Outcome of gastric electrical stimulator with and without pyloromyotomy for refractory gastroparesis.

BACKGROUND: Surgical treatments of refractory gastroparesis include pyloromyotomy and gastric electrical stimulator (GES). It is unclear if patients may benefit from a combined approach with concomitant GES and pyloromyotomy. METHODS: Retrospective cohort analysis of all patients with refractory gastroparesis treated with GES implantation with and without concomitant pyloromyotomy at Cleveland Clinic Florida from January 2003 to January 2023. Primary endpoint was efficacy (clinical response duration and success rate) and secondary endpoints included safety (postoperative morbidity) and length of stay. Success rate was defined as the absence of one of the following reinterventions during follow-up: Roux-en-Y gastric bypass (RYGB), pyloromyotomy, GES removal. RESULTS: During a period of 20 years, 134 patients were treated with GES implantation. Three patients with history of previous surgical pyloromyotomy or RYGB were excluded from the analysis. Median follow-up was 31 months (IQR 10, 72). Forty patients (30.5%) had GES with pyloromyotomy, whereas 91 (69.5%) did not have pyloromyotomy. Most of the patients had idiopathic (n = 68, 51.9%) or diabetic (n = 58, 43.3%) gastroparesis. Except for preoperative use of opioids (47.5 vs 14.3%; p < 0.001), patient's characteristics were similar in both groups. There were no significant differences between the two groups in terms of overall postoperative complications (17.5% vs 14.3%; p = 0.610), major postoperative complications (0% vs 2.2%; p = 1), and length of stay (2(IQR 1, 2) vs 2(IQR 1, 3) days; p = 0.068). At 5 years, success rate was higher in patients with than without pyloromyotomy however not statistically significant (82% versus 62%, p = 0.066). Especially patients with diabetic gastroparesis seemed to benefit from pyloromyotomy during GES (100% versus 67%, p = 0.053). In an adjusted Cox regression, GES implantation without pyloromyotomy was associated with a 2.66 times higher risk of treatment failure compared to GES implantation with pyloromyotomy (HR 2.66, 95% CI 1.03-6.94, p = 0.044). CONCLUSION: Pyloromyotomy during GES implantation for gastroparesis seems to be associated with a longer clinical response with similar postoperative morbidity and length of hospital stay than GES without pyloromyotomy. Patient with diabetic gastroparesis might benefit from a combination of GES implantation and pyloromyotomy.

Understanding intraoperative fluorescent cholangiography: ten steps for an effective and successful procedure.

BACKGROUND: Common bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) continue to be the source of morbidity and mortality. The reason for BDI is mostly related to the misidentification of the extrahepatic bile duct structures and the anatomic variability. Near-infrared fluorescent cholangiography (NIFC) has proven to enhance visualization of extrahepatic biliary structures during LCs. The purpose of this study was to describe the most important steps in the performance of NIFC. METHODS: In accordance to the most current surgical practice of LC at our institution, a consensus was achieved on the most relevant steps to be followed when utilizing NIFC. Dose of indocyanine green (ICG), time of administration, and identification of critical structures were previously determined based on prospective and randomized controlled studies performed at CCF. RESULTS: The ten steps identified as critical when performing NIFC during LC are preoperative administration of ICG, exposure of the hepatoduodenal ligament, initial anatomical evaluation, identification of the cystic duct and common bile duct junction, the cystic duct and its junction to the gallbladder, the CHD, the common bile duct, accessory ducts, cystic artery and, time-out and identification of Calot's triangle, and evaluation of the liver bed. CONCLUSIONS: Routine use of NIFC is a useful diagnostic tool to better visualize the extrahepatic biliary structures during LC. The implementation of specific standardized steps might provide the surgeon with a better algorithm to use this technology and consequently reduce the incidence of BDI.

Complications of feeding jejunostomy placement: a single-institution experience.

