A phase Ib feasibility trial of response adapted neoadjuvant therapy in gastric cancer (RANT-GC).

Current guidelines recommend neoadjuvant (NAC) and/or adjuvant chemotherapy for locally advanced gastric cancers (LAGCs). However, the choice and duration of NAC regimen is standardized, rather than personalized to biologic response, despite the availability of several different classes of agents for the treatment of gastric cancer (GC). The current trial will use a tumor-informed ctDNA assay (Signatera™) and monitor response to NAC. Based on ctDNA kinetics, the treatment regimen is modified. This is a prospective single center, single-arm, open-label study in clinical stage IB-III GC. ctDNA is measured at baseline and repeated every 8 weeks. Imaging is performed at the same intervals. The primary end point is the feasibility of this approach, defined as percentage of patients completing gastrectomy.

Comparison of BMI on operative time and complications of robotic inguinal hernia repair at a VA medical center.

BACKGROUND: BMI is a risk factor for recurrence and post-operative complications in both open and laparoscopic totally extraperitoneal approach (TEP) repair. Robotic surgery using the transabdominal preperitoneal approach (TAPP) is a safe and viable option for inguinal hernia repair (IHR). The objective of this study is to determine how difference in BMI influences rate of operative time, complications, and rate of recurrence in a robotic TAPP IHR. METHODS: We performed a retrospective review of patients who underwent robotic inguinal hernia repair between 2012 and 2019 at a Veterans Health Administration facility (N = 304). The operating time, outcomes, and overall morbidity and mortality for robotic IHR were compared between three different BMI Groups. These groups were divided into: "Underweight/Normal Weight" (BMI < 25) n = 102, "Pre-Obese" (BMI 25-29.9) n = 120, and "Obese" (BMI 30 +) n = 82. RESULTS: The average operating time of a bilateral IHR by BMI group was 83.5, 98.4, and 97.8 min for BMIs < 25, 25-29.9, and 30 +, respectively. Operating time was lower in the Underweight/Normal BMI group compared to the Pre-Obese group (p = 0.006) as well as the Obese group (p = 0.001). For unilateral repair, the average operation length by group was 65.2, 70.9, and 85.6 min for BMIs < 25, 25-29.9, and 30 +, respectively, demonstrating an increased time for Obese compared to Underweight/Normal BMI (p = 0.001) and for Obese compared to Pre-Obese (p = 0.01). Demographic/comorbidity variables were not significantly different, except for a higher percentage of white patients in the Underweight/Normal BMI group compared to the Pre-Obese and Obese groups (p = 0.02 and p = 0.0003). There was no significant difference in complications or recurrence. CONCLUSION: BMI has a significant impact on the operating time of both unilateral and bilateral robotic hernia repair. Despite this increased operative time, BMI group did not differ significantly in postoperative outcomes or in recurrence rates.

Venous thromboembolism risk for the contemporary bariatric surgeon.

BACKGROUND: Postoperative venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), are the leading causes of morbidity and mortality after bariatric surgery. Although several studies have examined VTE, few have examined risk factors separately for DVT and PE after contemporary bariatric surgery, including laparoscopic sleeve gastrectomy (LSG). Our objective was to define risk factors for DVT and PE independently for both LSG and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients using the largest validated bariatric surgery database. METHODS: The metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP) database was queried to identify patients who underwent LSG or LRYGB between January 2015 and December 2017. Perioperative data were compared using bivariate analysis. Risk of DVT and PE after LSG or LRYGB was determined using multivariable logistic regression analysis. RESULTS: During the study period, 369,032 bariatric cases (72% LSG, 28% LRYGB) were performed. The incidence of DVT was similar between LSG and LRYGB (0.2% vs. 0.2%, p = 0.96), while the incidence of PE was decreased for LSG compared to LRYGB (0.1% vs. 0.2%, p < 0.001). Operative length was associated with increased risk of postoperative DVT (OR 1.1, CI 1.01-1.30, p = 0.04) and postoperative PE (OR 1.4, CI 1.16-1.64, p < 0.001) after surgery. The largest independent risk factors for DVT were history of DVT (OR 6.2, CI 4.44-8.45, p < 0.001) and transfusion (OR 4.2, CI 2.48-6.63, p < 0.001). The largest independent risk factors for PE were transfusion (OR 5.0, CI 2.69-8.36, p < 0.001) and history of DVT (OR 2.8, CI 1.67-4.58, p < 0.001). LSG was associated with a decreased risk of PE compared to LRYGB (OR 0.7 CI 0.55-0.91, p = 0.01). CONCLUSIONS: Prolonged operative length is associated with a higher risk of DVT and PE after either LSG or LRYGB. Transfusion and history of DVT are the largest risk factors for developing DVT and PE. There is a decreased risk of PE after LSG compared to LRYGB.

