, 0.75 [95% CI, 0.63-0.87]), in T1 (OR, 0.81 [95% CI, 0.66-1.00]), in T2 (OR, 0.71 [95% CI, 0.50-1.00]), and in T3 (OR, 0.45 [95% CI, 0.28-0.70]). Conclusions and Relevance:In this study, cholecystectomy was associated with lower risk of APO in patients with AC across all trimesters, with the greatest benefit in T3. However, only 34.5% overall and 12.0% of patients in T3 had a cholecystectomy. These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC.

Introduction: Static through the scope (TTS) balloon dilation has comparable efficacy and safety profile to Savary dilation (SD) but is occasionally limited in the setting of proximal stenosis, long strictures or subtle narrowing(s) not appreciated via endoscopy (i.e. eosinophilic esophagitis). Accordingly, these scenarios may require mechanical dilators. SD are antegrade, push, tapered dilators that work by exerting longitudinal and radial force from the proximal to the distal end of the stenosis. Resistance during dilator passage also allows the endoscopist to gauge dilation effect. In comparison, balloon pull-through dilation (BPTD) is a less common retrograde technique that exerts longitudinal and radial force in the opposite direction but also provides tactile feedback. In addition, it allows for sizing and dilation of benign strictures throughout the entire length of the esophagus under direct visualization. Given limited data on the latter technique, we opted to report our experience with antegrade Savary and retrograde balloon dilation of benign esophageal strictures. Methods: Retrospective cohort study of adult patients who underwent upper endoscopy at our center from 01/2017 to 05/2022. Only esophageal or gastroesophageal junction benign stenosis were included. Wire-guided Savary and BPTD techniques were included. Static TTS dilation and other forms of dilation (i.e. pneumatic dilation) were excluded. 40 patients met inclusion criteria. Baseline variables were collected. The primary outcome was need for re-dilation within 1 year after therapeutic dilation was achieved (≥ 16 mm). Secondary outcomes were ability to reach therapeutic endpoint dilation and complication rate. Outcomes were compared by using the chi-square test for categorical variables. Results: There was no difference in the need for re-dilation at 1-year in both groups (SD 34.6% vs BPTD 15.4%, p = 0.208). Target endpoint dilation efficacy was similar in both groups (SD 100% vs BPTD 92.9%, p = 0.168). One minor complication occurred in BPTD group. Nevertheless, the rates were statistically similar in both groups (Table 1). Conclusion: Our experience suggests BPTD may be equally effective and safe as SD for benign esophageal stenosis. Prospective larger studies are needed to validate these preliminary findings. Table 1. - Comparison of Balloon Pull-Through Dilation and Savary Dilation: Demographics, Study Details, Complications, and Need for Re-dilation Results of Comparison of Balloon Pull-Through Dilation and Savary Dilation Type Of Procedure Balloon pull-through Savary Dilation P-value Count (n=14) N % Mean (Median) Count (n=26) N % Mean (Median) Gender Male 8 57.1% 12 46.2% Female 6 42.9% 14 53.8% Ethnicity Hispanic or Latino 5 35.7% 5 19.2% Not hispanic or Latino 9 64.3% 21 80.8% Race Black or African American 2 14.3% 1 3.8% Hispanic 5 35.7% 5 19.2% White 7 50.0% 20 76.9% BMI < 18.5, underweight 2 14.3% 1 3.8% >40, morbidly obese 1 7.1% 1 3.8% 18.5-24.9, healthy weight 2 14.3% 9 34.6% 25-29.9, overweight 5 35.7% 12 46.2% 30-39.9, obese 4 28.6% 3 11.5% Sedation Type Generalized anesthesia 2 14.3% 0 0.0% MAC 12 85.7% 26 100.0% Location of Stricture Lower Esophagus 10 71.4% 19 73.1% Middle Esophagus 2 14.3% 3 11.5% Upper Esophagus 2 14.3% 4 15.4% LA Grade Esophagitis LA Grade A 2 0.14% 2 7.7% LA Grade B 0 0.0% 0 0.0% LA Grade C 0 0.0% 1 0.04% LA Grade D 1 7.1% 0 0.0% Barrett's Esophagus Yes 3 21.4% 2 8.0% No 11 78.6% 23 92.0% Fluoroscopy Used Yes 0 0.0% 0 0.0% No 14 100.0% 26 100.0% Anticoagulation Yes 2 14.3% 1 3.8% No 12 85.7% 25 96.2% DAPT Therapy Yes 1 7.1% 0 0.0% No 13 92.9% 26 100.0% Complication Occurred Yes 1 7.1% 0 0.0% 0.168 No 13 92.9% 26 100.0% Type of Complication Deep Mucosal Tear 1 7.1% 0 0.0% Bleeding 0 0.0% 0 0.0% Bacteremia 0 0.0% 0 0.0% Observation 0 0.0% 0 0.0% Aspiration 0 0.0% 0 0.0% Therapeutic Dilation Achieved (therapeutic ≥ 16mm) Yes 13 92.9% 26 100.0% 0.168 No 1 7.1% 0 0.0% Need for re-dilation within one year after reaching therapeutic dilation Yes 2 15.4% 9 34.6% 0.208 No 11 84.6% 17 65.4% Number of re-dilations in one year 1.5 (1.5) 1.44 (1) Number of days to re-dilation 115 166

