Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.

BACKGROUND: Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. METHODS: A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data were analyzed using univariate analysis. RESULTS: One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7 years, 29.7 ± 5.7 kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6 months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. CONCLUSION: Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia.

BACKGROUND: Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution. METHODS: Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared. RESULTS: 58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106 min. vs. 145 min., p = 0.003) and longer median myotomy length (11 cm vs. 8 cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1 day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029). RESULTS: POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.

A comparative evaluation of robotic and laparoscopic Roux-en-Y gastric bypass: a critical evaluation on the impact of postoperative pain and opioid requirements.

INTRODUCTION: The benefits of minimally invasive surgery using laparoscopy on postoperative pain and opioid use are well established. Our goal was to determine whether patients who underwent Roux-en-Y gastric bypass using a robotic approach (RA-RYGB) had lower postoperative pain and required less opioids than those undergoing laparoscopic Roux-en-Y gastric bypass (L-RYGB). Secondary outcomes evaluated included length of stay, operative time, and readmissions. METHODS AND PROCEDURES: This was a retrospective cohort study from a tertiary academic medical center. Patients who underwent L-RYGB or RA-RYGB between 5/1/2018 and 10/31/2019 were included. Cases with concomitant hernia repair, chronic opioid use, and those who did not receive a TAP block or multimodal pain control were excluded. Baseline demographics were compared. Inpatient and outpatient opioid use in Morphine Milligram Equivalents (MME) and pain scores (10-point Likert scale) were compared. RESULTS: There were 573 RY patients included (462 L-RYGB; 111 RA-RYGB). Median and maximum inpatient pain scores were similar for L-RYGB and RA-RYGB (3.0 vs 3.1, p = 0.878; 7.0 vs 7.0, p = 0.688). Median inpatient opioid use and maximum single day use were similar for L-RYGB and RA-RYGB (40.0 MME vs. 42.0 MME, p = 0.671; 30.0 MME vs 30.0 MME, p = 0.648). Both the outpatient prescribing of opioids (50.2% vs. 42.3%, p = 0.136) and outpatient opioid MME at 2 weeks (L-RYGB 30.0 MME vs. 33.8 MME, p = 0.854) were comparable between cohorts. Patient reported pain at 2-week follow-up was significantly higher for RA-RYGB (68.1%) than L-RYGB (55.6%) (p = 0.030). RA-RYGB had a higher rate of 30-day readmission and longer operative times compared to the L-RYGB (6.3% vs 13.5%, p = 0.010; 144.5 vs 200.0 min, p < 0.001). CONCLUSION: This study identified no benefit for postoperative pain or opioid requirements in patients undergoing RA-RYGB compared to L-RYGB. The RA-RYGB group was significantly more likely to report pain at the two-week follow-up.

Emergency department overutilization following cholecystectomy and inguinal hernia repair.

BACKGROUND: Emergency Department (ED) utilization following general surgery procedures is poorly understood and places immense strain on the healthcare system. Inefficient ED utilization is responsible for up to $38 billion in wasteful spending annually. Nearly 56% of ED visits may be avoidable. The aim of our study was to quantify ED utilization following elective cholecystectomy (CCY) and inguinal hernia repair (IHR), to characterize the impact and identify causes. MATERIALS AND METHODS: This retrospective study included patients across eight hospitals in a single health system undergoing elective CCY and IHR between January 2018 to June 2019. Patients who returned to the ED within 30 and 90 days were analyzed for hospital readmission, preventability (based on the Goldfield criteria), relation to index surgery and clinician communication within 48 h of presentation. RESULTS: In total, 3678 patients had elective surgery in this timeframe. Of these, 476 patients (13.1%) visited the ED at least once within 90 days from their surgical admission discharge date and 114 were readmitted to the hospital (23.9%). Average length from discharge to ED presentation was 27.1 days. The mean cost associated with these ED visits was $974 per visit. 31.9% communicated with their clinician within 48 h of ED presentation. 73.9% of ED visits occurred between Monday - Friday and 51.5% took place between the hours of 8 am-5 pm. 46.6% of ED visits were related to the index operation and 40.7% of ED visits were deemed preventable. CONCLUSIONS: While hospital readmissions have been scrutinized in the literature, relatively little is known about postoperative ED utilization. Our study is one of the first to document postoperative ED utilization up to 90 days after surgery. For just two common elective general surgery procedures, we found these visits were financially burdensome and led to ED discharge in > 75% of patients. Numerous opportunities to improve care were identified. Most ED visits occurred on weekdays and during daylight hours, suggesting an opportunity to utilize outpatient clinics in lieu of the ED. Nearly 50% were related to the operation and nearly 40% were preventable. Revamping the discharge instructions and post-discharge communication-including novel strategies leveraging telemedicine-by providers has the potential to dramatically decrease postoperative ED utilization.