Outcomes of laparoscopic hiatal hernia repair based on surgical specialty: thoracic versus general surgeons.

BACKGROUND: Hiatal Hernia Repairs (HHR) are performed by both general surgeons (GS) and thoracic surgeons (TS). However, there are limited literature with respect to outcomes of HHR based on specialty training. The objective of this study was to compare the utilization, perioperative outcomes, and cost for HHR performed by GS versus TS. METHODS: The Vizient database was used to identify patients who underwent elective laparoscopic HHR between October 2014 and June 2018. Patients were grouped according to surgeon's specialty (GS vs. TS). Patient demographics and outcomes including in-hospital mortality were compared between groups. RESULTS: During the study period 13,764 patients underwent HHR by either GS or TS. GS performed 9930 (72%) cases while TS performed 3834 (28%) cases. There was no significant difference between GS versus TS with regard to serious morbidity (1.28% vs. 1.30%, p = 0.97) or mortality (0.10% vs. 0.21%, p = 0.19). The mortality index was 0.24 for GS versus 0.45 for TS. Compared to TS, laparoscopic HHR performed by GS was associated with a shorter LOS (2.57 days vs. 2.72 days, p < 0.001) and lower mean hospital costs ($7139 vs. $8032, p < 0.0001). CONCLUSIONS: Within the context of academic centers, laparoscopic HHRs are mostly performed by GS with comparable outcome between general versus thoracic surgeons.

Serum biomarkers of inflammation and adiposity in the LABS cohort: associations with metabolic disease and surgical outcomes.

BACKGROUND: The utility of serum biomarkers related to inflammation and adiposity as predictors of metabolic disease prevalence and outcomes after bariatric surgery are not well-defined. METHODS: Associations between pre- and post-operative serum levels of four biomarkers (C-reactive protein (CRP), cystatin C (CC), leptin, and ghrelin) with baseline measures of adiposity and metabolic disease prevalence (asthma, diabetes, sleep apnea), and weight loss and metabolic disease remission after bariatric surgery were studied in the Longitudinal Assessment of Bariatric Surgery (LABS) cohort. RESULTS: Baseline CRP levels were positively associated with the odds of asthma but not diabetes or sleep apnea; baseline CC levels were positively associated with asthma, diabetes, and sleep apnea; baseline leptin levels were positively associated with asthma and negatively associated with diabetes and sleep apnea; baseline ghrelin levels were negatively associated with diabetes and sleep apnea. Increased weight loss was associated with increased baseline levels of leptin and CRP and decreased baseline levels of CC. Remission of diabetes and asthma was not associated with baseline levels of any biomarker. A higher likelihood of asthma remission was associated with a greater decrease in leptin levels, and a higher likelihood of diabetes remission was predicted by a lesser decrease in CC. Bariatric surgery was associated with decreased post-operative CC, CRP, and leptin levels, and increased post-operative ghrelin levels. CONCLUSION: This is the largest study to date of serum biomarkers of inflammation and adiposity in a bariatric surgery cohort. Biomarker levels correlate with metabolic disease prevalence prior to bariatric surgery, and with weight loss but not metabolic disease remission after surgery. Bariatric surgery regulates serum biomarker levels in a manner consistent with anti-inflammatory and compensatory orexigenic effects. These data contribute to our understanding of the mechanisms underlying the biologic effects of bariatric surgery.

Robotic versus laparoscopic sleeve gastrectomy: a MBSAQIP analysis.