BACKGROUND: Feeding jejunostomy is an alternative route of enteral nutrition in patients undergoing major gastrointestinal operations when a feeding gastrostomy is not suitable. METHODS: A single institution review of patients who underwent open or laparoscopic jejunostomy tube (JT) placement between 2009 and 2019 was performed. Data collected included demographics, preoperative serum albumin, surgery indication, concomitancy of procedure, size of JT tube and time to its removal. JT complications were analyzed in the early postoperative period (< 30 days) and in a long-term follow-up (> 30 days). The Chi-square test was used to compare rates of complications according to tube size. RESULTS: Seventy-three patients underwent JT placement, and gastroesophageal cancer (n = 48, 65.7%) was the most common indication. The JT was most frequently placed concomitantly (n = 56, 76.7%) to the primary operation and through a laparoscopic approach (n = 66, 90.4%). A total of 14 patients (19.1%) had early complications and 15 had late complications (20.5%). The reasons for early complications were clogged JT (n = 8, 10.9%), JT dislodgement (n = 3, 4.1%), leakage (n = 2, 2.7%), small bowel obstruction adjacent to the site of the jejunostomy tube (n = 2, 2.7%), JT site infection (n = 1, 1.3%), and intraperitoneal JT displacement (n = 1, 1.3%). The reasons for late complications were clogged JT (n = 6, 8.2%), JT dislodgement (n = 6, 8.2%), JT site infection (n = 3, 4.1%), and JT leakage (n = 1, 1.3%). There was no procedure-related mortality in this series. However, 12 patients (16.4%) died due to their baseline disease. The mean time to tube removal was 83.4 ± 93.6 days. The most frequently used JT size was 14 French (n = 39, 53.4%) but in nine patients the tube size was not reported. No statistical significance (p = 0.75) was found when comparing the two most commonly used sizes to rates of complications. CONCLUSION: The rate of JT complications in our study is comparable to other published reports in literature. As an alternative route for nutritional status optimization, the procedure appears to be safe despite the number of complications.

Impact of rapid weight loss after bariatric surgery on the prevalence of arterial hypertension in severely obese patients with chronic kidney disease.

BACKGROUND: Arterial hypertension (HTN) is one of the most important risk factors for the development and progression of chronic kidney disease (CKD). Rapid weight loss after bariatric interventions has a positive impact on blood pressure levels of hypertensive patients. The aim of our study is to assess the prevalence of HTN in patients with CKD after bariatric surgery (BS). METHODS: We retrospectively reviewed severely obese patients who underwent BS from 2010 to 2017. We used guidelines of the American College of Cardiology to define HTN. Only patients meeting ACC criteria and the calculation of estimated glomerular filtration rate (eGFR) using CKD epidemiology collaboration study equation preoperatively and at 12-month follow-up were included in the analysis. RESULTS: From a total of 2900 patients, 29.13% (845) met the required criteria and had variables for the calculation of eGFR recorded preoperatively. 36.92% (312) had preoperative HTN and s classified as CKD stage ≥ 2. We observed a predominantly female population 63.83% (203) with mean age of 54.10 ± 11.58. Patients preoperatively classified in CKD 2, 3a, and 3b exhibited the greatest prevalence reduction of HTN at 12-month follow-up (68.59%, n = 214 vs. 36.59%, n = 114; 16.67%, n = 52 vs. 6.41%, n = 20; 7.69%, n = 24 vs. 1.28%, n = 4; p < 0.0001). A marked improvement in CKD was also observed along with improvement in HTN. The greatest benefit corresponded to patients classified preoperatively in CKD 2, 3a and 3b. A total of n = 70 (62.5%) patients with HTN were classified as CKD 2 preoperatively compared to n = 55 (49.11%) at 12-month follow-up (p = 0.0436). Similarly, n = 22 (19.64%) patients with HTN were classified preoperatively as CKD 3a compared to n = 7 (6.25%) and n = 12 (10.71%) patients as CKD 3b compared to n = 4 (3.57%) during the same time period (p = 0.0028, p = 0.0379, respectively). CONCLUSIONS: Rapid weight loss after BS significantly reduces prevalence of HTN in all stages of CKD at 12-month follow-up. Additionally, there was a positive impact on classification of CKD at 12-month follow-up.

Metabolic Surgery Reduces the Risk of Progression From Chronic Kidney Disease to Kidney Failure.

INTRODUCTION: According to the Chronic Kidney Disease Prognosis Consortium (CKD-PC), 1 in 4 patients age ≥ 65 in North America has some form of chronic kidney disease (CKD), while 3 in 100 will progress to kidney failure. The aim of this study was to evaluate whether bariatric surgery alters the progression of CKD to kidney failure in patients who are severely obese. METHODS: We conducted a retrospective review of all patients who underwent bariatric surgery at our institution over the last 16 years. Kidney function and injury were assessed using the average estimated glomerular filtration rate and urinary albumin-to-creatinine ratio (uACR) over 3 months preoperatively and postoperative at 12-month follow-up. The risk of progression from CKD to kidney failure was assessed using the Chronic Kidney Disease Prognosis Consortium (CKD-PC) equation. RESULTS: Out of 2924 patients reviewed over this period of time, 69 (2.4%) had the recorded data necessary to assess kidney injury and the risk of disease progression to kidney failure. Patients within moderate and severe stages of CKD-related albuminuria improved the most at 12-month follow-up (by 48% and 79%; P = 0.0001 and P = 0.025, respectively). This translated to a relative risk reduction for progression to kidney failure in CKD ≥ stage 3 patients of 70% at 2 years and 60% at 5 years (both P = 0.001). CONCLUSIONS: Bariatric surgery seems to improve kidney injury, especially among patients with the most severe stages of CKD. Marked 2- and 5-year risk reduction in the progression from CKD to kidney failure was observed.

