Background: Achalasia is a primary motility disorder of the esophagus, with approximately 5% of patients progressing to end-stage disease, defined as a dilated, tortuous esophagus which does not empty. These patients often have issues with ongoing chest pain, dysphagia, and regurgitation. Esophagectomy for the treatment of end-stage achalasia is controversial and recommended as a last resort by recent guidelines. This study evaluated long-term outcomes for patients following esophagectomy for end-stage achalasia. Methods: Questionnaires were mailed to patients who underwent esophagectomy for end-stage achalasia between 2001 to 2022 in South Australian hospitals. Outcome measures included symptoms at long-term follow-up, overall satisfaction measured on a 0-10 analogue score (0 = poor, 10 = highly satisfied), and level of function. Results: Of the 11 patients who underwent esophagectomy, eight completed a questionnaire at a mean of 7.2 years post-esophagectomy. The study included 6 men and 2 women with a median age of 52.5 years (interquartile range, 40-69 years). Operative mortality was 0%, with a complication rate of 38%. All patients indicated that they considered the decision to operate was correct, with a mean satisfaction score of 7.6 out of 10. Of the six patients who were gainfully employed prior to esophagectomy, five returned to their normal vocation. Conclusions: Esophagectomy can be considered as a treatment option for end-stage achalasia. All patients were positive about their decision to undergo major surgery, and all but one were satisfied with their long-term outcome. Despite recognition as an intervention of 'last resort', the decision to proceed to esophagectomy for end-stage achalasia should not be discounted.

IntroductionThe use of prosthetic mesh in laparoscopic repair of large hiatus hernias remains controversial. Clinical and quality of life outcomes from a randomized controlled trial of mesh versus suture repair previously showed few differences at early follow-up. This study evaluated longer-term quality of life outcomes from that trial.MethodsA prospective, multicentre, double blind randomized controlled trial assessed three methods of repair for large hiatus hernias: sutures-only versus absorbable mesh versus non-absorbable mesh. Quality of life was assessed using the Short-Form 36 (SF-36) questionnaire which was completed preoperatively and then at 3, 6, 12 months following surgery and annually thereafter. SF-36 outcomes were compared across the three repair techniques at longer-term follow-up (3-6 years), and to earlier baseline and 12-month outcomes.Results126 patients were randomized; 43-suture-only, 41-absorbable mesh and 42-non-absorbable mesh. Questionnaires were completed by 118 patients preoperatively, 115 at 12 months and 98 at longer-term follow-up (median 5 years). There were no significant differences between the repair techniques for the subscale and composite scores at longer-term follow-up. The mental component score improved significantly after surgery and was sustained across follow-up for all techniques. The physical component score also improved significantly but was lower at longer-term follow-up compared to the 12-month follow up in both mesh groups.ConclusionSurgical repair of large hiatus hernias provides sustained long-term improvement in quality of life. The addition of mesh does not improve quality of life.Trial RegistrationThis trial is registered with the Australia and New Zealand Clinical Trials Registry ACTRN12605000725662.

CONSTRUCT:We compared the quality of clinician-authored and student-authored multiple choice questions (MCQs) using a formative, mock examination of clinical knowledge for medical students.BACKGROUND:Multiple choice questions are a popular format used in medical programs of assessment. A challenge for educators is creating high-quality items efficiently. For expediency's sake, a standard practice is for faculties to repeat items in examinations from year to year. This study aims to compare the quality of student-authored with clinician-authored items as a potential source of new items to include in faculty item banks.APPROACH:We invited Year IV and V medical students at the University of Adelaide to participate in a mock examination. The participants first completed an online instructional module on strategies for answering and writing MCQs, then submitted one original MCQ each for potential inclusion in the mock examination. Two 180-item mock examinations, one for each year level, were constructed. Each consisted of 90 student-authored items and 90 clinician-authored items. Participants were blinded to the author of each item. Each item was analyzed for item difficulty and discrimination, number of item-writing flaws (IWFs) and non-functioning distractors (NFDs), and cognitive skill level (using a modified version of Bloom's taxonomy).FINDINGS:Eighty-nine and 91 students completed the Year IV and V examinations, respectively. Student-authored items, compared with clinician-authored items, tended to be written at both a lower cognitive skill and difficulty level. They contained a significantly higher rate of IWFs (2-3.5 times) and NFDs (1.18 times). However, they were equally or better discriminating items than clinician-authored items.CONCLUSIONS:Students can author MCQ items with comparable discrimination to clinician-authored items, despite being inferior in other parameters. Student-authored items may be considered a potential source of material for faculty item banks; however, several barriers exist to their use in a summative setting. The overall quality of items remains suboptimal, regardless of author. This highlights the need for ongoing faculty training in item writing.