A 3-Year MBSAQIP propensity-matched analysis of Roux-en-Y gastric bypass with concomitant cholecystectomy: Is the robotic or laparoscopic approach preferred?

BACKGROUND: The primary objective of this study was to compare outcomes of patients undergoing minimally invasive RYGB (MIS/RYGB) versus MIS/RYGB with concomitant Cholecystectomy (CCY). A secondary objective was to compare the outcomes for laparoscopic RYGB (LRYGB) and robotic RYGB (RRYGB) with concomitant CCY. METHODS: Outcomes of 117,939 MIS/RYGB with and without CCY were propensity-matched (Age, Gender, BMI, Comorbidities), 10:1, using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from 2015-2017. The MIS/RYGB with CCY were then separated into LRYGB and RRYGB cases for comparison. Exclusion criteria included emergency cases, conversions to open, and age less than 18. RESULTS: The operative time and length of stay (LOS) was significantly increased with addition of concomitant CCY. There was no significant difference in readmission, reoperation, intervention, morbidity, or mortality. The RRYGB with CCY approach was associated with a significantly longer operative times compared to the LRYGB with CCY (177 vs. 135 min, p < 0.0001). The laparoscopic and robotic groups demonstrated no significant difference LOS, readmission, reoperation, intervention, morbidity, or mortality rates. CONCLUSIONS: Our study demonstrates that concomitant cholecystectomy increased the operative time and length of stay. However, concomitant CCY was not associated with any increased morbidity. The study demonstrated no significant difference in morbidity between robotic and laparoscopic approach. The robotic approach, however, was associated with a significantly longer operative time compared to the laparoscopic approach. While the indications for CCY remain controversial, concomitant CCY does not convey additional risk regardless of operative approach.

CCL20 is up-regulated in non-alcoholic fatty liver disease fibrosis and is produced by hepatic stellate cells in response to fatty acid loading.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a prevalent complication of extreme obesity. Loading of the liver with fat can progress to inflammation and fibrosis including cirrhosis. The molecular factors involved in the progression from simple steatosis to fibrosis remain poorly understood. METHODS: Gene expression profiling using microarray, PCR array, and RNA sequencing was performed on RNA from liver biopsy tissue from patients with extreme obesity. Patients were grouped based on histological findings including normal liver histology with no steatosis, lobular inflammation, or fibrosis, and grades 1, 2, 3, and 4 fibrosis with coexistent steatosis and lobular inflammation. Validation of expression was conducted using quantitative PCR. Serum analysis was performed using ELISA. Expression analysis of hepatocytes and hepatic stellate cells in response to lipid loading were conducted in vitro using quantitative PCR and ELISA. RESULTS: Three orthogonal methods to profile human liver biopsy RNA each identified the chemokine CCL20 (CC chemokine ligand 20 or MIP-3 alpha) gene as one of the most up-regulated transcripts in NAFLD fibrosis relative to normal histology, validated in a replication group. CCL20 protein levels in serum measured in 224 NAFLD patients were increased in severe fibrosis (p < 0.001), with moderate correlation of hepatic transcript levels and serum levels. Expression of CCL20, but not its cognate receptor CC chemokine receptor 6, was significantly (p < 0.001) increased in response to fatty acid loading in LX-2 hepatic stellate cells, with relative increases greater than those in HepG2 hepatocyte cells. CONCLUSIONS: These results suggest that expression of CCL20, an important inflammatory mediator, is increased in NAFLD fibrosis. CCL20 serves as a chemoattractant molecule for immature dendritic cells, which have been shown to produce many of the inflammatory molecules that mediate liver fibrosis. These data also point to hepatic stellate cells as a key cell type that may respond to lipid loading of the liver.