BACKGROUND: Laparoscopic sleeve gastrectomy has become the procedure of choice for the treatment of morbid obesity. Robotic sleeve gastrectomy is an alternative surgical option, but its utilization has been low. The aim of this study was to evaluate the contemporary outcomes of robotic sleeve gastrectomy (RSG) versus laparoscopic sleeve gastrectomy (LSG) using a national database from accredited bariatric centers. STUDY DESIGN: Using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, clinical data for patients who underwent RSG or LSG were examined. Emergent and revisional cases were excluded. A multivariate logistic regression model was utilized to compare the outcomes between RSG and LSG. RESULTS: A total of 75,079 patients underwent sleeve gastrectomy with 70,298 (93.6%) LSG and 4781 (6.4%) RSG. Preoperative sleep apnea and hypoalbumenia were significantly higher in the RSG group (P < 0.01). Mean length of stay was similar between RSG and LSG (1.8 ± 2.0 vs. 1.7 ± 2.0 days, P = 0.17). Operative time was longer in the RSG group (102 ± 43 vs. 74 ± 36 min, P < 0.01). There was no significant difference in 30-day mortality between the RSG versus LSG group (0.02% vs. 0.01%, AOR 0.85; 95% CI 0.11-6.46, P = 0.88). However, RSG was associated with higher serious morbidity (1.1% vs. 0.8%, AOR 1.40; 95% CI 1.05-1.86, P < 0.01), higher leak rate (1.5% vs. 0.5%, AOR 3.14; 95% CI 2.65-4.42, P < 0.01), and higher surgical site infection rate (0.7% vs. 0.4%, AOR 1.55; 95% CI 1.08-2.23, P = 0.01). CONCLUSIONS: Robotic sleeve gastrectomy has longer operative time and is associated with higher postoperative morbidity including leak and surgical site infections. Laparoscopy should continue to be the surgical approach of choice for sleeve gastrectomy.

Effect of Bariatric Surgery on CKD Risk.

Obesity is linked to the development and progression of CKD, but whether bariatric surgery protects against CKD is poorly understood. We, therefore, examined whether bariatric surgery influences CKD risk. The study included 2144 adults who underwent bariatric surgery from March of 2006 to April of 2009 and participated in the Longitudinal Assessment of Bariatric Surgery-2 Study cohort. The primary outcome was CKD risk categories as assessed by the Kidney Disease Improving Global Outcomes (KDIGO) consortium criteria using a combination of eGFR and albuminuria. Patients were 79% women and 87% white, with a median age of 46 years old. Improvements were observed in CKD risk at 1 and 7 years after surgery in patients with moderate baseline CKD risk (63% and 53%, respectively), high baseline risk (78% and 56%, respectively), and very high baseline risk (59% and 23%, respectively). The proportion of patients whose CKD risk worsened was ≤10%; five patients developed ESRD. Sensitivity analyses using year 1 as baseline to minimize the effect of weight loss on serum creatinine and differing eGFR equations offered qualitatively similar results. Treatment with bariatric surgery associated with an improvement in CKD risk categories in a large proportion of patients for up to 7 years, especially in those with moderate and high baseline risk. These findings support consideration of CKD risk in evaluation for bariatric surgery and further study of bariatric surgery as a treatment for high-risk obese patients with CKD.

Laparoscopic anti-reflux surgery for idiopathic pulmonary fibrosis at a single centre.

We sought to assess whether laparoscopic anti-reflux surgery (LARS) is associated with decreased rates of disease progression in patients with idiopathic pulmonary fibrosis (IPF).The study was a retrospective single-centre study of IPF patients with worsening symptoms and pulmonary function despite antacid treatment for abnormal acid gastro-oesophageal reflux. The period of exposure to LARS was September 1998 to December 2012. The primary end-point was a longitudinal change in forced vital capacity (FVC) % predicted in the pre- versus post-surgery periods.27 patients with progressive IPF underwent LARS. At time of surgery, the mean age was 65 years and mean FVC was 71.7% pred. Using a regression model, the estimated benefit of surgery in FVC % pred over 1 year was 5.7% (95% CI -0.9-12.2%, p=0.088) with estimated benefit in FVC of 0.22 L (95% CI -0.06-0.49 L, p=0.12). Mean DeMeester scores decreased from 42 to 4 (p<0.01). There were no deaths in the 90 days following surgery and 81.5% of participants were alive 2 years after surgery.Patients with IPF tolerated the LARS well. There were no statistically significant differences in rates of FVC decline pre- and post-LARS over 1 year; a possible trend toward stabilisation in observed FVC warrants prospective studies. The ongoing prospective randomised controlled trial will hopefully provide further insights regarding the safety and potential efficacy of LARS in IPF.

Change in Pain and Physical Function Following Bariatric Surgery for Severe Obesity.