Surgery is the only effective treatment strategy for a symptomatic pharyngeal pouch. However, octo- and nonagenarians are often denied referral to a surgeon because of perceived increased risks. Here, we compare the outcomes of pharyngeal pouch surgery in octo- and nonagenarians with patients under 80 years-of-age and determine the factors which predict post-operative complications and improvement in swallowing. Analysis of a prospectively maintained database of patients who underwent pharyngeal pouch surgery across seven hospitals over 15 years. In total, 113 patients (≥80 years-of-age: 27, <80 years-of-age: 86) underwent endoscopic or open pharyngeal pouch surgery. Despite more comorbidities and a longer hospital stay (median: one extra day), patients ≥80 years-of-age had comparable operative time, complication profile, intensive care admission, emergency reoperation, and revisional pouch surgery as their younger counterparts. Furthermore, the severity of complications was not significantly different between the two age cohorts. No surgical mortality was recorded. Multivariate analysis demonstrated that diverticulectomy combined with cricopharyngeal myotomy independently predicted higher rates of complications (OR: 4.53, 95% CI: 1.43–14.33, p = 0.010), but also greater symptomatic improvement (OR: 4.36, 95% CI: 1.50–12.67, p = 0.007). Importantly, a greater proportion of octo- and nonagenarians experienced improved swallowing than patients <80 years-of-age (96.3% vs. 74.4%, p = 0.013). Moreover, advanced age was not predictive of post-operative complications on multivariate analysis. Pharyngeal pouch surgery in octo- and nonagenarians is safe and effective. Surgical correction in this age group alleviates symptoms and improves quality-of-life for most patients. These patients should not be denied surgery on the basis of advanced age alone.

Abstract Laparoscopic Nissen fundoplication for gastro-oesophageal reflux is followed by troublesome side effects in some patients. Partial fundoplications are proposed for reflux control with less side effects. We reported earlier outcomes from a randomised control trial of Nissen vs. anterior 180° partial fundoplication, with a good outcome following anterior 180° partial fundoplication at up to 10 years follow-up. For this study we determined very late clinical outcomes at up to 20 years follow-up. Methods 107 patients were randomised to Nissen vs. anterior 180° partial fundoplication. 15–20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardised clinical questionnaire that included 0–10 analogue scores and yes/no questions to evaluate reflux symptoms, side-effects and overall satisfaction with surgery. Results Heartburn (mean score 3.2 vs 1.4, p = 0.001) and proton pump inhibitor use (41.7% vs 17.1%, p = 0.023) were higher, dysphagia for solids (mean score 1.8 vs 3.3, p = 0.015) was less, and ability to belch was better preserved (84.2% vs 65.9%, p = 0.030) after anterior fundoplication. Overall outcome measures were similar for both groups (mean satisfaction score 8.4 vs 8.0, p = 0.444; 86.8% vs 90.2% satisfied with outcome). Six patients underwent revision from anterior to Nissen fundoplication for reflux, and 5 from Nissen to partial fundoplication for dysphagia. Two further patients underwent revision following Nissen fundoplication for reflux and paraoesophageal hernia respectively. Conclusion At up to 20 years follow-up Nissen and anterior 180-degree partial fundoplication achieve similar rates over overall success, but with a demonstrable trade-off between better reflux symptom control vs. more side-effects after Nissen fundoplication.