Laparoscopic paraesophageal hernia repair is safe in elderly patients.

BACKGROUND: Paraesophageal hernias (PEHs) occur frequently in the elderly. Patients may not be referred for repair due to age or concern for high operative morbidity and mortality. The aim of this study was to compare outcomes of PEH repair based on age. METHODS: Adult patients undergoing PEH repair between 2003 and 2012 at a tertiary referral center were included. Patients were divided by age (Y < 69, YO 70-79 and VO > 80). Body mass index (BMI), Charlson comorbidity index, operative time, estimated blood loss, length of stay, recurrence, Quality of Life in Reflux and Dyspepsia Questionnaire (QOLRAD) scores, morbidity and mortality were analyzed. RESULTS: Two hundred and sixty-seven patients were included: Group Y N = 140 (median age 58.5); Group YO N = 82 (median age 75.0); and Group VO N = 45 (median age 83.0). Group Y had a significantly lower age-adjusted Charlson score compared to the older groups. Group VO had significantly lower BMIs compared to Groups Y and YO. Both groups had similar operative times, intraoperative blood loss and rates of Collis gastroplasty. Group Y had significantly less acute presentations compared to the elderly groups YO 12.2 %, p = 0.028, and VO 22.2 %, p = <0.001. Group Y had a smaller percentage of intrathoracic stomach (55.7 %) as compared to Groups YO (65.1 %; p = 0.001) and VO (74.3 %; p = < 0.001). There were no significant differences in mortalities between all three groups. The mean length of hospital stay was significantly shorter in Group Y (2.45) than in both Group YO (3.12; p = 0.001) and Group VO (5.13; p = <0.001). Major morbidity was significantly lower in the younger group 3.6 % when compared to Group VO (17.8 %; p = 0.001). All groups demonstrated significant improvement in QOLRAD scores. CONCLUSION: The decision to perform laparoscopic paraesophageal hernia repair (LPEHR) in elderly patients remains challenging. LPEHR can be done safely and effectively in elderly patients at experienced centers.

Preoperative use of incretins is associated with increased diabetes remission after RYGB surgery among patients taking insulin: a retrospective cohort analysis.

OBJECTIVE: The main goal of this study was to determine the effects of incretins on type 2 diabetes (T2D) remission after Roux-en-Y gastric bypass (RYGB) surgery for patients taking insulin. BACKGROUND: Type 2 diabetes is a chronic disease with potentially debilitating consequences. RYGB surgery is one of the few interventions that can remit T2D. Preoperative use of insulin, however, predisposes to significantly lower T2D remission rates. METHODS: A retrospective cohort of 690 T2D patients with at least 12 months follow-up and available electronic medical records was used to identify 37 T2D patients who were actively using a Glucagon-like peptide 1 (GLP-1) agonist in addition to another antidiabetic medication, during the preoperative period. RESULTS: Here, we report that use of insulin, along with other antidiabetic medications, significantly diminished overall T2D remission rates 14 months after RYGB surgery (9%) compared with patients not taking insulin (56%). Addition of the GLP-1 agonist, however, increased significantly T2D early remission rates (22%), compared with patients not taking the GLP-1 agonist (4%). Moreover, the 6-year remission rates were also significantly higher for the former group of patients. The GLP-1 agonist did not improve the remission rates of diabetic patients not taking insulin as part of their pharmacotherapy. CONCLUSIONS: Preoperative use of antidiabetic medication, coupled with an incretin agonist, could significantly improve the odds of T2D remission after RYGB surgery in patients also using insulin.

