The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on revisional bariatrics.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program designated bariatric surgery as a clinical pathway. Among the tiers of the Masters Program, revisional bariatric surgery is the highest tier of "mastery" within the pathway. This article presents the top 10 seminal studies representing the current landscape of revisional bariatrics. METHODS: The literature was systematically searched and seminal articles designated by consensus agreement of the SAGES Metabolic and Bariatric Surgery committee using multiple criteria, including impact on the field, citation frequency, and expert opinion. Articles were reviewed by committee members and presented in summarized fashion. RESULTS: The top 10 papers are presented in grouped thematic categories covering the early evolution of revisional bariatrics, changing criteria for reoperative bariatric surgery, divergence of revision versus conversion bariatric surgery, and recent technologic innovations in revisional bariatric surgery. Each summary is presented with expert appraisal and commentary. CONCLUSION: These seminal papers represent a snapshot of the dynamic field of revisional bariatric surgery and emphasize the need to not only remain current with contemporary trends but also keep a patient-oriented perspective on patient and intervention selection for optimal success.

SAGES white paper on the current state of community practice surgeons: re-discovering the value of our community practice surgeons.

BACKGROUND: The Community Practice (CP) surgeon is the first point of access to surgical care globally and performs the majority of procedures in the USA. CP surgeons include those of various practice models, locations and communities, education and training, and much more. It is a diverse group that drives quality, access to care, research, and innovation. The SAGES CP Committee was formed to better define the role and highlight the contribution of the CP surgeon, as well as advocate for the position of CP surgeons in our society. METHODS: In 2018, a survey was distributed to the SAGES membership asking members to self-identify as either a Community Surgeon or Academic Surgeon. RESULTS: The majority (71%) of SAGES members surveyed self-identified as "Community Surgeons." This was in stark contrast to the distribution of Community versus Academic Surgeons in SAGES leadership (25% versus 75%, respectively). CONCLUSION: By better defining the characteristics and role of the CP, SAGES will be better informed on how to effectively engage with this large group within the society and increase its representation within the leadership. The CP Committee met on a biannual basis over a period of two years focusing on assessing their role in the SAGES organization. The committee members created the following initial goals: (1) define in a broad sense the characteristics of a CP Surgeon, (2) discuss and characterize the value of the CP surgeons, (3) highlight past and future areas of contributions of the group, and (4) delineate ways to engage and represent this subgroup. This manuscript is a culmination of the work of this committee while also serving as a way to support the initiatives and direction of SAGES leadership.

Long-term follow-up evaluation of endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass.

BACKGROUND: Endoscopic sclerotherapy using sodium morrhuate has been used to treat patients with weight regain after Roux-en-Y gastric bypass whose presumed etiology is loss of restriction due to gastrojejunostomy dilation. Weight loss and stability have been demonstrated in several studies with short-term follow-up evaluation. METHODS: This retrospective review evaluated all the patients who underwent sclerotherapy for a dilated gastrojejunostomy between 2007 and 2012. RESULTS: The study identified 48 patients with a mean follow-up period of 22 months (range 12-60 months). The mean age of these patients was 47.5 ± 10.5 years, and 92 % were women. The average weight loss from the primary procedure was 132.5 ± 54.82 lb, and the average weight regain from the lowest weight to the maximum weight before sclerotherapy was 46 ± 40.32 lb. The median number of sclerotherapy sessions was two (range 1-4). The pre-procedure mean gastrojejunostomy diameter was 20 ± 3.6 mm, and the mean volume of sodium morrhuate injected per session was 12.8 ± 3.7 ml. The average weight loss from sclerotherapy to the final documented weight was 3.17 ± 19.70 lb, which was not statistically significant. The following variables in the multivariate analysis were not associated with statistically significant weight loss: volume of sodium morrhuate, patient age, gastrojejunostomy diameter, number of sclerotherapy sessions, decrease in gastrojejunostomy diameter between the first and second sessions, and number of follow-up years. Weight stabilization or loss was achieved by 58 % of our cohort, with a mean weight loss of 15.9 ± 14.6 lb in this subgroup. CONCLUSION: The long-term follow-up evaluation of patients undergoing sclerotherapy of the gastrojejunostomy for weight regain after gastric bypass showed only a marginal weight loss, which was not statistically significant in our study population, although more than 50 % of the patients achieved weight loss or stabilization.

Laparoscopic repair of perforated marginal ulcer following Roux-en-Y gastric bypass: a case series.