Objective: To determine very late clinical outcomes at up to 20 years follow-up from a randomized controlled trial of Nissen versus anterior 180-degree partial fundoplication. Summary Background Data: Nissen fundoplication for gastroesophageal reflux can be followed by troublesome side effects. To address this, partial fundoplications have been proposed. Previously reports from a randomized controlled trial of Nissen versus anterior 180-degree partial fundoplication at up to 10 years follow-up showed good outcomes for both procedures. Methods: One hundred seven participants were randomized to Nissen versus anterior 180-degree partial fundoplication. Fifteen to 20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardized questionnaire with 0 to 10 analog scores and yes/no questions to determine reflux symptoms, side-effects, and satisfaction with surgery. Results: After anterior fundoplication heartburn (mean score 3.2 vs 1.4, P = .001) and proton pump inhibitor use (41.7% vs 17.1%, P = .023) were higher, offset by less dysphagia for solids (mean score 1.8 vs 3.3, P = .015), and better ability to belch (84.2% vs 65.9%, P = .030). Measures of overall outcome were similar for both groups (mean satisfaction score 8.4 vs 8.0, P = .444; 86.8% vs 90.2% satisfied with outcome). Six participants underwent revision after anterior fundoplication (Nissen conversion for reflux – 6), and 7 underwent revision after Nissen fundoplication (Nissen to partial fundoplication for dysphagia – 5; redo Nissen for reflux – 1; paraesophageal hernia –1). Conclusions: At 15 to 20 years follow-up Nissen and anterior 180-degree partial fundoplication achieved similar success, but with trade-offs between better reflux control versus more side-effects after Nissen fundoplication.

Objective To determine very late clinical outcomes at up to 20 years follow-up from a randomized controlled trial of Nissen vs. anterior 180-degree partial fundoplication. Summary background data Nissen fundoplication for gastroesophageal reflux can be followed by troublesome side effects. To address this, partial fundoplications have been proposed. Previously reports from a randomized controlled trial of Nissen vs. anterior 180-degree partial fundoplication at up to 10 years follow-up showed good outcomes for both procedures. Methods 107 participants were randomized to Nissen vs. anterior 180-degree partial fundoplication. 15-20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardized questionnaire with 0-10 analogue scores and yes/no questions to determine reflux symptoms, side-effects and satisfaction with surgery. Results After anterior fundoplication heartburn (mean score 3.2 vs 1.4, p = 0.001) and proton pump inhibitor use (41.7% vs 17.1%, p = 0.023) were higher, offset by less dysphagia for solids (mean score 1.8 vs 3.3, p = 0.015), and better ability to belch (84.2% vs 65.9%, p = 0.030). Measures of overall outcome were similar for both groups (mean satisfaction score 8.4 vs 8.0, p = 0.444; 86.8% vs 90.2% satisfied with outcome). Six participants underwent revision following anterior fundoplication (Nissen conversion for reflux - 6), and 7 underwent revision following Nissen fundoplication (Nissen to partial fundoplication for dysphagia - 5; redo Nissen for reflux - 1; paraesophageal hernia -1). Conclusions At 15-20 years follow-up Nissen and anterior 180-degree partial fundoplication achieved similar success, but with trade-offs between better reflux control vs. more side-effects after Nissen fundoplication.

Pseudoachalasia, or secondary achalasia, is an uncommon esophageal dysmotility syndrome with symptoms and manometric findings indistinguishable from primary achalasia, but due to any mechanism other than idiopathic degeneration of the inhibitory neurons of the esophageal submucosal myenteric plexus. Whilst pseudoachalasia is rare, affecting some 1.4–5.4% of all achalasia patients, it is essential this diagnosis is always considered and excluded, as the treatment and outcomes for these patients will be very different from those with true achalasia. Pseudoachalasia can be difficult to differentiate from primary or “idiopathic achalasia”. Several particular clinical features have been described as more common in patients with pseudoachalasia than in achalasia, but because of the low prevalence of this condition, the positive predictive value remains low. The majority of patients with pseudoachalasia have an underlying malignancy, predominantly gastro-esophageal adenocarcinoma, which is usually advanced. Management revolves around treating the underlying cause where possible, as this may lead to reversal of the esophageal dysmotility. In patients presenting with symptoms and manometry findings consistent with achalasia, the diagnosis initially should be one of an achalasia-like syndrome. Idiopathic achalasia can then only be confirmed after other potential causes have been considered and excluded. We describe a case of pseudoachalasia encountered in our clinical practice, followed by a review of current practice regarding diagnosis and management of pseudoachalasia.

Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29-0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95% CI: 1.17-3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.