With the advent of the laparoscopic era in the 1990s, laparoscopic Heller myotomy replaced pneumatic dilation as the first-line treatment for achalasia. An advantage of this approach was the addition of a fundoplication to reduce gastroesophageal reflux disease (GERD). More recently, Peroral Endoscopic Myotomy has competed for first-line therapy, but the postoperative GERD may be a weakness. This study leverages our experience to characterize GERD following LHM with Toupet fundoplication (LHM+T ) so that other treatments can be appropriately compared. A single-institution retrospective review of adult patients with achalasia who underwent LHM+T from January 2012 to April 2022 was performed. We obtained routine 6-month postoperative pH studies and patient symptom questionnaires. Differences in questionnaires and reflux symptoms in relation to pH study were explored via Kruskal–Wallis test or chi-square tests. Of 170 patients who underwent LHM+T , 51 (30

INTRODUCTION: Retained gastric food content encountered during upper endoscopy may reduce diagnostic accuracy and increase the risk of aspiration. The aim of this study was to evaluate endoscopists' practice patterns and clinical outcomes in patients with retained gastric food content encountered during endoscopy. METHODS: Consecutive patients with retained gastric food content during first-time endoscopy at Loma Linda University Health (January 2016–March 2021) were identified. Primary endpoints were a complete examination (deep duodenal intubation) and 30-day postprocedural respiratory adverse events. RESULTS: Of 17,868 patients undergoing endoscopy, 629 (3.5%) (mean age 55 ± 17 years) met inclusion criteria. Moderate sedation was performed in 506 (80.4%), anesthesiologist-assisted sedation in 16 (2.5%), and general anesthesia in 107 (17.0%) patients. 534 (84.9%) patients received a complete examination, and endoscopist-specific completion rates varied by quintile among 26 endoscopists (range 70.3%–98.0%, P < 0.0001). Large food gastric content decreased (adjusted odds ratio [aOR] 0.3, 95% confidence interval [CI] 0.2–0.4) while obtaining mucosal biopsies increased (aOR 2.5, 95% CI 1.4–4.7) the likelihood of complete examination after adjusting for endoscopist-specific completion rates. Subsequently, 58 (9.2%) patients required repeat endoscopy within 30 days. During follow-up, 41 (6.5%) patients developed respiratory adverse events including 21 (3.3%) requiring ventilatory support. Hospitalized patients (aOR 37.8, 95% CI 4.9–289.0) compared with outpatients and large compared with small gastric food content (aOR 2.1, 95% CI 1.1–4.2) increased the likelihood of respiratory adverse events. DISCUSSION: Although deep duodenal intubation was achieved in most patients receiving endoscopy, the rate of complete examination varied among individual endoscopists and the extent of food burden. Respiratory adverse events occurred almost exclusively in hospitalized patients and were associated with high morbidity including half developing respiratory failure.