High cardiovascular risk patients benefit more from bariatric surgery than low cardiovascular risk patients.

INTRODUCTION: Atherosclerotic cardiovascular disease (ASCVD) and Framingham risk scores (FRS) are used to calculate 10-year risk of coronary death, nonfatal myocardial infarction, or fatal/nonfatal stroke. Our goal is to evaluate the association between preoperative cardiovascular risk and weight loss. METHODS: We retrospectively reviewed bariatric surgeries from 2010 to 2016. Patients who met criteria for calculating 10-year ASCVD score and FRS were included. Data collected included baseline demographics, perioperative parameters, and postoperative outcomes at 12 months. Simple linear regression and multiple linear regression models were applied to test influence of individual or multiple factors of interest on 12-month weight loss outcomes. RESULTS: Of 1330 bariatric patients studied, 360 patients met criteria for ASCVD and FRS calculation. Sleeve gastrectomy (LSG) was the most prevalent surgery 63.05%, followed by Roux-en-Y gastric bypass (LRYGB) 20.55%, revision procedures 11.9%, and adjustable gastric banding (LAGB) 4.4%. Initial BMI was 42.71 ± 7.85 kg/m2 for females and 42.72k ± 7.42 kg/m2 for males, with a 12-month percentage of estimated BMI loss (%EBMIL) of 66.51% in females and 60.29% in males. Preoperative 10-year ASCVD score was higher in males than females with a 34.73% relative risk reduction (RRR) in males and 35.3% RRR in females at 12-month follow-up. Regarding FRS, preoperative risk was 33.13 ± 21.1% in males and 15.71 ± 14.52% in females, with an RRR of 25.8% in males and 32.2% in females. Univariate analysis of preoperative FRS and %EBMIL showed that for every percentage unit increase in the patient's preoperative FRS, %EBMIL decreases 0.31 percentile unit (P < 0.001). Furthermore, preoperative ASCVD score is also significantly associated with %EMBIL-for every percentage unit increase in preoperative ASCVD score, %EBMIL decreases 0.42 percentile credits. CONCLUSION: Study results suggest ASCVD and FRS are equally reduced after bariatric surgery, especially after LSG and LRYGB. Moreover, preoperative FRS and ASCVD risk score showed an inversely proportional relationship with %EBMIL loss at 12 months.

Reduction of Framingham BMI score after rapid weight loss in severely obese subjects undergoing sleeve gastrectomy: a single institution experience.

BACKGROUND: There is vast evidence that supports the importance of obesity in the pathogenesis and progression of cardiovascular disease. Rapid weight loss induced by laparoscopic Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (LAGB) has proven beneficial. The aim of this study is to evaluate laparoscopic sleeve gastrectomy (LSG) as an alternative treatment modality and its impact on the Framingham-BMI 10-year risk score. METHODS: We retrospectively reviewed all patients that underwent bariatric surgery at our institution between 2010 and 2014. Patients who met the criteria for calculating the Framingham BMI 10-year risk score were included. Data collected included baseline demographics, perioperative parameters such as tobacco use, diagnosis of diabetes, treatment for hypertension, BMI and postoperative outcomes at 3 and 12 months. RESULTS: From our 1129 bariatric patients, 358 (31.7%) met criteria for the Framingham BMI 10-year risk score calculation. LSG was the most prevalent surgery 61.45% (N = 220) followed by LRYGB 22.06% (N = 79). Females composed 69% (N = 248) of our population. The average age for females was 52.3 ± 10.8 years and for males 54.07 ± 11.2 years. The initial Framingham 10-year score risk was significantly higher in males compared with females (36.16% ± 22.3 vs. 16.97% ± 15.6 (p < 0.001)). After 12-month follow-up, the absolute risk reduction in males was 11.58% (p < 0.001) and 6.17% in females (p < 0.001). The preoperative heart age was high in females and males (69.23 ± 15.72 years and 73.55 ± 13.55 years, respectively (p = 0.012)), and after 12 months it was reduced 7.19 years in females (p < 0.001) and 7.04 years in males (p < 0.001). The percentage of estimated BMI loss at 1 year was 64.43% in females and 60.69% in males. CONCLUSION: Sleeve gastrectomy has demonstrated to be an effective method of treatment for obesity. Our results suggest that rapid weight loss after LSG has a positive impact in the reduction of the 10-year cardiovascular disease risk. Further prospective studies may be needed to better assess these findings.