OBJECTIVE To determine whether absorbable or nonabsorbable mesh repair of large hiatus hernias is followed by less recurrences at late follow-up compared to sutured repair. SUMMARY OF BACKGROUND DATA Radiological recurrences have been reported in up to 30% of patients after repair of large hiatus hernias, and mesh repair has been proposed as a solution. Earlier trials have revealed mixed outcomes and early outcomes from a trial reported previously revealed no short-term advantages for mesh repair. METHODS Multicentre prospective double-blind randomized controlled trial of 3 methods of hiatus hernia repair; sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome - hernia recurrence assessed by barium meal X-ray and endoscopy at 3-4 years. Secondary outcomes - clinical symptom scores at 2, 3, and 5 years. RESULTS 126 patients were enrolled - 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Clinical outcomes were obtained at 5 years in 89.9%, and objective follow-up was obtained in 72.3%. A recurrent hernia (any size) was identified in 39.3% after suture repair, 56.7% - absorbable mesh, and 42.9% - nonabsorbable mesh (P = 0.371). Clinical outcomes were similar at 5 years, except chest pain, diarrhea, and bloat symptoms which were more common after repair with absorbable mesh. CONCLUSIONS No advantages were demonstrated for mesh repair at up to 5 years follow-up, and symptom outcomes were worse after repair with absorbable mesh. The longer-term results from this trial do not support mesh repair for large hiatus hernias.

BACKGROUND:The side-effects of Nissen fundoplication have led to modifications, including partial fundoplications such as an anterior 90° wrap. Five-year follow-up of two randomized trials suggested fewer side-effects following anterior 90° partial fundoplication, but better reflux control after Nissen fundoplication. However, longer-term outcomes have not been reported. This study combined data from previous trials to determine 10-year outcomes.METHODS:From 1999 to 2003, 191 patients were enrolled in two randomized trials comparing anterior 90° partial versus Nissen fundoplication. Trial protocols were similar, and data were combined to determine long-term clinical outcomes. Patients completed annual questionnaires assessing dysphagia, heartburn, medications, satisfaction and other symptoms. Visual analogue scales (0-10), a composite dysphagia score (0-45) and yes/no responses were used.RESULTS:Of the 191 patients, 152 (79·6 per cent) were available for 10-year follow-up. After anterior 90° fundoplication, patients reported less dysphagia to solids (score 2·03 versus 3·18 for the Nissen procedure; P = 0·037). Heartburn scores were lower after Nissen fundoplication (1·90 versus 2·83 for anterior 90° fundoplication; P = 0·035) and fewer patients required proton pump inhibitors (PPIs) (22 versus 39 per cent respectively; P = 0·035). Satisfaction scores were similar for both anterior 90° and Nissen groups (7·45 versus 7·36 respectively; P = 0·566), and the majority considered their original decision for surgery to be correct (86 versus 84 per cent; P = 0·818).CONCLUSION:After 10 years, both procedures achieved similar success as measured by global satisfaction measures. Patients who had a Nissen fundoplication reported more dysphagia, whereas more heartburn and PPI consumption were reported after anterior 90° fundoplication. Registration numbers: ACTRN12607000298415 and ACTRN12607000304437 (http://www.anzctr.org.au/).

Objective: To evaluate late outcomes from a randomized trial of division versus no division of short gastric vessels during laparoscopic Nissen fundoplication at up to 20 years follow-up. Background: Nissen fundoplication is an established procedure for the treatment of gastroesophageal reflux disease. Controversy about whether side effects such as dysphagia could be reduced by division of the short gastric vessels led to the establishment of a randomized trial in 1994. Early results showed equivalent reflux control and dysphagia, but more bloating after vessel division. Methods: A total of 102 patients underwent a laparoscopic Nissen fundoplication between May 1994 and October 1995, and were randomized to short gastric vessel division (50) versus nondivision (52). Follow-up was obtained yearly to 20 years using a standardized questionnaire administered by a blinded investigator. Clinical outcomes at 20 years or most recent follow-up were determined. Results: No significant differences for heartburn symptom and satisfaction scores or medication use were found between treatment groups. At 15 to 20 (mean 19.6) years follow-up, significant differences persisted for epigastric bloating: 26% versus 50% for nondivision versus division groups (P = 0.046). Heartburn symptom scores were low and not different for nondivision versus division groups (mean analog scores 1.4 vs 2.1/10, P = 0.152). Overall satisfaction after surgery was high in both groups (mean analog scores 8.1 vs 8.6/10, P = 0.989). Conclusions: Although laparoscopic Nissen fundoplication has durable efficacy for heartburn symptom control at up to 20 years follow-up, division of short-gastric vessels failed to confer any reduction in side effects, and was associated with persistent epigastric bloat symptoms at late follow-up in this trial.