Next-generation sequence analysis of genes associated with obesity and nonalcoholic fatty liver disease-related cirrhosis in extreme obesity.

OBJECTIVES: Genome-wide association studies (GWAS) have led to the identification of single nucleotide polymorphisms in or near several loci that are associated with the risk of obesity and nonalcoholic fatty liver disease (NAFLD). We hypothesized that missense variants in GWAS and related candidate genes may underlie cases of extreme obesity and NAFLD-related cirrhosis, an extreme manifestation of NAFLD. METHODS: We performed whole-exome sequencing on 6 Caucasian patients with extreme obesity [mean body mass index (BMI) 84.4] and 4 obese Caucasian patients (mean BMI 57.0) with NAFLD-related cirrhosis. RESULTS: Sequence analysis was performed on 24 replicated GWAS and selected candidate obesity genes and 5 loci associated with NAFLD. No missense variants were identified in 19 of the 29 genes analyzed, although all patients carried at least 2 missense variants in the remaining genes without excess homozygosity. One patient with extreme obesity carried 2 novel damaging mutations in BBS1 and was homozygous for benign and damaging MC3R variants. In addition, 1 patient with NAFLD-related cirrhosis was compound heterozygous for rare damaging mutations in PNPLA3. CONCLUSIONS: These results indicate that analyzing candidate loci previously identified by GWAS analyses using whole-exome sequencing is an effective strategy to identify potentially causative missense variants underlying extreme obesity and NAFLD-related cirrhosis.

Urgent laparoscopic repair of acutely symptomatic PEH is safe and effective.

BACKGROUND: Acute incarceration of paraesophageal hernias (PEHs) requiring urgent or emergent surgery is rare. Patients are often elderly with significant comorbidities and have historically been treated with open abdominal or thoracic incisions. Our study was designed to evaluate the feasibility, safety, and efficacy of laparoscopic paraesophageal hernia repair (LPEHR) in patients with PEH and acute gastric volvulus. METHODS: We reviewed our prospectively maintained database and identified 269 patients who underwent an initial LPEHR between January 2003 and January 2012. Patients were divided into group A (acute), group B (age- and comorbidity-matched 1:3), and group C (all elective repairs). Group A included those admitted with acute symptoms related to PEH and underwent urgent repair. Patient age, Charlson score, operative time, length of stay (LOS), morbidity, mortality, and recurrence rates were compared. RESULTS: Patients who underwent urgent LPEHR had a higher perioperative morbidity rate than the elective and matched groups. The overall mortality rate was low and no statistical difference was found between groups A, B, and C. LOS in group A was longer than groups B and C. The need for ICU admission was also higher in group A. There was no statistical difference in recurrence rates. CONCLUSIONS: Historically, patients presenting with acute symptoms related to PEH have required open repair, which is associated with significant morbidity and mortality. The acute group was older and sicker than our elective LPEHR patients and had more adverse events resulting in a longer LOS, even when compared with comorbidity-matched elective patients. However, the LOS remained shorter than that reported for open repair and there was no mortality. The recurrence rates in all groups were low and comparable to elective repairs.

Endoscopically guided sutured gastropexy: a novel treatment of gastric volvulus.

Video 1An overview of the case, background information on gastric volvulus, 3-dimensional models of the different types of gastric volvuli, and novel endoscopic and surgical techniques.

Impact of Urinary Catheterization on Postoperative Outcomes After Roux-En-Y Gastric Bypass Surgery in Propensity-Matched Cohorts.

