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.

The association of permanent versus absorbable fixation on developing chronic post-herniorrhaphy groin pain in patients undergoing laparoscopic inguinal hernia repair.

INTRODUCTION: Fixation of mesh during minimally invasive inguinal hernia repair is thought to contribute to chronic post-herniorrhaphy groin pain (CGP). In contrast to permanent tacks, absorbable tacks are hypothesized to minimize the likelihood of CGP. This study aimed to compare the rates of CGP after laparoscopic inguinal hernia repair between absorbable versus permanent fixation at maximum follow-up. METHODS: This is a post hoc analysis of a randomized controlled trial in patients undergoing laparoscopic inguinal hernia repair (NCT03835351). All patients were contacted at maximum follow-up after surgery to administer EuraHS quality of life (QoL) surveys. The pain and restriction of activity subdomains of the survey were utilized. The primary outcome was rate of CGP, as defined by a EuraHS QoL pain domain score ≥ 4 measured at ≥ 1 year postoperatively. The secondary outcomes were pain and restriction of activity domain scores and hernia recurrence at maximum follow-up. RESULTS: A total of 338 patients were contacted at a mean follow-up of 28 ± 11 months. 181 patients received permanent tacks and 157 patients received absorbable tacks during their repair. At maximum follow-up, the rates of CGP (27 [15%] vs 28 [18%], P = 0.47), average pain scores (1.78 ± 4.38 vs 2.32 ± 5.40, P = 0.22), restriction of activity scores (1.39 ± 4.32 vs 2.48 ± 7.45, P = 0.18), and the number of patients who reported an inguinal bulge (18 [9.9%] vs 15 [9.5%], P = 0.9) were similar between patients with permanent versus absorbable tacks. On multivariable analysis, there was no significant difference in the odds of CGP between the two groups (OR 1.23, 95% CI [0.60, 2.50]). CONCLUSION: Mesh fixation with permanent tacks does not appear to increase the risk of CGP after laparoscopic inguinal hernia repair when compared to fixation with absorbable tacks. Prospective trials are needed to further evaluate this relationship.

Bariatric Surgery Improves Heart Geometry and Plasticity.

BACKGROUND: Obesity is commonly associated with increased sympathetic tone, changes in heart geometry, and mortality. The aforementioned translates into a higher and potentially modifiable mortality risk for this specific population. OBJECTIVES: The aim of the study was to analyze the extent of changes in the heart ventricular structure following rapid weight loss after bariatric surgery. SETTING: Academic, university-affiliated hospital. METHODS: We retrospectively reviewed all the patients that underwent bariatric surgery at our institution between 2010 and 2015. Data analyzed included demographics, BMI, and associated medical problems. Preoperative and postoperative echography readings were compared looking at the heart geometry, cardiac volumes, and wall thickness. RESULTS: Fifty-one patients who had bariatric surgery and had echocardiography before and after the surgery were identified. There were 33 females (64.7%). The mean age was 63.4 ± 12.0 years with an average BMI of 40.3 ± 6.3. The mean follow-up was 1.2 years after the procedure. At 1 year follow-up 25 patients (49%, p = 0.01) showed normal left ventricular geometry. The left ventricular mass (229 ± 82.1 vs 193.2 ± 42.5, p<0.01) and the left ventricular end diastolic volume (129.4 ± 53 vs 96.4 ± 36.5, p = 0.01) showed a significant modification following the procedure. There was a significant improvement in the interventricular septal thickness (p = 0.01) and relative wall thickness (p < 0.01) following surgery. CONCLUSION: The patients with obesity present a significant cardiac remodeling from concentric remodeling to normal geometry after bariatric surgery. The decrease in BMI has a direct effect on improvement of the left ventricular structure. Further studies must be carried out to define the damage of obesity to diastolic function.

Pathogenetic mechanisms of nonalcoholic fatty liver disease and inhibition of the inflammasome as a new therapeutic target.

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, and its incidence is increasing. Nonalcoholic steatohepatitis (NASH), the progressive form of the disease, can lead to end-stage liver disease. The pathogenesis of the disease is not fully understood, and there is currently no specific treatment. Therefore, an effective and reliable treatment modality is needed. In recent years, the inflammasome has been shown to play a vital role in many stages of NAFLD pathogenesis. In particular, the detection, by toll-like receptors, of pathogen-associated molecular patterns induced by the gut-liver axis triggers the formation of the NLRP3 (NLR family pyrin domain-containing protein 3) inflammasome. Stimulation of damage-associated molecular patterns also activates the NLRP3 inflammasome. The activated inflammasome has caspase-1 activity, which leads to the release of interleukin (IL)-1 and IL-18 and formation of pores in the cell wall. This process spreads the inflammatory process to the outside of the cell and induces inflammatory cell death (pyroptosis). Subsequent progression of the inflammatory process leads to fibrosis. Recent evidence suggests that the NLRP3 inflammasome may be a potential target for the treatment of NASH. The discovery of specific NLRP3 inflammasome blockers in recent years and evidence of their positive effects in experimental models support this therapeutic approach. In this article, we discuss recent evidence on the pathogenesis of NAFLD, the role of the inflammasome in the pathogenesis of NAFLD, and the potential effects of inhibition of the inflammasome.