Background:The multiple-choice question (MCQ) has been shown to measure the same constructs as the short-answer question (SAQ), yet the use of the latter persists. The study aims to evaluate whether assessment using the MCQ alone provides the same outcomes as testing with the SAQ.Methods:A prospective study design was used. A total of 276 medical students participated in a mock examination consisting of forty MCQs paired to forty SAQs, each pair matched in cognitive skill level and content. Each SAQ was marked by three independent markers. The impact of item-writing flaws (IWFs) on examination outcome was also evaluated.Results:The intraclass correlation coefficient (ICC) was 0.75 for the year IV examinations and 0.68 for the year V examinations. MCQs were more prone to IWFs than SAQs, but the effect when present in the latter was greater. Removal of questions containing IWFs from the year V SAQ allowed 39% of students who would otherwise have failed to pass.Discussion:The MCQ can test higher order skills as effectively as the SAQ and can be used as a single format in written assessment provided quality items testing higher order cognitive skills are used. IWFs can have a critical role in determining pass/fail results.

This article was migrated. The article was marked as recommended. Background: Item-writing flaws (IWFs) are common in multiple choice questions (MCQs) despite item-writing guidelines. Previous studies have shown that IWFs impact validity as observed through student performance, item difficulty, and discrimination. Most previous studies have examined IWFs collectively and have shown that they have a diverse impact. The aim of the study was to determine if the effects of individual types of IWFs are systematic and predictable. Method: A cross-over study design was used. 100 pairs of MCQ items (with and without an IWF) were constructed to test 10 types of IWFs. Medical students were invited to participate in a mock examination. Paper A consisted of 50 flawed followed by 50 unflawed items. Paper B consisted of 50 unflawed followed by 50 flawed items. The effect of each of the IWFs on mean item scores, item difficulty and discrimination were examined. Results: The hypothesised effect of IWFs on mean item scores was confirmed in only 4 out of 10 cases. 'Longest choice is correct', 'Clues to the right answer (Eponymous terms)' and 'Implausible distractors' positively impacted, while 'Central idea in choices rather than stem' negatively impacted mean item scores. Other flaws had either the opposite or no statistically significant effect. IWFs did not impact item difficulty or discrimination. Conclusion: The effect of IWFs is neither systematic nor predictable. Unpredictability in assessment produces error and thus loss of validity. Therefore, IWFs should be avoided. Faculties should be encouraged to invest in item-writing workshops in order to improve MCQs. However, the cost of doing so should be carefully weighed against the benefits of developing programmes of assessment.

Abstract Background Nissen fundoplications have been reported to have various side effects, which have led to modifications, including partial fundoplications such as anterior 90° wrap. Five-year follow up of randomised trials suggest less side effects following anterior 90° partial compared to Nissen fundoplication, although Nissen fundoplication achieved better reflux control. There is, however, limited longer-term outcome data for Nissen versus 90° anterior partial fundoplication. This study determined outcomes of previous randomised control trials at 10 + years follow-up. Methods From 1999 to 2003, 191 patients were enrolled in two randomised trials comparing anterior 90° partial versus Nissen fundoplication, with outcomes available for 155 (78%) at 10 years. Patients completed annual questionnaires assessing dysphagia, heartburn, medications, satisfaction and other symptoms. Visual analogue scales (0–10), a validated dysphagia score (0–45), Visick score (1–5) and yes/no responses were used. The two trials were combined to evaluate long-term outcomes. Results Following anterior 90° fundoplication patients reported less dysphagia to liquids (0.8 vs 1.8, P = 0.032) and solids (2.0 vs 3.3, P = 0.015). Dysphagia assessed using the 0–45 scale was also less following anterior 90° fundoplication (7.6 vs 12.7, P = 0.023). There was no significant difference in heartburn scores (2.8 vs 1.9 P = 0.053), although more patients were consuming PPIs following anterior 90° fundoplication at 10 years (43.8% vs 20.0% P = 0.004). Overall satisfaction scores were similar for both groups (7.9 vs 7.5, P = 0.215), and the majority considered their original decision for surgery to be correct (78.1% vs. 84.6%, P = 0.387). Reoperation rates were similar (anterior 90° - 13.7% vs Nissen 10.8%, P = 0.796). Conclusion At 10 years follow up, both procedures achieved similar overall success rates as measured by global satisfaction measures, but with more dysphagia following Nissen fundoplication, versus a higher rate of PPI consumption after anterior 90° fundoplication. Heartburn symptom differences failed to reach statistical significance. Disclosure All authors have declared no conflicts of interest.