BACKGROUND: The impact of urinary catheter avoidance in bariatric enhanced recovery after surgery (ERAS) protocols is yet to be established. The purpose of the current study is to determine whether urinary catheter use in patients undergoing Roux-en-Y gastric bypass (RYGB) procedures has an effect on postoperative outcomes. METHODS: An institutional database was utilized to identify adult patients undergoing primary minimally invasive RYGB surgery. Outcomes included incidence of urinary tract infection (UTI) within 30 days postoperatively, 30-day readmission rates, proportion of patients discharged after postoperative day 1 (delayed discharge), length of stay (LOS), and operating room time. These were compared between propensity-matched groups with and without urinary catheter placement. RESULTS: There were no significant differences in postoperative UTI's (2.2% for both cohorts, P = .593) or 30-day readmission rates for patients with and without urinary catheters (6.6% and 4.4%, respectively, P = .260). Mean LOS (1.7 vs. 1.5 days, P = .001) and the proportion of patients having a delayed discharge (47.3% vs. 33.7%, P = .001) was greater in patients with a catheter. Operating room time was longer in the urinary catheter group (221.8 vs. 207.9 minutes, P = .002). DISCUSSION: Avoidance of indwelling urinary catheters in RYGB surgical patients decreased delayed discharges and LOS without affecting readmission or reoperation rates. Therefore, we recommend that avoidance of urinary catheters in routine RYGB surgery be considered for inclusion into standardized ERAS protocols. Urinary catheters should continue to be utilized in select cases, however, as these were not shown to affect rate of UTIs.

An electronic health record-enabled obesity database.

BACKGROUND: The effectiveness of weight loss therapies is commonly measured using body mass index and other obesity-related variables. Although these data are often stored in electronic health records (EHRs) and potentially very accessible, few studies on obesity and weight loss have used data derived from EHRs. We developed processes for obtaining data from the EHR in order to construct a database on patients undergoing Roux-en-Y gastric bypass (RYGB) surgery. METHODS: Clinical data obtained as part of standard of care in a bariatric surgery program at an integrated health delivery system were extracted from the EHR and deposited into a data warehouse. Data files were extracted, cleaned, and stored in research datasets. To illustrate the utility of the data, Kaplan-Meier analysis was used to estimate length of post-operative follow-up. RESULTS: Demographic, laboratory, medication, co-morbidity, and survey data were obtained from 2028 patients who had undergone RYGB at the same institution since 2004. Pre-and post-operative diagnostic and prescribing information were available on all patients, while survey laboratory data were available on a majority of patients. The number of patients with post-operative laboratory test results varied by test. Based on Kaplan-Meier estimates, over 74% of patients had post-operative weight data available at 4 years. CONCLUSION: A variety of EHR-derived data related to obesity can be efficiently obtained and used to study important outcomes following RYGB.

Outcomes of Bariatric Surgery in Patients on Chronic Opioids: Can Bariatric Surgery Assist with Decreasing Long-term Opioid Utilization?

PURPOSE: The aim of our study was to assess long-term opioid use following bariatric surgery in patients on preoperative narcotics. METHODS: We evaluated patients utilizing preoperative opioids (OP) who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2020. Patients were propensity-matched to those without preoperative opioid use (NOP) by demographics and comorbidities. Our objectives were to compare opioid use at 1 and 3 years after surgery and evaluate perioperative outcomes. RESULTS: A total of 806 patients, matched 1:1 were evaluated, with 82.7% being females. Mean age was 46.5 years in the OP and 45.6 years in the NOP (p = 0.0018), preoperative BMI was 45.8 in the OP and 46.1 in the NOP (p = 0.695). All patients were followed up for 1 year. In the OP, 156 (38.7%) patients were taking opioids 1 year after surgery as opposed to 27 (6.7%) in the NOP (p < 0.0001). Three years after surgery, 74 (37.5%) patients in the OP and 27 (14.4%) in the NOP were taking outpatient opioids (p < 0.0001). There was no statistically significant difference between OP and NOP groups in terms of readmissions (9.4% vs. 5.7% p = 0.06), reinterventions (3.7 vs. 1.7% p = 0.13), reoperations (3.5% vs. 1.5% p = 0.11), or emergency room visits (8.9% vs. 7.2% p = 0.44). There were no mortalities. CONCLUSION: Most patients requiring preoperative opioids can be weaned off after bariatric surgery. Enhanced recovery pathways are key to obtaining these results. Preoperative opioid use is not associated with increased complications compared to opioid-naïve patients.