INTRODUCTION: Marginal ulcer perforation is a known complication of Roux-en-Y gastric bypass (RYGB), and laparoscopic repair may be a feasible option minimizing the morbidity associated with a large laparotomy incision. We present our experience with laparoscopic repair of perforated marginal ulcers in patients who have previously undergone RYGB. METHODS: A retrospective chart review from August 2005 to April 2007 was performed identifying all patients who underwent laparoscopic repair of perforated marginal ulcer after RYGB at one hospital. The perforation was repaired either by laparoscopic primary suture closure followed by application of an omental patch or by laparoscopic Graham patch without primary suture repair. Operative time, duration of hospitalization, postoperative follow-up, and postoperative complications were recorded. Data are presented as mean ± standard deviation. RESULTS: Six patients underwent laparoscopic repair of a perforated marginal ulcer. Operative time was 101.8 ± 50 minutes with a mean hospitalization of 5.3 ± 2.7 days. Follow-up was 6.2 ± 7.5 months. Postoperative complications included 2 patients with nausea and vomiting related to an exposed suture at the gastrojejunostomy, 1 patient with chronic gastritis, and 1 patient developed a stricture at the gastrojejunostomy. CONCLUSIONS: We present the largest series to date of laparoscopic repair of perforated marginal ulcers utilizing an omental patch for repair. We demonstrate that a laparoscopic repair can be completed in a reasonable operative time, with minimal postoperative hospitalization, and low associated morbidity. Patients who develop a perforated marginal ulcer after RYGB can be safely and effectively treated with laparoscopic repair with an omental patch.

Laparoscopic transperitoneal repair of flank hernias: a retrospective review of 27 patients.

INTRODUCTION: Incisional hernias of the flank are rare with scattered case reports regarding the feasibility of laparoscopic treatment. Treatment can be technically challenging due to patient positioning and adequate mesh overlap and fixation. The aim of this study is to describe the surgical technique and present outcomes of the largest known case series of laparoscopic repair of flank hernia. METHODS: A retrospective chart review was performed from April 2002 to August 2006 at two university hospitals utilizing three surgeons' experience. All patients who underwent a laparoscopic repair of a flank hernia were identified and reviewed with regards to short-term outcomes. RESULTS: Twenty-seven patients were identified with incisional flank hernia treated laparoscopically. Average defect size was 188 cm(2) repaired with an average mesh size of 650 cm(2). Mean operating room (OR) time was 144 min and mean length of stay (LOS) was 3.1 days. There were two reoperations within the cohort: one for a new, unrelated midline hernia 7 months after repair of the initial flank hernia and one for chronic pain with removal of a previously placed polypropylene mesh in the subcutaneous tissue of the abdominal wall. Neither patient had failure of the laparoscopic flank hernia repair. Two other patients were conservatively treated for chronic pain. Mean follow-up was 3.6 months. CONCLUSIONS: In the laparoscopic repair of flank hernias adequate retroperitoneal dissection and wide mesh overlap is imperative. Laparoscopic repair can be performed safely and effectively with good short-term outcomes.

Technique of laparoscopic ventral hernia repair can be modified to successfully repair large defects in patients with loss of domain.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) can be challenging in patients with large abdominal wall defects and loss of domain (LOD). When hernia contents are reduced, the pneumoperitoneum preferentially fills the sac, leaving no space for mesh manipulation. This study presents a modification for LVHR in LOD patients, as well as outcomes for a series of patients. METHODS: Between September 2002 and August 2004, 10 patients with large ventral hernias and LOD underwent attempts at LVHR. The technique is modified by placing additional trocars to allow for fixation from above the mesh. Patient data were harvested from a prospective database and analyzed. RESULTS: All hernias were recurrent in nature. Mean defect size was 626 cm(2), requiring 1 to 4 pieces of sutured Gore Dualmesh for a tension-free repair. Three patients' procedures were aborted after adhesiolysis, with concerns about missed enterotomies. All 3 underwent delayed mesh placement within the same hospitalization. Only 2 were successful. The third patient had significant bowel edema precluding mesh placement. Two patients were converted to open repairs (Rives-Stoppa and component separation). There were no mortalities, but there were 2 major complications: inferior vena cava thrombosis and transient abdominal compartment syndrome. In follow-up (7.7 months) there were 2 recurrences secondary to excision of infected mesh. CONCLUSION: It is possible to obtain a successful LVHR in patients with large defects and LOD. The technique is complex and is modified to allow for mesh fixation from above the mesh. Frequent change in patient positioning allows for visualization below the fascial defect.

Management of anastomotic leaks after Roux-en-Y bypass using self-expanding polyester stents.