Reply: We appreciate the interest of Antoniou et al in our recent article titled ‘‘Laparoscopic Repair of very Large Hiatus Hernia with Sutures Versus Absorbable Mesh Versus Nonabsorbable Mesh: A Randomized Controlled Trial.’’ They correctly highlight the limitations of the data we reported. In particular, they highlight the difference between clinical significance versus statistical significance. Before generalizing outcomes from any randomized trial to clinical practice, any differences identified must be determined to be not only statistically significant, but also clinically significant. In other words, the effect size or magnitude of difference must be big enough to be significant in the clinical context. Using P values alone to assess the significance of data is not appropriate, and we hope the readers of our article will also consider the clinical data, which were extensively described in our report. We are acutely aware that the data presented in our randomized trial might be interpreted in different ways, perhaps influenced by bias and beliefs held by individual readers. Our study showed that some outcome differences reached statistical significance in secondary analyses. However, these differences were small and unlikely to be clinically significant. The primary outcome measures were not statistically different. All data were presented in the report and we hope that readers will carefully consider the outcomes and draw reasonable conclusions. Our study was powered a priori to identify a 25% reduction in the incidence of hiatus hernia (identified at x-ray or endoscopy) between either of the mesh groups versus the suture repair group. We are confident that all readers will agree that a reduction of this magnitude is clinically significant. A secondary power calculation showed that when the 2 mesh groups were combined, then for comparison of mesh versus sutured repair the study was powered to detect a 13% difference. This is still likely to be of clinical importance. The actual outcomes that were identified to be different at P < 0.05 were all small, and we do agree with Antoniou et al that these differences are unlikely to be clinically significant. However, we disagree with the implication that the trend differences between the Timesh repair versus sutured repair groups can be claimed to be clinically significant. Although a trend is evident in the data presented, this trend never reached statistical significance, so it is not reasonable to claim this is a clinically significant difference. As pointed out in our article, it is possible that these differences might become significant in a larger trial, but equally they might not, so we encourage more randomized trials, which address this question. It should be noted, however, that when setting up our trial, the power calculations and recruitment targets were based on outcomes reported from previous trials, and our trial actually enrolled more patients than any previously reported randomized trial, including the trial reported from Antoniou et al’s group in 2005. We agree with Antoniou et al that longer follow-up is required, and individuals recruited are currently completing endoscopy and barium meal x-ray radiology at 3–4 years follow-up. These data will be analyzed and reported when the trial will be completed. Currently, the only randomized trial reporting long-term follow-up failed to show any difference for mesh versus no mesh at median 5 years follow-up, similar to the results reported in our article. It is now 10 years since Antoniou et al’s group described 12 months follow-up in their earlier trial, and we would be very interested to see their long-term follow-up data. In the absence of long-term outcomes from randomized trials reporting evidence of improved outcomes for mesh, the efficacy of mesh repair of the hiatus during laparoscopic repair of very large hiatus hernia remains uncertain.

PURPOSEFollow-up practices for patients who have undergone surgical resection of esophagogastric malignancies are variable and poorly documented. To better understand practice, a questionnaire was used to survey surgeons and medical oncologists to determine whether any consensus exists.METHODSAn opt-in online questionnaire was sent to esophagogastric surgeons and medical oncologists via the membership lists for the Australian and New Zealand Gastric and Oesophageal Surgery Association (ANZGOSA), the Australian Gastro-Intestinal Trials Groups (AGITG), and the Medical Oncology Group of Australia (MOGA). The questionnaire proposed five clinical scenarios and provided a range of follow-up options for each scenario. Clinicians were asked to indicate which best matched their clinical practice.RESULTSMost clinicians follow patients for at least 3-5 years following resection of gastric or esophageal cancer. In total, 52% perform routine surveillance imaging, with individual scenarios not altering this. Tumor markers are infrequently used. Endoscopy and routine blood tests are used by around half the respondents.CONCLUSIONThere was little consensus about the use of investigations to monitor patients following esophagogastric cancer surgery. Choices do not follow guidelines or evidence. The identified patterns of postoperative surveillance practice appear not to be evidence based, and generally do not match recently published Australian guidelines.