After completion of training, practicing surgeons rely on hands-on courses to expand their procedure armamentarium and improve their surgical technique. However, such courses vary in standardized teaching methods. SAGES developed the Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program as a method of longitudinal instruction utilizing standardized teaching techniques, mentorship, and webinars to cover additional techniques. This study examines the adoption of learned techniques and participant confidence before and after an ADOPT course focused on extended-view totally extraperitoneal (eTEP) hernia repair. A hands-on course focused on eTEP hernia repair was conducted with enrollment capped at 10 participants. Pre-course and post-course surveys at 3, 6, and 12 months determined implementation of the learned procedure, case volume, and confidence with eTEP skills. A 5-point Likert scale (1 = not confident at all to 5 = completely confident) assessed confidence levels. Survey responses were summarized using descriptive statistics. Of the 10 participants, 10 (100

Health care accounts for almost 10

BACKGROUND:In patients with paraesophageal hernias (PEH), the course of the esophagus is often altered, which may affect esophageal motility. High-resolution manometry (HRM) is frequently used to evaluate esophageal motor function prior to PEH repair. This study was performed to characterize esophageal motility disorders in patients with PEH as compared to sliding hiatal hernia and to determine how these findings affect operative decision-making.METHODS:Patients referred for HRM to a single institution from 2015 to 2019 were included in a prospectively maintained database. HRM studies were analyzed for the appearance of any esophageal motility disorder using the Chicago classification. PEH patients had confirmation of their diagnosis at the time of surgery, and the type of fundoplication performed was recorded. They were case-matched based on sex, age, and BMI to patients with sliding hiatal hernia who were referred for HRM in the same period.RESULTS:There were 306 patients diagnosed with a PEH who underwent repair. When compared to case-matched sliding hiatal hernia patients, PEH patients had higher rates of ineffective esophageal motility (IEM) (p<.001) and lower rates of absent peristalsis (p=.048). Of those with ineffective motility (n=70), 41 (59%) had a partial or no fundoplication performed during PEH repair.CONCLUSION:PEH patients had higher rates of IEM compared to controls, possibly due to a chronically distorted esophageal lumen. Offering the appropriate operation hinges on understanding the involved anatomy and esophageal function of each individual. HRM is important to obtain preoperatively for optimizing patient and procedure selection in PEH repair.

Background Type II hiatal hernias (HH) are characterized by a portion of the gastric fundus located above the esophageal hiatus adjacent to the esophagus while the gastroesophageal junction (GEJ) remains fixed below the esophageal hiatus. This type of HH has been called the “true” paraesophageal hernia (PEH) because the fundus appears to the side of the esophagus. In our experience, Type II HHs are occasionally identified on radiographic testing, however they are rarely, if ever, confirmed intraoperatively. This led to our question: Does Type II HH exist? Methods We searched for evidence of type II HH in three locations: 1. Retrospective review of all first-time PEH repairs (excluding Type I HHs and re-operative cases) performed at the University of Washington Medical Center from 1994 to 2021; 2. Operative videos available on YouTube and WebSurg websites; and 3. Abstracts from the SAGES annual meetings from 2005 to 2021. Results We found no evidence of Type II HH in any of our three searches. We performed 846 PEH repairs: 760 Type III, 75 Type IV, and 11 parahiatal. Upon website video review, we found only one possible type II hernia, though it too was likely a para-hiatal hernia. No video or case presentations of a type II HH were identified within SAGES annual meeting abstracts. Conclusion Type II HHs do not exist as they are currently defined. Although uncommon, parahiatal hernia can easily be misinterpreted as Type II HH. We should consider changing the hiatal hernia classification system to prevent ongoing clinical confusion.