IMPORTANCE: The variability and durability of improvements in pain and physical function following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) are not well described. OBJECTIVES: To report changes in pain and physical function in the first 3 years following bariatric surgery, and to identify factors associated with improvement. DESIGN, SETTING, AND PARTICIPANTS: The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study at 10 US hospitals. Adults with severe obesity undergoing bariatric surgery were recruited between February 2005 and February 2009. Research assessments were conducted prior to surgery and annually thereafter. Three-year follow-up through October 2012 is reported. EXPOSURES: Bariatric surgery as clinical care. MAIN OUTCOMES AND MEASURES: Primary outcomes were clinically meaningful presurgery to postsurgery improvements in pain and function using scores from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (ie, improvement of ≥5 points on the norm-based score [range, 0-100]) and 400-meter walk time (ie, improvement of ≥24 seconds) using established thresholds. The secondary outcome was clinically meaningful improvement using the Western Ontario McMaster Osteoarthritis Index (ie, improvement of ≥9.7 pain points and ≥9.3 function points on the transformed score [range, 0-100]). RESULTS: Of 2458 participants, 2221 completed baseline and follow-up assessments (1743 [78.5%] were women; median age was 47 years; median body mass index [BMI] was 45.9; 70.4% underwent RYGB; 25.0% underwent LAGB). At year 1, clinically meaningful improvements were shown in 57.6% (95% CI, 55.3%-59.9%) of participants for bodily pain, 76.5% (95% CI, 74.6%-78.5%) for physical function, and 59.5% (95% CI, 56.4%-62.7%) for walk time. Additionally, among participants with severe knee or disability (633), or hip pain or disability (500) at baseline, approximately three-fourths experienced joint-specific improvements in knee pain (77.1% [95% CI, 73.5%-80.7%]) and in hip function (79.2% [95% CI, 75.3%-83.1%]). Between year 1 and year 3, rates of improvement significantly decreased to 48.6% (95% CI, 46.0%-51.1%) for bodily pain and to 70.2% (95% CI, 67.8%-72.5%) for physical function, but improvement rates for walk time, knee and hip pain, and knee and hip function did not (P for all ≥.05). Younger age, male sex, higher income, lower BMI, and fewer depressive symptoms presurgery; no diabetes and no venous edema with ulcerations postsurgery (either no history or remission); and presurgery-to-postsurgery reductions in weight and depressive symptoms were associated with presurgery-to-postsurgery improvements in multiple outcomes at years 1, 2, and 3. CONCLUSIONS AND RELEVANCE: Among a cohort of participants with severe obesity undergoing bariatric surgery, a large percentage experienced improvement, compared with baseline, in pain, physical function, and walk time over 3 years, but the percentage with improvement in pain and physical function decreased between year 1 and year 3. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00465829.

The impact of laparoscopic anti-reflux surgery in patients with Barrett's esophagus.

BACKGROUND: Barrett's esophagus (BE) is a major risk factor for esophageal adenocarcinoma. It is believed that BE is caused by chronic gastro-esophageal reflux disease (GERD). Laparoscopic anti-reflux surgery (LARS) restores the competency of the cardia and may thereby change the natural course of BE. We studied the impact of LARS on the histological profile of BE and on the control of GERD. METHODS: We identified all patients with BE who underwent LARS from 1994 to 2007 and contacted them to assess post-operative GERD symptoms via questionnaire. Endoscopy findings, histology, 24 hour pH monitoring, and manometry were also collected using our prospectively maintained database. Histological regression was defined as either loss of dysplasia or disappearance of BE. RESULTS: Two hundred and fifteen patients met the initial inclusion criteria; in 82 of them histology from post-operative endoscopy was available for review. Endoscopy was performed a median of 8 years (range, 1-16 years) after surgery. Regression of BE occurred in 18 (22%) patients while in 6 (7%) BE progressed to dysplasia or cancer. Thirty-six (43%) patients underwent pre- and post-operative manometry. The median lower esophageal sphincter pressure increased from 9 to 17 mmHg in these patients. Thirty-four (41%) patients underwent pre- and post-operative pH studies. The median DeMeester score decreased from 54 to 9. Sixty-seven (82%) of 82 patients completed the post-operative questionnaire; 86% of these patients reported improvement in heartburn and regurgitation. CONCLUSIONS: LARS was associated with both physiologic and symptomatic control of GERD in patients with BE. LARS resulted in regression of BE in 22% of patients and progression in 7%. Thus, continued surveillance of Barrett's is needed after LARS.