Achalasia is a disease characterized by dysphagia, regurgitation, chest pain, and weight loss. It is now classified into three subtypes according to the Chicago classification. Type III achalasia is characterized by lower esophageal sphincter obstruction but also spastic activity in the esophageal body. This spastic activity could lead to a different symptom profile to other achalasia patients. We reviewed the notes of 36 patients with type III achalasia to determine their clinical presentation. We compared them with 137 patients with type II achalasia and 21 with distal esophageal spasm. Type III patients had a mean age of 63 years, and they had symptoms for a mean of 4.5 years prior to diagnosis. 97% presented with dysphagia, 79% with regurgitation, 61% with chest pain and 22% with weight loss. This pattern was similar to that of type II patients with the exception of age (mean of 63 years vs. 52 years) and length of symptoms prior to diagnosis (mean of 4.5 years vs. 2.5 years). Type III patients had a similar age (mean of 63 years and 64 years) to distal esophageal spasm patients. Type III patients have a similar symptom profile to type II patients, and more symptoms than distal esophageal spasm patients, suggesting that most symptoms in achalasia are due to lower esophageal sphincter obstruction rather than esophageal spasm. Type III achalasia patients arise in a distinctly older population than type II achalasia, suggesting these two groups might be distinct regarding their underlying pathophysiological process.

INTRODUCTION: An accurate and rapid assessment of an acutely unwell patient's clinical status is paramount for the physician. There is an increasing trend to rely on investigations and results to inform a clinician of a patient's clinical status, with the subtleties of clinical observation often ignored. The aim of this study was to determine if a patient's use of a smartphone during the initial clinical assessment by a surgical consultant could be used as a surrogate marker for patient well-being, represented as their suitability for same-day discharge. METHODS: This was a prospective observational study performed over 2 periods at a tertiary hospital in South Australia. All patients admitted by junior surgical doctors from the emergency department to the acute surgical unit were eligible for inclusion. Upon consultant review, their status as a smartphone user was recorded in addition to their duration of hospital stay and basic demographic data. All patients and all but 1 of the consultants were blinded to the trial. RESULTS: Two hundred and twenty-one patients were eligible for inclusion. Of these patients, 11.3% were observed to be using a smartphone and 23.5% of patients were discharged home on day 1. Those who were observed to be using a smartphone were 5.29 times more likely to be discharged home on day 1 and were less likely to be subsequently readmitted. CONCLUSIONS: The addition of the smartphone sign to a surgeon's clinical acumen can provide yet another tool in aiding the decision for suitability for discharge. (C) 2018 Society of Hospital Medicine

Objective: The aim of the current study was to assess symptomatic outcome and need for surgical reintervention for patients identified with pathological esophageal acid exposure by routine postoperative 24-hour pH-monitoring. Background: Although laparoscopic fundoplication is associated with excellent short- and midterm results, recurrent symptoms pose an important challenge. Postoperative pH-monitoring is considered the “gold standard” for diagnosing recurrent GERD and frequently used for routine postoperative follow up. Methods: Analysis of prospectively collected data from patients who underwent laparoscopic fundoplication between April 1994 and June 2015 and underwent routine postoperative 24-hour pH-monitoring was performed. Symptomatic outcome and need for surgical reintervention up to 5 years was compared between patients with pathological and physiological postoperative esophageal acid exposure. Primary endpoints were heartburn score and need for surgical reintervention for recurrent reflux. Results: A total of 309 patients in whom routine postoperative 24-hour pH-monitoring was performed were included. Pathological acid exposure was present in 33 patients (11%) compared with 276 patients (89%) with physiological acid exposure. During 5-year follow up, there were no differences in heartburn, dysphagia, or satisfaction scores. Eighteen percent of all patients with abnormal postoperative pH-studies underwent redo fundoplication during 5-year follow up. Conclusions: Pathological acid exposure demonstrated by routine postoperative pH-monitoring was not associated with worse symptomatic outcome in terms of reflux control and satisfaction. A possible explanation for this finding is that laparoscopic fundoplication reduces the patients’ ability to perceive reflux. This underlines the importance of assessing the association between symptomatic outcome and esophageal function tests in determining outcome of antireflux surgery.