Fluorescent incisionless cholangiography as a teaching tool for identification of Calot's triangle.

BACKGROUND: Intraoperative incisionless fluorescent cholangiogram (IOIFC) has been demonstrated to be a useful tool to increase the visualization of Calot's triangle. This study evaluates the identification of extrahepatic biliary structures with IOIFC by medical students and surgery residents. METHODS: Two pictures were taken, one with xenon light and one with near-infrared (NIR) light, at the same stage during dissection of Calot's triangle in ten different cases of laparoscopic cholecystectomy (LC). All twenty pictures were organized in a random fashion to remove any imagery bias. Twenty students and twenty residents were asked to identify the biliary anatomy. RESULTS: Medical students were able to accurately identify the cystic duct on an average 33.8 % under the xenon light versus 86 % under NIR light (p = 0.0001), the common hepatic duct (CHD) on an average 19 % under the xenon light versus 88.5 % under NIR light (p = 0.0001), and the junction on an average 24 % under xenon light versus 80.5 % under NIR light (p = 0.0001). Surgery residents were able to accurately identify the cystic duct on an average 40 % under the xenon light versus 99 % under NIR light (p = 0.0001), the CHD on an average 35 % under the xenon light versus 96 % under NIR light (p = 0.0001), and the junction on an average 24 % under the xenon light versus 95.5 % under NIR light (p = 0.0001). CONCLUSIONS: IOIFC increases the visualization of Calot's triangle structures when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.

Is bariatric surgery safe in the elderly population?

BACKGROUND: Bariatric surgery has proven to be the most effective treatment for morbid obesity in all age groups and is considered superior to medical treatment. The aim of our study was to report the outcomes of bariatric surgery in patients over 65 years of age at our institution. METHODS: A retrospective review of a prospectively collected database was conducted of all patients > 65 years who underwent a bariatric procedure between 2005 and 2015 at our institution. We compared this group to a control group of patients < 65 years of age who were operated on during the last 5 years, from 2011 to 2015. Data analyzed included age, preoperative BMI, postoperative complications, and comorbidities. RESULTS: Of 1613 patients studied, 1220 patients were under 65 years of age, and in Group B, 393 were >65 years of age at time of surgery. There was a significant difference in proportion of male patients among groups; 42 % in Group B were male compared to 30 % in Group A (p < 0.001). Caucasians represented the majority in both groups. Both groups had comparable preoperative BMI 42.27 kg/m2 for the younger Group A population versus 41.64 kg/m2 for Group B (p = 0.074). Group B had more comorbidities than Group A: hypertension (p < 0.001), sleep apnea (p < 0.001), and hypercholesterolemia (p < 0.001). No difference was found between groups in history of depression (p = 0.409) or type II diabetes (p = 0.961). Distribution of procedures was significantly different between groups, with more LSG in Group A (p < 0.001). Elderly patients had longer length of stay (LOS) by one day on average (LOS = 3 days, p < 0.001), but a lower readmission rate (10 % vs. 7 %) (p = 0.023). Complication rates were comparable in both groups, except for incidence of de novo GERD, which was higher in Group B (5 % vs. 8 %) (p = 0.005). CONCLUSIONS: Elderly patients are usually sicker in terms of comorbidities than the younger population. However, age does not seem to represent a risk of surgical complications after bariatric surgery.

Safety and efficacy of 1020 consecutive laparoscopic sleeve gastrectomies performed as a primary treatment modality for morbid obesity. A single-center experience from the metabolic and bariatric surgical accreditation quality and improvement program.

BACKGROUND: LSG is widely accepted as a definitive treatment for obesity. Due to lack of large series with long-term follow-up, disagreement remains regarding its safety and efficacy. We present a series of 1020 consecutive LSGs performed with long-term follow-up. METHODS: A retrospective review of a prospectively collected database was conducted on patients who underwent LSG from January 2005 to February 2014. Data included weight, height, BMI, ideal body weight, comorbid conditions, intraoperative complications, mean length of hospital stay (LOS), early (<30 days) readmission, early and late (>30 days) postoperative complications, and percentage of excess weight loss (%EWL). RESULTS: Of the 1020 patients, 66.6 % (n = 679) were female, with a mean age of 38.4 ± 16.5 years. Mean BMI at the time of first visit was 43.4 ± 5.8 kg/m(2). The most common comorbid conditions identified were diabetes mellitus (89.4 %), sleep apnea (86.4 %), hypertension (80.3 %), and hyperlipidemia (70 %). Over the entire follow-up period, 57 % of diabetic patients experienced significant improvement or remission. There was no mortality in this series. Early postoperative complications within 30 days of surgery included leak in 0.1 % (n = 1), stricture in 0.1 % (n = 1), emesis in 23 % (n = 234), dehydration in 19 % (n = 194), prolonged ileus in 18 % (183), and self-limited bleeding in 3 % (n = 30). Mean LOS was of 3.4 ± 2.1 days, with a 3.8 % overall rate of early readmissions. Long-term morbidity was found in 3.9 % of patients (n = 40) and included stricture in 0.49 % (n = 5) and GERD in 6 % (n = 61). The overall 30-day mortality rate was 0 %. Mean %EWL at 3 months to 1, 3, 5, and 8 years was 72 ± 16.8, 86 ± 22.3, 63 ± 19, 61 ± 11, and 52 ± 9.2, respectively. CONCLUSIONS: This study confirms that LSG is safe and has very low rates of early and long-term complications when compared to other well-established procedures. Additionally, LSG that appears results in significant improvement of obesity-related comorbid conditions.