Asymptomatic Cholelithiasis and Bariatric Surgery: a Comprehensive Long-Term Analysis of the Risks of Biliary Disease in Patients Undergoing Primary Roux-en-Y Gastric Bypass.

PURPOSE: Currently, there is little consensus on management of the in situ gallbladder of patients undergoing gastric bypass. Our aim was to evaluate outcomes of selective concomitant cholecystectomy (CCY) and long-term biliary outcomes after Roux-en-Y gastric bypass (RYGB). MATERIALS AND METHODS: We performed a retrospective analysis of patients undergoing laparoscopic RYGB (LRYGB) between 2008 and 2018. Chi-square, Fisher's exact, or Wilcoxon rank-sum tests were used to compare outcomes. Concomitant CCY was performed on a selective basis. RESULTS: Three thousand and four patients underwent a RYGB (LRYGB n = 2458, open RYGB n = 546). Fifty-two percent (n = 1670) of patients had undergone CCY at any stage. Thirty-one percent of patients (n = 933) had CCY prior to RYGB, 13% (n = 403) had a concomitant CCY and 13% (n = 214) of the remainder required interval CCY. In the LRYGB subgroup, 29.9% (n = 735) had a prior CCY; 12.9% (n = 202) of those with an in situ gallbladder required interval CCY. Those who underwent concomitant CCY/LRYGB (n = 328) were compared with LRYGB alone (n = 1231). The concomitant CCY group was significantly older and had higher percentage of females, higher preoperative BMI, higher Charlson Comorbidity Index, and a higher medication count. There was no significant difference in BMI nadir, length of stay, complications, or mortality. Interval CCY had a higher incidence of CCY-related complications. CONCLUSION: Our study suggests a higher percentage of bariatric patients with in situ gallbladders will undergo interval CCY than documented in recently published guidelines. Concomitant CCY can be performed without an increase in length of stay or complications. Interval CCY may be associated with a higher complication rate.

The Longitudinal Efficiency of Robotic Surgery: an MBSAQIP Propensity Matched 4-Year Comparison of Robotic and Laparoscopic Bariatric Surgery.

BACKGROUND: The objective of this study was to examine the MBSAQIP database to assess efficiency trends and perioperative outcomes in robotic bariatric surgery. METHODS: Robotic (RA) and laparoscopic (L) sleeve gastrectomy (SG) and gastric bypass (RYGB) were compared using the 2015-2018 MBSAQIP Participant Use Data Files. Patients were propensity matched 1:1 based on sex, body mass index, assistant, and previous obesity or foregut surgery. A total of 93,802 patients were included. RESULTS: Median operative times were significantly longer for both RA-SG (89 vs. 62 min; p < 0.0001) and RA-RYGB (141 vs. 105 min; p < 0.0001) compared with laparoscopic. Over the 4-year period, the difference in operative times (OR delta) between RA-SG and L-SG was unchanged while the difference in operative times between RA-RYGB and L-RYGB increased. Both robotic groups were significantly more likely to be readmitted (RA-SG p = 0.001, RA-RYGB p = 0.006). Robotic SG was more likely to have a reintervention (p = 0.018) and extended length of stay (LOS) (> 4 days) compared with laparoscopic (p = < 0.0002). No significant differences were noted in morbidity and mortality by approach. CONCLUSIONS: Operative times were 30% longer for RA-SG and 25% longer for RA-RYGB when compared with laparoscopic. There was no significant improvement in OR delta for either RA-SG or RA-RYGB over the four years. Readmission rates were higher for both RA-SG and RA-RYGB. Robotic SG had a greater percentage of patients with extended LOS compared with laparoscopic. No evidence of improved efficiency for robotic bariatric surgery as defined by operative time or clinical outcomes was identified.