IMPORTANCE Several professional practice guidelines recommend per-oral endoscopic myotomy (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety. OBJECTIVE To evaluate the use, safety, health care utilization, and costs associated with the use of POEM for treatment of achalasia relative to laparoscopic Hellermyotomy (LHM) and pneumatic dilation (PD). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective national cohort study of commercially insured patients, aged 18 to 63 years, who underwent index intervention for achalasia with either LHM, PD, or POEM in the US between July 1, 2010, and December 31, 2017. Patient data were obtained from a national commercial claims database. Included in the study were patients with at least 12 months of enrollment after index treatment and a minimum of 6 months of continuous enrollment before their index procedure. Patients 64 years or older were excluded to avoid underestimation of health care claims from enrollment in Medicare supplemental insurance. Data were analyzed from July 1, 2019, to July 1, 2021. MAIN OUTCOMES AND MEASURES Changes in the proportion of annual procedures performed for achalasia were evaluated over time. The frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, were compared. Negative binomial regression was used to compare the incidence rates of subsequent diagnostic testing, reintervention, and unplanned hospitalization. Generalized linear models were used to compare differences in 1-year health-related expenditures across procedures. RESULTS This cohort study included a total of 1921 patients (median [IQR] age: LHM group, 48 [37-56] years; 737 men [51%]; PD group, 51 [41-58] years; 168 men [52%]; POEM group, 50 [40-57] years; 80 men [56%]). The use of POEM increased 19-fold over the study period, from 1.1% (95% CI, 0.2%-3.2%) of procedures in 2010 to 18.9% in 2017 (95% CI, 13.6%-25.3%; P = .01). Adverse events were rare and did not differ between procedures. Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR], 2.2; 95% CI, 1.9-2.6) and reinterventions (IRR, 1.9; 95% CI, 1.1-3.3). When compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5; 95% CI, 1.3-1.8) but fewer reinterventions (IRR, 0.4; 95% CI, 0.2-0.6). The total 1-year health care costs were similar between POEM and LHM, but significantly lower for PD (mean cost difference, $7674; 95% CI, $657-$14 692). CONCLUSIONS AND RELEVANCE Results of this cohort study suggest that POEM was associated with higher health care utilization compared with LHM and lower subsequent health care utilization but higher costs compared with PD. The use of POEM is increasing rapidly; payers should recognize the totality of evidence and current treatment guidelines as they consider reimbursement for POEM. Patients should be informed of the trade-offs between approaches when considering treatment.

Background The COVID-19 pandemic caused many surgical providers to conduct outpatient evaluations using remote audiovisual conferencing technology (i.e., telemedicine) for the first time in 2020. We describe our year-long institutional experience with telemedicine in several general surgery clinics at an academic tertiary care center and examine the relationship between area-based socioeconomic measures and the likelihood of telemedicine participation. Methods We performed a retrospective review of our outpatient telemedicine utilization among four subspecialty clinics (including two acute care and two elective surgery clinics). Geocoding was used to link patient visit data to area-based socioeconomic measures and a multivariable analysis was performed to examine the relationship between socioeconomic indicators and patient participation in telemedicine. Results While total outpatient visits per month reached a nadir in April 2020 (65% decrease in patient visits when compared to January 2020), there was a sharp increase in telemedicine utilization during the same month (38% of all visits compared to 0.8% of all visits in the month prior). Higher rates of telemedicine utilization were observed in the two elective surgery clinics (61% and 54%) compared to the two acute care surgery clinics (14% and 9%). A multivariable analysis demonstrated a borderline-significant linear trend (p = 0.07) between decreasing socioeconomic status and decreasing odds of telemedicine participation among elective surgery visits. A sensitivity analysis to examine the reliability of this trend showed similar results. Conclusion Telemedicine has many patient-centered benefits, and this study demonstrates that for certain elective subspecialty clinics, telemedicine may be utilized as the preferred method for surgical consultations. However, to ensure the equitable adoption and advancement of telemedicine services, healthcare providers will need to focus on mitigating the socioeconomic barriers to telemedicine participation.

Inguinal hernias represent one of the most common pathologic conditions presenting to the general surgeon. In surgical practice, several controversies persist: when to operate, the utility of a laparoscopic versus open approach, the applicability of robotic surgery, the approach to bilateral hernias, management of athletic-related groin pain ("sports hernia"), and the role of tissue-based repairs in modern hernia surgery. Ideally, surgeons should approach each patient individually and tailor their approach based on patient factors and preferences. The informed consent process is critical, especially given increasing recognition of the risk of long-term chronic pain following hernia repair.

In their letter about the commentary "Virtual Interviews for Fellowship and Residency Applications Are Effective Replacements for In-Person Interviews and Should Continue Post-COVID," 1 Wright A.S. Virtual interviews for fellowship and residency applications are effective replacements for in-person interviews and should continue post-COVID. J Am Coll Surg. 2020; 231: 678-680 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Haley and colleagues raise several very salient concerns about the impact of virtual interviews for residency and fellowship, especially with regard to equity and the potential for differential impacts on those who are underrepresented in medicine (UIM). That Invited Commentary was based on the article "Initial Experience with a Virtual Platform for Advanced Gastrointestinal Minimally Invasive Surgery Fellowship Interviews." 2 Majumder A. Eckhouse S.R. Brunt L.M. et al. Initial experience with a virtual platform for advanced gastrointestinal minimally invasive surgery fellowship interviews. J Am Coll Surg. 2020; 231: 670-678 Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Virtual Interviews: An Imperfect Solution to Address InequityJournal of the American College of SurgeonsVol. 233Issue 1PreviewIn the article, "Virtual Interviews for Fellowship and Residency Applications Are Effective Replacements for In-Person Interviews and Should Continue Post-COVID," Wright1 discussed how the COVID-19 pandemic resulted in residency and fellowship interviews shifting to virtual formats. The author mentioned several benefits and challenges to interviewing virtually and suggested virtual-only interviews be mandated in future years.1 This article contributes to the much-needed dialogue about the inequities associated with traditional in-person interviewing; however, we believe it is important to consider other factors that might limit residency programs transitioning to a fully virtual model. Full-Text PDF