The relationship between intracranial pressure and obesity: an ultrasonographic evaluation of the optic nerve.

BACKGROUND: Measurements of optic nerve sheath diameter (ONSD) with noninvasive ocular ultrasonography have been shown to be accurate in determining increased intracranial pressure. Obesity is associated with chronic increases in intraabdominal pressure that could consequently result in intracranial hypertension. By utilizing ONSD ultrasonographic measurements, we compare the difference that may exist between obese and non-obese patients. STUDY DESIGN: We prospectively collected data from patients who underwent laparoscopic procedures in the supine position between July 2013 and March 2014. Ophthalmic pathology was not present in any patient. Ultrasonographic measurement of the ONSD was obtained sagittally with a 12-MHz transducer 3 mm from its origin. The measurements were taken at 0, 15, and 30 min, and at the end of surgery. RESULTS: There were 62 subjects, 28 females (45.2 %) and 34 males (54.8 %), with a mean age of 44.22 ± 10.44 years (range 23-66). Forty-eight percent of patients were non-obese, and 52 % of patients were obese. The mean body mass index was 30.70 ± 7.61 kg/m(2) (range 20.0-59.5). The mean ONSD of non-obese and obese patients was 4.7 and 5.5 mm at baseline (p = 0.01), 5.4 and 6.2 mm at 15 min (p = 0.01), 5.8 and 6.6 mm at 30 min (p = 0.01), and 5.1 and 5.7 mm after deflation of pneumoperitoneum (p = 0.03), respectively. CONCLUSIONS: Utilizing a noninvasive method to measure the ONSD, a chronic increase in intracranial pressure in obese patients was demonstrated. The increase in the ONSD during laparoscopic procedures reflects a temporary increase in the intracranial pressure from baseline.

Impact of controlled intraabdominal pressure on the optic nerve sheath diameter during laparoscopic procedures.

BACKGROUND: Acute elevations of intraabdominal pressure (IAP) are seen in many clinical scenarios with a consequent elevation in intracranial pressure (ICP). With the optic nerve sheath (ONS) being a part of the dura mater and the optic nerve surrounded by cerebral spinal fluid, a change in pressure within the subarachnoid space would be detected by ultrasonography, and invasive methods could be avoided. The study objective was to evaluate ultrasonographic modifications observed on the optic nerve sheath diameter during acute elevations of IAP in patients undergoing laparoscopic procedures. STUDY DESIGN: We prospectively collected data from patients who underwent laparoscopic procedures between July and August 2013. The optic nerve sheath diameter was measured sagittally with a 12-MHz transducer. The measurements were obtained at baseline, 15 and 30 min, and at the end of surgery. RESULTS: There were 16 females (36.4%) and 28 males (63.6%), with a mean age of 44.22 ± 10.44 years (range 23-66) and body mass index of 29.45 ± 6.53 kg/m(2) (range 21-39). The mean optic nerve sheath diameter was 4.8 ± 1.0 mm at baseline, 5.5 ± 1.1 mm at 15 min, 5.9 ± 1.0 mm at 30 min, and 5.1 ± 1.2 mm after deflation of pneumoperitoneum. The diameter increased significantly at 15 min by a median of 0.6 mm (interquartile range 0.3, 0.8; p < 0.0001) and at 30 min by a median of 1.0 mm (interquartile range 0.7, 1.4; p < 0.0001), returning close to baseline after surgery. CONCLUSION: The acute elevation in IAP during laparoscopy significantly increased the optic nerve sheath diameter. The changes in the ONSD reflect a temporary and reversible increase in the ICP due to the acute elevation of IAP.

Unidirectional barbed sutures as a novel technique for laparoscopic ventral hernia repair.