Outcomes of Complex Gastrointestinal Cancer Resection at US News & World Report Top-Ranked vs Non-Ranked Hospitals.

BACKGROUND: The US News & World Report (USNWR) annual ranking of the best hospitals for gastroenterology and gastrointestinal surgery offers direction to patients and healthcare providers, especially for recommendations on complex medical and surgical gastrointestinal (GI) conditions. The objective of this study was to examine the outcomes of complex GI cancer resections performed at USNWR top-ranked, compared to non-ranked, hospitals. STUDY DESIGN: Using the Vizient database, data for patients who underwent esophagectomy, gastrectomy, and pancreatectomy for malignancy between January and December 2018 were reviewed. Perioperative outcomes were analyzed according to USNWR rank status. Primary outcome was in-hospital mortality. Secondary outcomes include length of stay, mortality index (observed-to-expected mortality ratio), rate of serious complication, and cost. Secondary analysis was performed for outcomes of patients who developed serious complications. RESULTS: There were 3,054 complex GI cancer resections performed at 42 top-ranked hospitals vs 3,608 resections performed at 198 non-ranked hospitals. The mean annual case volume was 73 cases at top-ranked hospitals compared to 18 cases at non-ranked hospitals. Compared with non-ranked hospitals, top-ranked hospitals had lower in-hospital mortality (0.96% vs 2.26%, respectively, p < 0.001) and lower mortality index (0.71 vs 1.53, respectively). There were no significant differences in length of stay, rate of serious complications, or direct cost between groups. In patients who developed serious morbidity, top-ranked hospitals had a lower mortality compared with non-ranked hospitals (8.2% vs 16.8%, respectively, p < 0.01). CONCLUSIONS: Within the context of complex GI cancer resection, USNWR top-ranked hospitals performed a 4-fold higher case volume and were associated with improved outcomes. Patients with complex GI-related malignancies may benefit from seeking surgical care at high-volume regional USNWR top-ranked hospitals.

Novel Interdisciplinary Approach to GERD: Concomitant Laparoscopic Hiatal Hernia Repair with Transoral Incisionless Fundoplication.

BACKGROUND: Transoral incisionless fundoplication (TIF) is an endoscopic alternative for the treatment of GERD. However, TIF does not address the hiatal hernia (HH). We present a novel approach with a laparoscopic HH repair followed by same-session TIF, coined concomitant transoral incisionless fundoplication (cTIF). The aim of this study was to assess the efficacy, safety, and feasibility of cTIF in a collaborative approach between Gastroenterology and surgery. STUDY DESIGN: Patients with confirmed GERD and >2 cm HH who underwent cTIF between 2018 and 2020 were included. Symptoms were assessed using the Reflux Disease Questionnaire, GERD Health-Related Quality of Life Index, and the Reflux Symptom Index pre and post cTIF. One-way ANOVA and paired samples t-test were used for statistical analysis. RESULTS: Sixty patients underwent cTIF (53% were men, mean age was 59.3 years) with 100% technical success. Mean ± SD HH measurement on endoscopy was 2.9 ± 1.5 cm. Scores on Reflux Disease Questionnaire for symptom frequency and symptom severity improved significantly from before to 6 months after cTIF (17.4 to 4.72; p < 0.01 and 16.7 to 4.56; p < 0.05, respectively). According to the GERD Health-Related Quality of Life Index, significant decreases were seen post cTIF in heartburn (23.26 to 7.37; p < 0.01) and regurgitation (14.26 to 0; p = 0.05). Reflux Symptom Index similarly decreased after cTIF (17.7 to 8.1 post cTIF; p < 0.01). Mean DeMeester score decreased from 43.7 to 4.9 and acid exposure time decreased from 12.7% to 1.28% post cTIF (p = 0.06). CONCLUSIONS: We present a novel multidisciplinary approach to GERD using a combined endoscopic and surgical approach with close collaboration between Gastroenterology and surgery. Our results suggest that cTIF is safe and effective in reducing reflux symptoms in a large spectrum of GERD patients.

The Role of Endoscopic Stent in Management of Postesophagectomy Leaks.