Background: People of South Asian and African Caribbean ethnicities living in UK have a high risk of cardiometabolic disease. Limited data exist regarding detailed cardiometabolic phenotyping in this population. Methods enabling this are widely available, but the practical aspects of undertaking such studies in large and diverse samples are seldom reported.Methods: The Southall and Brent Revisited (SABRE) study is the UK's largest tri-ethnic longitudinal cohort. Over 1,400 surviving participants (58–85 years) attended the 2nd study visit (2008–2011); during which, comprehensive cardiovascular phenotyping, including 3D-echocardiography [3D-speckle-tracking (3D-STE)], computed tomography, coronary artery calcium scoring, pulse wave velocity, central blood pressure, carotid artery ultrasound, and retinal imaging, were performed. We describe the methods used with the aim of providing a guide to their feasibility and reproducibility in a large tri-ethnic population-based study of older people.Results: Conventional echocardiography and all vascular measurements showed high feasibility (>90% analyzable of clinic attendees), but 3D-echocardiography (3DE) and 3D-STE were less feasible (71% 3DE acquisition feasibility and 38% 3D-STE feasibility of clinic attendees). 3D-STE feasibility differed by ethnicity, being lowest in South Asian participants and highest in African Caribbean participants (p < 0.0001). Similar trends were observed in men (P < 0.0001) and women (P = 0.005); however, in South Asians, there were more women with unreadable 3D-images compared to men (67 vs. 58%). Intra- and inter-observer variabilities were excellent for most of conventional and advanced echocardiographic measures. The test-retest reproducibility was good-excellent and fair-good for conventional and advanced echocardiographic measures, respectively, but lower than when re-reading the same images. All vascular measures demonstrated excellent or fair-good reproducibility.Conclusions: We describe the feasibility and reproducibility of detailed cardiovascular phenotyping in an ethnically diverse population. The data collected will lead to a better understanding of why people of South Asian and African Caribbean ancestry are at elevated risk of cardiometabolic diseases.

Background The use of biologic mesh in paraesophageal hernia repair (PEHR) has been associated with decreased short-term recurrence but no statistically significant difference in long-term recurrence. Because of this, we transitioned from routine to selective use of mesh for PEHR. The aim of this study was to examine our indications for selective mesh use and to evaluate patient outcomes in this population. Methods We queried a prospectively maintained database for patients who underwent laparoscopic PEHR with biologic mesh from October 2015 to October 2018, then performed a retrospective chart review. The decision to use mesh was made intraoperatively by the surgeon. Recurrence was defined as the presence of > 2 cm intrathoracic stomach on postoperative upper gastrointestinal (UGI) series. Results Mesh was used in 61/169 (36%) of first-time PEHRs, and in 47/82 (57%) of redo PEHRs. Among first-time PEHRs, the indications for mesh included hiatal tension (85%), poor crural tissue quality (11%), or both (5%). Radiographic recurrence occurred in 15% of first-time patients (symptomatic N = 2, asymptomatic N = 3). There were no reoperations for recurrence. Among redo PEHRs, the indication for mesh was most commonly the redo nature of the repair itself (55%), but also hiatal tension (51%), poor crural tissue quality (13%), or both (4%). Radiographic recurrence occurred in 21% of patients (symptomatic N = 4, asymptomatic N = 1). There was 1 reoperation for recurrence in the redo-repair group. Conclusions We selectively use biologic mesh in a third of our first-time repair patients and in over half of our redo-repair patients when there is a perceived high risk of recurrence based on hiatal tension, poor tissue quality, or prior recurrence. Despite the high risk for radiologic recurrence, there was only 1 reoperation for recurrence in the entire cohort.