BACKGROUND: Incisional hernias remain a significant complication of abdominal surgeries. Primary closure of the hernia defect has been suggested to improve long-term abdominal wall function. However, this can be technically challenging and time consuming. This study describes laparoscopic use of non-absorbable barbed sutures in primary closure of hernia defects in addition to intraperitoneal mesh. METHODS: Patients who underwent laparoscopic primary ventral hernia repair with mesh were prospectively reviewed. Two groups were defined: Operations performed with barbed sutures for primary closure in addition to mesh and operations with only mesh without defect repair. The surgical technique involved running the hernia defect with a 2-polypropylene non-absorbable unidirectional barbed suture and subsequently fixing the mesh intraperitoneally with tacks. In both groups, a single transfascial centering suture was also utilized. RESULTS: Twenty-eight cases with barbed suture and mesh reinforcement and 29 cases with mesh-only were identified. The average dimensions of the ventral hernia defects were 57.8 (6-187) and 44.6 cm(2) (9-156) in the barbed suture with mesh and mesh-only group, respectively, p = 0.23. Median operating time was 78 min (range 35-187 min) in the barbed suture with mesh group versus 62 min (34-155 min) in the mesh-only group, p = 0.44. The median suturing time of closing the ventral hernia defect was 16 min (11-24 min). There were no differences in the pain scores. Mean follow-up for both groups was 8.2 ± 3.6 months (1-17 months) with one hernia recurrence in the mesh-only group, p = 0.41. CONCLUSIONS: The barbed suture closure system could be used for rapid and effective primary defect closure in laparoscopic ventral hernia repair in addition to intraperitoneal mesh placement. No significant difference in operating time was detected when compared to the mesh-only approach. Further evidence to support these findings and longer follow-up periods is warranted to evaluate short- and long-term complications.

Technical description and feasibility of laparoscopic adrenal contouring using fluorescence imaging.

BACKGROUND: Identification of adrenal glands from the surrounding structures during laparoscopic surgery can be challenging especially in obese individuals. This can increase the chances for hemorrhage and conversion to open surgery. We present the first report of fluorescent infrared visualization of the adrenal glands in a large animal model. METHODS: Five adult Yorkshire pigs were utilized for the study, in compliance with the animal study regulations. After an intravenous bolus administration of 3 mL of indocyanine green (ICG), visualization was performed with a xenon/infrared light source and a laparoscope with a charge-coupled filter device. Activation of the device was done with a foot pedal. Images were analyzed using histogram software and the difference of enhancement was statistically analyzed using unpaired two-tailed t test. RESULTS: The right adrenal glands were visualized in all five animals immediately after administering ICG. Fluorescence facilitated demarcation of adrenal gland tissue from surrounding adipose tissue. Peritoneum and fat was visualized in black color. Adrenal enhancement lasted for 4 h in all cases. The mean value for adrenal fluorescence using histogram count was 71.75 pixels, and for adrenal xenon was 168.87 pixels (p = 0.0002; 95 % CI -130.93 to -0.63). The mean value for fat fluorescence using histogram count was 5.54 pixels and fat xenon was 187.15 pixels (p = 0.0001; 95 % CI -199.39 to -163.82). Although there was no significant difference between adrenal and fat enhancement with xenon light (p = 0.24; 95 % CI -15.53 to 52.09), the difference became significant between adrenal and fat fluorescence (p = 0.0001; 95 % CI 48.51-83.9). CONCLUSION: Fluorescence imaging appears to be a feasible and easy method to differentiate adrenal glands from the surrounding tissue in a large animal model. Further studies are necessary to investigate the real application of this method during laparoscopic adrenalectomy in humans.

Routine use of fluorescent incisionless cholangiography as a new imaging modality during laparoscopic cholecystectomy.

BACKGROUND: Intraoperative incisionless fluorescent cholangiography (IOIFC) has been described to identify extrahepatic biliary anatomy. Potential advantages of the routine use of intraoperative incisionless fluorescent cholangiography were evaluated in a consecutive series of cases. METHODS: A total of 45 patients undergoing laparoscopic cholecystectomy between January and July 2013 were consented and included in this study. We analyzed a prospectively collected database for feasibility, cost, time, usefulness, teaching tool, safety, learning curve, X-ray exposure, complexity, and real-time surgery of IOIFC. A single dose of 0.05 mg/kg of Indocyanine green was administered prior to surgery. During the procedure, a laparoscopic fluorescence system was used. RESULTS: IOIFC could be performed in all 45 patients, whereas intraoperative cholangiography could be performed in 42 (93 %). Individual median cost of performing IOFC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 USD) per patient, p = 0.0001). IOFC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes, p < 0.0001). The cystic duct was identified by IOFC in 44 out of 45 patients (97.77 %). CONCLUSION: IOIFC appears to be a feasible, low-cost, expeditious, useful, and effective imaging modality when performing LC. It is safe, easy to perform and interpret, and does not require a learning curve or X-ray. It can be used for real time surgery to delineate the extrahepatic biliary structures.

Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Despite the standardization of laparoscopic cholecystectomy (LC), the rate of bile duct injury (BDI) has risen from 0.2 to 0.5%. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. This study evaluated costs and effectiveness of routinely implemented FC and IOC during LC. MATERIALS AND METHODS: Between February and June 2013, the authors prospectively collected the data of all patients undergoing laparoscopic cholecystectomy. We retrospectively reviewed and compared the use of FC and IOC. Procedure time, procedure cost, and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method. RESULTS: A total of 43 patients (21 males and 22 females) were analyzed during the study period. Mean age was 49.53 ± 14.35 years and mean body mass index was 28.35 ± 8 kg/m(2). Overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 vs. 7.15 ± 3.76 min; p < 0.0001). FC was successfully performed in 43 of 43 cases (100%) and IOC in 40 of 43 cases (93.02%). FC was less expensive than IOC (US$14.10 ± 4.31 vs. US$778.43 ± 0.40; p < 0.0001). According to the survey, all surgeons found routine use of FC useful. CONCLUSION: In this study, FC was effective in delineating important anatomic structures. It required less time and expense than IOC, and was perceived by the surgeons to be easier to perform, and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.

Changes in renal blood flow after surgically induced weight loss: can bariatric surgery halt the progression of chronic kidney disease?

BACKGROUND: We previously demonstrated how kidney injury in patients with morbid obesity can be reversed by bariatric surgery (BaS). OBJECTIVE(S): Based on previous experience, we hypothesize patients' potentially reversible kidney injury might be secondary to reduction in renal blood flow (RBF), which improves following BaS. SETTING: Academic Hospital. METHODS: We conducted a retrospective analysis of patients who underwent BaS at our institution from 2002 to 2019. We identified patients with chronic kidney disease (CKD) using the estimated glomerular filtration rate (eGFR) from the CKD Epidemiology Collaboration Study (CKD-EPI) classification system. We used the BUN/Creatinine (Cr) ratio pre- and postoperatively to determine a prerenal (decreased RBF) versus intrinsic component as the responsible cause of CKD in this patient population. Decreased RBF was defined as BUN/Cr > 20 preoperatively. RESULTS: Our analysis included n = 2924 patients, of which 11% (n = 325) presented decreased RBF. From our original sample, only n = 228 patients had the complete data necessary to assess both eGFR and RBF (BUN/Cr). Patients with baseline CKD stage 2 demonstrated preoperative BUN/Cr 20.85 ± 10.23 decreasing to 14.99 ± 9.10 at 12-month follow-up (P < .01). Patients with baseline CKD stage 3 presented with preoperative BUN/Cr 23.88 ± 8.75; after 12-month follow-up, BUN/Cr ratio decreased to 16.38 ± 9.27 (P < .01). Patients with CKD stage 4 and ESRD (eGFR < 30) did not demonstrate a difference for pre- and postoperative BUN/Cr 21.71 ± 9.28 and 19.21 ± 14.58, respectively. CONCLUSION(S): According to our findings, patients with CKD stages 1-3 present improvement of their kidney function after BaS. This amelioration could be secondary to improvement of the RBF, an unstudied reversible mechanism of kidney injury in the bariatric population.

Laparoscopic versus robotic-assisted primary bariatric-metabolic surgery. Are we still expecting to overcome the learning curve? A propensity score-matched analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

BACKGROUND: Robotic surgery is becoming increasingly popular in bariatric-metabolic surgery. However, its superiority regarding postoperative outcomes compared with conventional laparoscopy has not been clearly proven. With growing adoption of robotic surgery and improved technologies, benefits should become more evident. OBJECTIVES: Evaluate readmission and reoperation rates after bariatric-metabolic surgery performed by conventional laparoscopy versus robotic-assisted from 2015 to 2021. SETTING: Academic institution. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) was reviewed for primary bariatric operations performed with conventional laparoscopy versus robotic-assisted. Postoperative outcomes were compared in a propensity score-matched sample. RESULTS: Of 1,059,348 cases meeting inclusion criteria, 921,322 (87%) were conventional laparoscopic bariatric-metabolic surgeries, which were matched 1:1 with robotic-assisted cases (138,026). Reoperation (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.00-1.15, P = .0463), postoperative morbidity (OR 1.07; 95% CI 1.01-1.12, P = .0193), readmission (OR 1.14; 95% CI 1.09-1.18, P < .0001), and emergency department visits (OR 1.06; 95% CI 1.03-1.09, P = .0003) at 30 days postoperatively were significantly greater for robotic-assisted cases. Robotic-assisted cases had a similar mortality rate at 30 days postoperatively and length of stay >3 days when compared with conventional laparoscopic cases. Similar results were observed in cases from 2020 to 2021, except for reoperation and emergency department visits, which showed no difference between groups and length of stay >3 days, which was greater in robotic-assisted cases. CONCLUSIONS: Our results show a greater readmission and reoperation rate and greater morbidity at 30 days postoperatively in robotic-assisted bariatric-metabolic surgery compared with conventional laparoscopy. Analyzing only cases performed between 2020 and 2021, robotic surgery also does not show superiority over conventional laparoscopy.