Nerve spectroscopy: understanding peripheral nerve autofluorescence through photodynamics.

BACKGROUND: Being able to accurately identify sensory and motor nerves is crucial during surgical procedures to prevent nerve injury. We aimed to (1) evaluate the feasibility of performing peripheral human nerve visualization utilizing nerves' own autofluorescence in an ex-vivo model; (2) compare the effect of three different nerve fiber fixation methods on the intensity of fluorescence, indicated as the intensity ratio; and (3) similarly compare three different excitation ranges. METHODS: Samples from various human peripheral nerves were selected postoperatively. Nerve fibers were divided into three groups: Group A nerve fibers were washed with a physiologic solution; Group B nerve fibers were fixated with formaldehyde for 6 h first, and then washed with a physiologic solution; Group C nerve fibers were fixated with formaldehyde for six hours, but not washed afterwards. An Olympus IX83 inverted microscope was used for close-up image evaluation. Nerve fibers were exposed to white-light wavelength spectrums for a specific time frame prior to visualization under three different filters-Filter 1-LF405-B-OMF Semrock; Filter 2-U-MGFP; Filter 3-U-MRFPHQ Olympus, with excitation ranges of 390-440, 460-480, and 535-555, respectively. The fluorescence intensity of all images was subsequently analyzed using Image-J Software, and results compared by analysis of variance (ANOVA). RESULTS: The intensity ratios observed with Filter 1 failed to distinguish the different nerve fiber groups (p = 0.39). Conversely, the intensity ratios seen under Filters 2 and 3 varied significantly between the three nerve-fiber groups (p = 0.021, p = 0.030, respectively). The overall intensity of measurements was greater with Filter 1 than Filter 3 (p < 0.05); however, all nerves were well visualized by all filters. CONCLUSION: The current results on ex vivo peripheral nerve fiber autofluorescence suggest that peripheral nerve fiber autofluorescence intensity does not greatly depend upon the excitation wavelength or fixation methods used in an ex vivo setting. Implications for future nerve-sparing surgery are discussed.

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.

Discordance in prediction for prognosis of type 2 diabetes after metabolic surgery: comparison of the ABCD, DiaRem, and individualized metabolic surgery models.

PURPOSE: Metabolic surgery has been performed as a treatment option for uncontrolled type 2 diabetes (T2D), and several scoring systems for predicting postoperative T2D remission have been proposed. This study was designed to assess consistency of 3 existing scoring systems in patients with T2D duration <1 year. METHODS: This study included 186 patients with T2D enrolled in a university hospital prospective database between 2011 and 2013. Externally validated scoring systems for predicting T2D prognosis after metabolic surgery were identified and selected through systematic literature search. We assessed concordance between ABCD, DiaRem, and individualized metabolic surgery (IMS) scores in participants using kappa statistical analysis and 1-way analysis of variance. RESULTS: Of the participants, 52 and 82 patients were expected to have favorable T2D remission after metabolic surgery with ABCD score of 10-5 and DiaRem score of 0-7, respectively, and a slight-to-fair concordance was shown between the 2 scoring systems (kappa measure, 0.07; standard error [SE], 0.05 and kappa measure, 0.25; SE, 0.19, respectively). The DiaRem score increased with T2D severity determined by IMS score (P < 0.001), while the ABCD score showed no significant association with IMS score. CONCLUSION: ABCD and DiaRem scores showed significant discordance when applied to potential metabolic surgery candidates in whom postoperative T2D remission rate was highly expected. The IMS score showed a dose-response association with DiaRem score but had no significant association with the ABCD score.

Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50 kg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ±â€Š5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.

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.

Impact of preoperative wireless pH monitoring in the evaluation of esophageal conditions prior to bariatric surgery in a severely obese patient population.