INTRODUCTION: Anastomotic leak is a dreaded complication following esophagectomy. Conventional management for leaks includes invasive reoperation and even gastrointestinal diversion. OBJECTIVE: The aim of this study was to examine our contemporary outcome of using endoscopic esophageal stenting as primary therapy for management of anastomotic leak following minimally invasive esophagectomy (MIE). METHODS: We reviewed data on 11 patients who developed an esophageal leak following 111 MIE between January 2011 and December 2019. Of the 11 anastomotic leaks, 10 patients had an anastomotic disruption and underwent endoscopic esophageal stenting as primary therapy for management of leaks, while 1 patient had an anastomotic disruption complicated by an associated tracheoesophageal fistula that required surgical reoperation and subsequent colonic interposition. Main outcome measures focused on the 10 patients who were managed with endoscopic stenting, including length of hospital stay following leak management, need for thoracotomy or gastrointestinal diversion for leak, stent complications, and leak-associated mortality. RESULTS: Of the 10 patients who underwent endoscopic esophageal stenting as primary therapy for management of leaks, there were 8 males with a median age of 66 years. The median time to diagnosis of anastomotic leak was 10 days postoperatively. One of the ten patients also underwent percutaneous drain placement, while none of the patients required thoracotomy. Median duration of stent placement was 39 (range, 29-105) days. Median length of stay after stent placement was 10 (range, 4-43) days. The median number of stent exchange was 1 (range, 1-3) stent. Gastrointestinal continuity was maintained in all patients. The 90-day leak-associated mortality was 9.1% (1 of 11 patients). CONCLUSIONS: Endoscopic stenting is an effective primary therapy in the management of postesophagectomy leak and avoids the need for an invasive, reoperative thoracotomy or gastrointestinal diversion procedure.

Tumor subsite location within the colon is prognostic for survival after colon cancer diagnosis.

PURPOSE: Proximal colon cancers are more likely to present with advanced stage than distal cancers; however, previous reports conflict regarding the independent prognostic significance of tumor location on survival. We examined survival by colon cancer subsite location by use of data from the California Cancer Registry. METHODS: An analysis of colon cancer cases from 1994 to 2004 was conducted, with follow-up through 2006. Colon subsite location was defined as proximal colon (cecum, ascending colon, hepatic flexure), transverse colon, descending colon (splenic flexure, descending colon), and sigmoid colon. Subsite-specific survival analyses were conducted with use of the Kaplan-Meier method and Cox proportional hazards ratios. RESULTS: A total of 82,926 colon cancer cases were identified, including 40,078 proximal (48%), 8,023 transverse (10%), 8,657 descending (10%), and 26,168 sigmoid cancers (32%). A larger proportion of sigmoid cancers (30.5%) presented as Stage I compared with proximal (18.5%), transverse (16.8%), or descending colon cancers (20.1%). Proximal cancers had the greater proportion with high tumor grade (27%), and had a greater mean number of lymph nodes examined. There were no differences in treatment rendered when each colon subsite was stratified by stage. After adjustment for stage, grade, treatment, lymph node examination, and other relevant clinical variables, sigmoid cancers had decreased colorectal cancer-specific mortality compared with proximal tumors (hazards ratio = 0.88; 95% confidence interval, 0.85-0.92). CONCLUSIONS: In this analysis, sigmoid colon cancers were observed to have earlier stage, lower tumor grade, and independently decreased colorectal cancer-specific mortality compared with proximal tumors.

Improvement of restrictive and obstructive pulmonary mechanics following laparoscopic bariatric surgery.

BACKGROUND: Morbidly obese patients often have impaired respiratory mechanics leading to restrictive and obstructive lung diseases. Weight loss after bariatric surgery has been shown to improve or resolve many obesity-related comorbidities. However, few studies have examined long-term changes in pulmonary mechanics after bariatric surgery. We hypothesize that pulmonary function improves after surgically induced weight loss. METHODS: We examined the pulmonary function of 104 morbidly obese patients who underwent laparoscopic gastric bypass or gastric banding. Pulmonary studies, including forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC), peak expiratory flow (PEF), and forced expiratory volume at midexpiratory phase (FEV(25-75%)) were measured preoperatively and at 3-month intervals. All results are expressed as a percentage of the baseline values. RESULTS: There were 80 females and 24 males with a mean age of 41 years. The mean body mass index was 48 kg/m(2). The mean percentage of excess body weight loss at 12 months was 54%. At 12 months postoperatively, restrictive pulmonary mechanics significantly improved as demonstrated by an increase in the FEV(1) to 112% of baseline value, increase in the FVC to 109% of baseline value, increase in the PEF to 115% of baseline value, and increase in the FEV(25-75%) to 130% of baseline value. Additionally, the percentage of patients with obstructive lung pattern (FEV(1)/FVC ratio less than 0.8) decreased from 9.6% preoperatively to 1.9% postoperatively (p=0.03). CONCLUSIONS: Weight loss after laparoscopic gastric bypass significantly improves restrictive and obstructive respiratory mechanics. The improvements were observed as early as 3 months postoperatively.