BACKGROUND: To analyze the outcomes of a series of endoscopically placed polyester self-expanding polyflex stents (SEPSs) for the management of anastomotic leaks after Roux-en-Y bypass. Anastomotic leaks after gastric bypass cause significant morbidity and mortality. Covered polyester SEPSs might have a role in the treatment of these leaks. METHODS: A retrospective chart review was performed from January 2006 to November 2006 that included all acute and chronic leaks treated with SEPSs. RESULTS: A total of 6 patients were treated with stents, with a mean procedure time of 22 minutes. Of these 6 patients, 5 had acute postoperative leaks and 1 had a chronic fistula. Five patients started oral intake 1-6 days after their procedure. All acute leaks had complete healing at a median of 44 days. The patient with a chronic gastrocutaneous fistula required revisional surgery for fistula closure. In addition, 5 patients had stent migration, and 3 required stent replacement. CONCLUSION: An endoscopically placed SEPS provides a less-invasive alternative to treat acute anastomotic leaks after Roux-en-Y bypass while simultaneously allowing oral intake. The results of this case series have demonstrated this treatment to be safe and effective.

Use of endoscopic stents to treat anastomotic complications after bariatric surgery.

BACKGROUND: Complications after bariatric surgery often require longterm parenteral nutrition to achieve healing. Recently, endoscopic treatments have become available that provide healing while allowing for oral nutrition. The purpose of this study was to present outcomes of the largest series to date treating staple line complications after bariatric surgery with endoscopic covered stents. STUDY DESIGN: A retrospective evaluation was performed of all patients treated for staple line complications after bariatric surgery at a single tertiary care bariatric center. Acute postoperative leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after both gastric bypass and sleeve gastrectomy were included. RESULTS: From January 2006 to June 2007, 19 patients (11 with acute leaks, 2 with chronic fistulas, and 6 with strictures) were treated with a total of 34 endoscopic silicone covered stents (23 polyester, 11 metal). Mean followup was 3.6 months. Immediate symptomatic improvement occurred in 90% (91% of acute leaks, 100% of fistulas, and 84% of strictures). Oral feeding was started in 79% of patients immediately after stenting. Resolution of leak or stricture after stent treatment occurred in 16 of 19 patients (84%). Healing of leak, fistula, and stricture occurred at means of 33 days, 46 days, and 7 days, respectively. Three patients (1 with leak, 1 with fistula, and 1 with stricture) had unsuccessful stent treatment. Migration of the stent occurred in 58% of 34 stents placed. Most migration was minimal, but three stents were removed surgically after distal small bowel migration. There was no mortality. CONCLUSIONS: Treatment of anastomotic complications after bariatric surgery with endoscopic covered stents allows rapid healing while simultaneously allowing for oral nutrition. The primary morbidity is stent migration.

Use of decellularized human skin to repair esophageal anastomotic leak in humans.

Multiple surgical techniques have been described for repair of esophageal leaks. None of the repairs are optimal, and the morbidity and mortality of an esophageal leak remains high. To our knowledge, this is the first case report of use of AlloDerm (Lifecell Corp, Brachburg, NJ) to successfully repair a thoracic anastomotic esophageal leak.

Endovascular stent graft repair of a persistent sciatic artery aneurysm.

An 88-year-old female presented with a large, painful, pulsatile buttock mass. Computed tomographic angiogram with three-dimensional reconstruction and lower extremity arteriogram revealed a 5 cm sciatic artery aneurysm. We report a case of successful repair of a sciatic artery aneurysm with endovascular stent graft.

An evaluation of resident training in breast procedures.

BACKGROUND: The purpose of this study was to determine if senior residents are participating in advanced level breast cases. METHODS: A retrospective review of 1,583 breast procedures on 1,213 patients over 2 years was performed. Each case was evaluated for the type of case: (1) junior level (PGY 1 and 2)--core needle biopsy, fine needle aspirate, excisional biopsy, needle localized biopsy, lumpectomy, partial mastectomy, and simple mastectomy; and (2) senior level--stereotactic breast biopsy, sentinel lymph node biopsy, axillary dissection, and modified radical mastectomy. All cases were reviewed for level of resident involved. RESULTS: Overall, seniors performed 31% of the cases, junior residents performed 42%, and 27% were unattended by any resident. Senior level breast cases were specifically examined to compare whether a senior or junior was present. Overall, 891 defined senior cases were performed. A senior level resident attended 34% of these, leaving 66% covered by junior residents or uncovered altogether. CONCLUSIONS: It is clear when evaluating breast procedures that senior residents are less involved than junior residents. Furthermore, the fact that many of the reported cases (28%) and, more significantly, senior level cases (26%) have no resident involved leads us to conclude that senior level residents are not taking advantage of the opportunity to gain experience in performing advanced level breast procedures in our surgical program.