BACKGROUND: Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure in the United States; however, it can be associated with development of de novo gastroesophageal reflux (GERD) or worsening of existing GERD. Preoperative esophagogastroduodenoscopy (EGD) and findings of esophagitis are commonly used as screening tool, but the alternative use of preoperative objective measurement of acid reflux has not been studied. OBJECTIVE: The aim of this study was to evaluate if preoperative objective measurement of acid reflux by using wireless pH monitoring (WPHM) could have an impact on surgical planning and outcomes. SETTING: Academic Center of Excellence. METHODS: Retrospective review of a prospectively collected database of 43 adult obese patients with reflux symptoms who underwent outpatient EGD and WPHM between September 2011 and September 2017. RESULTS: Change in planned surgical management from SG to Roux-en-Y-gastric bypass with the use of WPHM occurred in 21.0% (n = 9) of patients. Only 2.3% (n = 1) developed de novo GERD after SG. Nonerosive reflux disease was the most common esophageal condition on preoperative EGD. EGD, as a single diagnostic tool, appeared insufficient to diagnose acid reflux and help with the decision planning in this patient population. CONCLUSIONS: Based on objective data obtained by measurement of GERD, using preoperative WPHM compared with preoperative EGD alone aids in a better patient selection for either SG or Roux-en-Y-gastric bypass. Our cohort with preoperative WPHM required no surgical conversions or revisions.

American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery.

The American Society for Metabolic and Bariatric Surgery issues the following guidelines for the purpose of enhancing quality of care in hernia treatment through metabolic and bariatric surgery. In this statement, suggestions for management are presented that are derived from available knowledge, peer-reviewed scientific literature, and expert opinion. This was accomplished by performing a review of currently available literature regarding obesity, obesity treatments, and hernia surgery. The intent of issuing such a guideline is to provide objective information regarding the impact of obesity treatment on effective and durable hernia repair. The guideline may be revised in the future should additional evidence become available.

Midterm outcomes of laparoscopic sleeve gastrectomy as a stand-alone procedure in super-obese patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been gaining popularity as a safe and effective bariatric procedure for patients with morbid obesity. However, the long-term outcomes of LSG alone in patients with body mass index over 50 kg/m2, or super obesity, have not been analyzed in comparison to those of other bariatric procedures. OBJECTIVES: This study aimed to compare midterm results of LSG and laparoscopic Roux-en-Y gastric bypass (RYGB) and to evaluate the efficacy of LSG as a stand-alone bariatric procedure for patients with super obesity. SETTING: Tertiary medical center. METHODS: The 3-year outcomes of 607 super-obese patients who underwent either LSG or RYGB at an academic institution between December 2003 and February 2012 were retrospectively reviewed. Patient records at 6, 12, 18, 24, and 36 months of follow-up were analyzed. RESULTS: The average percent excess weight loss and change in body mass index of the LSG versus RYGB group showed no significant difference at any follow-up period. The rate of resolution of type 2 diabetes and the mean hemoglobin A1C level in both groups were also comparable. The dramatic loss of patient data beginning at the 12-month follow-up (220/607, 36.24%) was also analyzed. The surgery type was associated with the duration of follow-up at .133, with a P value of .001. CONCLUSIONS: We concluded that LSG is a comparably effective stand-alone procedure for patients with super obesity as RYGB. Our study is the first to suggest that compared with RYGB, LSG is associated with a shorter duration of postoperative follow-up.

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.

Comparison between major and minor surgical procedures for the treatment of chronic staple line disruption after laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become the most common weight loss surgery procedure. The procedure's most dreaded surgical complication is staple-line disruption (SLD). So far, no definitive treatment modality has been established for this complication. OBJECTIVES: The aim of this study is to review the treatment options used at our institution for patients with SLD after LSG and to evaluate the outcome of different interventions. METHODS: A retrospective review of a prospectively collected database of all patients who underwent SLD between January 2005 and April 2014 was performed. SLD was defined as a leak identified on computed tomography or upper gastrointestinal series. We compared the cure rate between a major surgical procedure and patients treated with a variety of other minor treatment modalities. Special focus is given to the technique of proximal gastrectomy with Roux-en-Y esophagojejunostomy (PGEJ). The procedure consists of the en bloc resection of the proximal stomach immediately proximal to the gastroesophageal junction and including the fistulous tract. The jejunum is transected 50 cm distal to the ligament of Treitz and reconstruction of the gastrointestinal tract is performed with a Roux-en-Y esophagojejunostomy. RESULTS: Thirty-one patients had SLD after their LSG. Patients were divided into 2 groups based on the treatment modality: Group A (PGEJ) and Group B (minor surgical procedure). Group A (n = 19) had 1 releak. Group B (n = 11) had 5 releaks. The cure rate for patients who underwent PGEJ was 94.7%. The cure rate for patients who were treated with a different approach was 54.5% (P = .01). CONCLUSION: Our experience demonstrates that the cure rate of PGEJ is high. Minor surgical procedures are effective in approximately half of the patients, so when the leak becomes chronic, PGEJ can provide a long-term solution.

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.