Video: minimally invasive Ivor-Lewis esophagogastrectomy for gastric cardia cancer.

INTRODUCTION: Gastric cardia cancer with involvement of the esophagus may require an esophagogastrectomy to obtain negative tumor margins. Multiple studies have shown that minimally invasive esophagectomy is a safe approach for the treatment of esophageal cancer [1-3]. We describe the technique of a minimally invasive Ivor-Lewis esophagectomy in a 55-year-old patient with a gastric cardia tumor. METHODS: In the laparoscopic phase, diagnostic laparoscopy was negative for metastasis. The stomach and distal esophagus were mobilized. The stomach was divided distal to the tumor and a thin gastric conduit was created. The specimen was removed through an extended abdominal port. In the thoracoscopic phase, the esophagus was mobilized. To ensure adequate proximal margins the esophageal stump was divided 1 cm below the azygous vein. A gastroesophageal anastomosis was created using a circular stapler. RESULTS: Total operative time was 210 min (laparoscopic time, 135 min; thoracoscopic time, 75 min). There were no intraoperative complications. Tumor margins were negative and there were 44 lymph nodes harvested. On postoperative day 2 the patient was transferred to the surgical floor and started on enteral feeds. On postoperative day 4 the esophagram was negative for leaks or obstruction. Patient was started on an oral diet and discharged on postoperative day 5. Final pathology revealed a T3N1M0 (stage III) gastric cardia tumor. The patient underwent adjuvant chemoradiation therapy and at 15 months postoperatively the patient was recurrence free. CONCLUSION: We recently reported our experience with 104 minimally invasive esophagectomy procedures, of which seven patients had a diagnosis of gastric cardia cancer [4]. The mean number lymph nodes harvested was 23 ± 12. Minimally invasive Ivor-Lewis esophagogastrectomy for the treatment of gastric cardia cancer is technically feasible and safe for large gastric cardia tumors.

Hospital volume is not a predictor of outcomes after gastrectomy for neoplasm.

Studies have shown conflicting data with regard to the volume and outcome relationship for gastrectomy. Using the University HealthSystem Consortium national database, we examined the influence of the hospital's volume of gastrectomy on outcomes at academic centers between 2004 and 2008. Outcome measures, including length of stay, 30-day readmission, morbidity, and in-hospital mortality, were compared among high- (13 or greater), medium- (6 to 12), and low-volume (five or less) hospitals. There were 10 high- (n = 593 cases), 36 medium- (n = 1076 cases), and 75 low-volume (n = 500 cases) hospitals. There were no significant differences between high- and low-volume hospitals with regard to length of stay, overall complications, 30-day readmission rate, and in-hospital mortality (2.4 vs 4.4%, respectively, P = 0.06). Despite the small number of gastrectomies performed at the low-volume hospitals, these same hospitals performed a large number of other types of gastric surgery such as gastric bypass for the treatment of morbid obesity (102 cases/year). Within the context of academic medical centers, lower annual volume of gastrectomy for neoplasm is not a predictor of poor outcomes which may be explained by the gastric operative experience derived from other types of gastric surgery.

Recent experience with abdominal perineal resection with vertical rectus abdominis myocutaneous flap reconstruction after preoperative pelvic radiation.