Overall outcomes of laparoscopic-assisted ERCP after Roux-en-Y gastric bypass and sphincter of Oddi dysfunction subgroup analysis.

Background and study aims Biliary access following Roux-en-Y gastric bypass (RYGB) anatomy presents a significant challenge. Long-term outcomes of laparoscopic-assisted trans-gastric ERCP (LA-ERCP) including sphincter of Oddi dysfunction (SOD) subtypes have not been thoroughly examined. Our study aims to present our overall outcomes of trans-gastric LAERCP and examine a significant subgroup of patients with SOD after RYGB. Patients and methods A retrospective review of RYGB patients who underwent LA-ERCP between 2009 and 2016 identified 51 patients. A subgroup of 22 patients with SOD were examined and contacted by phone survey to determine long-term symptom resolution. Results Post-procedure length of stay was 1.9 days (SD 3.0). There was one conversion from laparoscopic to open procedure. Selective cannulation rate was 100 %. Mean follow-up was 14.6 months. There were two major operative complications, two major ERCP-related complications, and five wound infections (9.8 %). No deaths or episodes of pancreatitis occurred. Seventeen patients had biliary SOD (Type I = 9, Type II = 8). The remaining four had pancreatic SOD (Type I = 1, Type II = 4). SOD subgroup follow-up was 21.4 months (SD 18.1). All patients with Type I biliary and 75 % with Type I pancreatic SOD reported complete resolution of their symptoms. Conclusions Consistent with other published series, LA-ERCP yields excellent cannulation rates after RYGB. Successful treatment of pancreatic and Type 1 biliary SOD suggests that there is significant symptomatic benefit to treating this patient population. However, an overall complication rate of approximately 15 % with LAERCP leaves open the possibility for improvements in access techniques in post-RYGB patients.

First assistant impact on early morbidity and mortality in bariatric surgery.

BACKGROUND: The future of bariatric surgery depends largely on how effectively residents and fellows are trained. The challenge is to assure patient safety during training. Our study compares the impact of first assistants on patient outcomes after Roux-en-Y gastric bypass and sleeve gastrectomy. METHODS: A retrospective review of primary, elective Roux-en-Y gastric bypass and sleeve gastrectomy procedures performed in 2015 and 2016 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant user files was performed. Patient cohorts were categorized by the level of training of the surgical first assistant (FA). Multivariate regression models were developed to determine the impact of the FA level on patient outcomes, adjusting for patient demographic characteristics and co-morbid conditions. RESULTS: Compared with an attending weight loss surgeon as FA, minimally invasive surgery fellows and general surgery residents were more likely to have an unplanned admission to the intensive care unit (ICU) within 30 days (odds ratio [OR] 1.422, 95% confidence interval [CI] 1.196-1.691; OR 1.206, 95% CI 1.034-1.406, respectively, P < .0001) and were more likely to have a 30-day hospital readmission (OR 1.143, 95% CI 1.056-1.236; OR 1.127, 95% CI 1.055-1.204, respectively, P < .0001). Compared with having a weight loss surgeon as FA, operative duration was significantly longer for all other assistant levels, or no assistant (P < .0001). CONCLUSION: The training level of the FA does not impact early patient mortality or reoperation rates after Roux-en-Y gastric bypass or sleeve gastrectomy. However, unplanned intensive care unit admissions and readmissions within 30 days were significantly associated with surgical resident or minimally invasive surgery fellow FAs. Further analysis is needed to understand this cause and effect; however, these data provide direction to redesign residency and fellowship training.