Impact of Rapid Weight Loss after Bariatric Surgery in Systemic Inflammatory Response and Pulmonary Hemodynamics in Severely Obese Subjects with Pulmonary Hypertension.

BACKGROUND: Pulmonary hypertension (PH) can be associated with obesity. The excessive production of proinflammatory mediators by dysfunctional adipocytes may enhance remodeling of the pulmonary vasculature and worsen pulmonary hemodynamics. This study aimed to describe the changes in pulmonary arterial pressures and systemic inflammation in patients with obesity with PH after bariatric surgery (BaS). STUDY DESIGN: In this retrospective cohort study, we compared patients with PH who underwent BaS from 2008 to 2018 at our institution (group 1) to a group of severely obese patients with PH (group 2). Echocardiographic right ventricular systolic pressure (RVSP) was used as an indirect measurement of pulmonary arterial pressures. Red blood cell distribution width (RDW) was used as a marker of systemic inflammation. RESULTS: A total of 40 patients were included, 20 per group. In group 1, the RVSP decreased from 44.69 ± 7.12 mmHg to 38.73 ± 12.81 mmHg (p = 0.041), and the RDW decreased from 15.22 ± 1.53 to 14.41 ± 1.31 (p = 0.020). In group 2, the RVSP decreased from 60.14 ± 18.08 to 59.15 ± 19.10 (0.828), and the RDW increased from 15.37 ± 1.99 to 15.38 ± 1.26 (0.983). For both groups, we found a positive correlation between RVSP and RDW changes, although the correlation was not statistically significant. CONCLUSIONS: Previous studies suggest BaS could be a safe and effective procedure to achieve weight loss in obese patients with PH, with an additional modest improvement in pulmonary hemodynamics. The results of this study reinforce this observation and suggest that such improvement could be related to a decrease in systemic inflammation. Further prospective studies with bigger samples are needed to better understand these findings.

Midterm benefits of metabolic surgery on symptom remission and medication use in patients with pseudotumor cerebri.

BACKGROUND: Pseudotumor cerebri is a serious obesity-related disorder that can result in severe complications. The aim of this study was to compare metabolic surgery with medical management of pseudotumor cerebri at a single bariatric center. METHODS: After institutional review board approval, a retrospective review was conducted of individuals with severe obesity and pseudotumor cerebri (nonbariatric group) and patients with preoperative pseudotumor cerebri (bariatric group). The variables included demographic characteristics, comorbidities, and pseudotumor cerebri-related risk factors. Symptoms, medication use, and body mass index were analyzed during a 4-year follow-up. RESULTS: A total of 86 patients with pseudotumor cerebri were included in the analysis. In the nonbariatric group (n = 77), the mean age was 34.1 ± 10.5 years and initial body mass index 37.2 ± 6.5 kg/m2. Initially, the most common symptom was headache (90.9%; n = 70), with a mean lumbar opening pressure of 341.94 ± 104.50 mm H2O. In the bariatric group (n = 9), the mean age was 36.1 ± 8.9 years and preoperative body mass index 46.1 ± 5.5 kg/m2. The most common preoperative symptom was headache (100%; n = 9), with a lumbar opening pressure of 320 ± 44.27 mm H2O. During the 4-year follow-up, both groups presented with a significant decrease in pseudotumor cerebri-related symptoms at 3 months (P < .0001). Additionally, pseudotumor cerebri medication use significantly decreased after 3 months in the bariatric group (P = .0406), whereas in the nonbariatric group decreased at 18 months (P = .023). Bariatric patients presented with a significant decrease in body mass index in ≤3 months of surgery (P = .0380), which was not observed in nonbariatric patients (P = .6644). CONCLUSION: Metabolic surgery seems to provide a greater decrease in pseudotumor cerebri symptoms and medication use in a shorter period of time compared with medical management alone.