Abdominoperineal resection (APR) after pelvic radiation can be complicated by an increased rate of difficult to treat perineal wound complications. In an effort to improve postoperative morbidity after APR, myocutaneous flap reconstructions have been used. We review our recent experience with APR with vertical rectus abdominis myocutaneous flap reconstruction (VRAM) after preoperative pelvic radiation. A retrospective review of patients who underwent APR with VRAM reconstruction after pelvic radiation from December 2004 to July 2008 was conducted. Outcome measures included demographics, comorbidities, length of stay, wound complications, and morbidity and mortality. Fifteen patients with a mean age of 61 +/- 9 years underwent APR with VRAM reconstruction. Five patients also required posterior vaginectomy with the APR. Indications for APR were rectal cancer (n = 14, 93%) and anal canal cancer (n = 1, 7%). There were no intraoperative complications. Mean estimated blood loss was 635 +/- 446 mL and mean intraoperative blood transfusion requirements were 1 +/- 2 units. Mean length of hospital stay was 11 +/- 4 days. Six (40%) patients had minor perineal wound complications. One (7%) patient had a perineal wound infection requiring reoperation with washout and reapproximation. There was no 30-day or in-hospital mortality. All VRAM flaps remained viable through follow-up. APR with VRAM flap reconstruction after preoperative pelvic radiation can be performed safely with limited wound complications and no mortality.

Laparoscopic fundoplication compared with laparoscopic gastric bypass in morbidly obese patients with gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease (GERD) is commonly associated with morbid obesity. Laparoscopic fundoplication is a standard surgical treatment for GERD, and laparoscopic gastric bypass has been shown to effectively resolve GERD symptoms in the morbidly obese. We sought to compare the in-hospital outcomes of morbidly obese patients who underwent laparoscopic fundoplication for the treatment of GERD versus laparoscopic gastric bypass for the treatment of morbid obesity and related conditions, including GERD, at U.S. academic medical centers. METHODS: Using the "International Classification of Diseases, 9th Revision" procedural and diagnoses codes for morbidly obese patients with GERD, we obtained data from the University HealthSystem Consortium database for all patients who underwent laparoscopic fundoplication or laparoscopic gastric bypass from October 2004 to December 2007 (n=27,264). The outcome measures included the patient demographics, length of stay, in-hospital overall complications, mortality, risk-adjusted mortality ratio (observed to expected mortality), and hospital costs. RESULTS: Compared with the patients who underwent laparoscopic gastric bypass, those who underwent laparoscopic fundoplication had a lower severity of illness score (P<.05). The overall in-hospital complications were significantly lower in the laparoscopic gastric bypass group (P<.05). The mean length of stay, observed mortality, risk-adjusted mortality, and hospital costs were comparable between the 2 treatment groups. CONCLUSION: Laparoscopic gastric bypass is as safe as laparoscopic fundoplication for the treatment of GERD in the morbidly obese. Hence, morbidly obese patients with GERD should be referred for bariatric surgery evaluation and offered laparoscopic gastric bypass as a surgical option.

National trends in use and outcome of laparoscopic adjustable gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding is gaining popularity in the United States. Our objective was to examine the use and outcomes of laparoscopic adjustable gastric banding at academic medical centers. METHODS: Using the "International Classification of Diseases, Ninth Revision" diagnosis and procedure codes, data were obtained from the University Health System Consortium Clinical Database for all laparoscopic adjustable gastric banding and gastric bypass procedures performed from 2004 to 2007. Quartile trends in the use of all procedures were determined, and a comparison of in-hospital morbidity and mortality between laparoscopic adjustable gastric banding and laparoscopic gastric bypass was performed. RESULTS: A total of 31,333 bariatric surgery procedures were performed from 2004 to 2007. During this period, the use of laparoscopic adjustable gastric banding and gastric bypass procedures increased from 7% to 23% and 53% to 66%, respectively. A concurrent decrease occurred in the use of open gastric bypass procedures from 40% to 11%. Compared with laparoscopic gastric bypass, laparoscopic adjustable gastric banding was associated with a significantly shorter length of stay (1.3 versus 2.7 d, P<.01), lower morbidity (2.8% versus 7.5%, P<.01), lower 30-day readmission rate (.7% versus 2.5%, P<.01), lower in-hospital mortality (.02% versus .08%, P<.01), and lower hospital cost ($8689 versus 14,386, P<.01). CONCLUSION: From 2004 to 2007, significant growth occurred in the number of laparoscopic adjustable gastric banding (+329%) and laparoscopic gastric bypass (+125%) procedures, with a precipitous decrease in the number of open gastric bypass (-73%) procedures. The increasing popularity of the laparoscopic adjustable gastric band procedure could in part be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass.