SAGES/AHPBA guidelines for the use of microwave and radiofrequency liver ablation for the surgical treatment of hepatocellular carcinoma or colorectal liver metastases less than 5 cm.

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the liver's two most common malignant neoplasms. Liver-directed therapies such as ablation have become part of multidisciplinary therapies despite a paucity of data. Therefore, an expert panel was convened to develop evidence-based recommendations regarding the use of microwave ablation (MWA) and radiofrequency ablation (RFA) for HCC or CRLM less than 5 cm in diameter in patients ineligible for other therapies. METHODS: A systematic review was conducted for six key questions (KQ) regarding MWA or RFA for solitary liver tumors in patients deemed poor candidates for first-line therapy. Subject experts used the GRADE methodology to formulate evidence-based recommendations and future research recommendations. RESULTS: The panel addressed six KQs pertaining to MWA vs. RFA outcomes and laparoscopic vs. percutaneous MWA. The available evidence was poor quality and individual studies included both HCC and CRLM. Therefore, the six KQs were condensed into two, recognizing that these were two disparate tumor groups and this grouping was somewhat arbitrary. With this significant limitation, the panel suggested that in appropriately selected patients, either MWA or RFA can be safe and feasible. However, this recommendation must be implemented cautiously when simultaneously considering patients with two disparate tumor biologies. The limited data suggested that laparoscopic MWA of anatomically more difficult tumors has a compensatory higher morbidity profile compared to percutaneous MWA, while achieving similar overall 1-year survival. Thus, either approach can be appropriate depending on patient-specific factors (very low certainty of evidence). CONCLUSION: Given the weak evidence, these guidelines provide modest guidance regarding liver ablative therapies for HCC and CRLM. Liver ablation is just one component of a multimodal approach and its use is currently limited to a highly selected population. The quality of the existing data is very low and therefore limits the strength of the guidelines.

SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM).

BACKGROUND: Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM. METHODS: Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research. RESULTS: The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence. CONCLUSIONS: These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.

Surgical approach to microwave and radiofrequency liver ablation for hepatocellular carcinoma and colorectal liver metastases less than 5 cm: a systematic review and meta-analysis.

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the two most common malignant neoplasms of the liver. The objective of this study was to assess outcomes of surgical approaches to liver ablation comparing laparoscopic versus percutaneous microwave ablation (MWA), and MWA versus radiofrequency ablation (RFA) in patients with HCC or CRLM lesions smaller than 5 cm. METHODS: A systematic review was conducted across seven databases, including PubMed, Embase, and Cochrane, to identify all comparative studies between 1937 and 2021. Two independent reviewers screened for eligibility, extracted data for selected studies, and assessed study bias using the modified Newcastle Ottawa Scale. Random effects meta-analyses were subsequently performed on all available comparative data. RESULTS: From 1066 records screened, 11 studies were deemed relevant to the study and warranted inclusion. Eight of the 11 studies were at high or uncertain risk for bias. Our meta-analyses of two studies revealed that laparoscopic MW ablation had significantly higher complication rates compared to a percutaneous approach (risk ratio = 4.66; 95% confidence interval = [1.23, 17.22]), but otherwise similar incomplete ablation rates, local recurrence, and oncologic outcomes. The remaining nine studies demonstrated similar efficacy of MWA and RFA, as measured by incomplete ablation, complication rates, local/regional recurrence, and oncologic outcomes, for both HCC and CRLM lesions less than 5 cm (p > 0.05 for all outcomes). There was no statistical subgroup interaction in the analysis of tumors < 3 cm. CONCLUSION: The available comparative evidence regarding both laparoscopic versus percutaneous MWA and MWA versus RFA is limited, evident by the few studies that suffer from high/uncertain risk of bias. Additional high-quality randomized trials or statistically matched cohort studies with sufficient granularity of patient variables, institutional experience, and physician specialty/training will be useful in informing clinical decision making for the ablative treatment of HCC or CRLM.

Minimally invasive versus open hepatectomy for the resection of colorectal liver metastases: a systematic review and meta-analysis.

BACKGROUND: While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor. METHODS: PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD). RESULTS: From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17). CONCLUSIONS: Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.

Combined Effect of Deceased Donor Macrovesicular and Microvesicular Steatosis on Liver Transplantation Outcomes: Analysis of SRTR Data Between 2010 and 2018.

BACKGROUND: Because of the rising prevalence of obesity, the use of steatotic grafts in orthotopic liver transplantation is becoming increasingly obligatory. The purpose of this study was to determine the relative distribution of microvesicular steatosis (MiS) burden across categories of macrovesicular steatosis (MaS) and the effect of biopsy-sourced MaS and MiS on graft failure, recipient death, and retransplantation. METHODS: We performed a retrospective analysis of 13,889 adults with deceased donor liver transplantations from the Scientific Registry of Transplant Recipients between 2010 and 2018. Multivariable Cox proportional hazards models were run to examine the independent and combined effects of MaS and MiS on major transplantation outcomes. RESULTS: Recipients had a mean age of 56.5 years and a body mass index (BMI) of 29.2 kg/m2; 70% were men, and 74% were non-Hispanic white. Considering the independent effect of MaS, recipients of livers with 30% to 60% MaS had 97% and 129%, 71% and 81%, 39% and 43%, and 40% and 19% increased risks of graft failure and death at 1 month, 3 months, 1 year, and 3 years post-transplantation, respectively. Considering the combined effects of MaS and MiS, 16% to 60% MaS increased the risk of graft failure and recipient death regardless of MiS burden within the first 3 months post-transplantation. These risks were also increased among recipients of livers with 5% to 15% MaS and the additional burden of 16% to 60% MiS. CONCLUSIONS: Our findings suggest that risk threshold of adverse transplantation outcomes owing to steatosis appears to be lower than previously recognized and currently practiced. These risks must be weighed and mitigated against the duress of organ shortage and saving lives.

The liver transplant risk score prognosticates the outcomes of liver transplant recipients at listing.

BACKGROUND: We assessed if the risk of post-liver transplant mortality within 24 h could be stratified at the time of listing using the liver transplant risk score (LTRS). Secondary aims were to assess if the LTRS could stratify the risk of 30-day, 1-year mortality, and survival beyond the first year. METHODS: MELD, BMI, age, diabetes, and the need for dialysis were the five variables used to calculate the LTRS during patients' evaluation for liver transplantation. Mortality rates at 24 h, 30 days, and 1-year were compared among groups of patients with different LTRS. Patients with ABO-incompatibility, redo, multivisceral, partial graft and malignancies except for hepatocellular carcinoma were excluded. Data of 48,616 adult liver transplant recipients were extracted from the Scientific Registry of Transplant Recipients between 2002 and 2017. RESULTS: 24-h mortality was 0.9%, 1.0%, 1.1%, 1.7%, 2.3%, 2.0% and 3.5% for patients with LTRS of 0,1,2,3,4, 5 and ≥ 6, respectively (P < 0.001). 30-day mortality was 3.5%, 4.2%, 4.9%, 6.2%, 7.6%, 7.2% and 10.1% respectively (P < 0.001). 1-year mortality was 8.6%, 10.8%, 12.9%, 13.9%, 18.5%, 20.3% and 28.6% respectively (P < 0.001). 10-year survival was 61%, 56%, 57%, 54%, 47%, and 31% for patients with 0, 1, 2, 3, 4, 5 and ≥ 6 points respectively (P < 0.001). CONCLUSION: Perioperative mortality and long-term survival of patients undergoing LT can be accurately estimated at the time of listing by the LTRS.

Preoperative Stratification of Liver Transplant Recipients: Validation of the LTRS.

BACKGROUND: The liver transplant risk score (LTRS) was developed to stratify 90-day mortality of patients referred for liver transplantation (LT). We aimed to validate the LTRS using a new cohort of patients. METHODS: The LTRS stratifies the risk of 90-day mortality of LT recipients based on their age, body mass index, diabetes, model for end-stage liver disease (MELD) score, and need for dialysis. We assessed the performance of the LTRS using a new cohort of patients transplanted in the United States between July 2013 and June 2017. Exclusion criteria were age <18 years, ABO incompatibility, redo or multivisceral transplants, partial grafts, malignancies other than hepatocellular carcinoma and fulminant hepatitis. RESULTS: We found a linear correlation between the number of points of the LTRS and 90-day mortality. Among 18 635 recipients, 90-day mortality was 2.7%, 3.8%, 5.2%, 4.8%, 6.7%, and 9.3% for recipients with 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). The LTRS also stratified 1-year mortality that was 5.5%, 7.7%, 9.9%, 9.3%, 10.8%, and 15.4% for 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). An inverse correlation was found between the LTRS and 4-year survival that was 82%, 79%, 78%, 82%, 78%, and 66% for patients with 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). The LTRS remained an independent predictor after accounting for recipient sex, ethnicity, cause of liver disease, donor age, cold ischemia time, and waiting time. CONCLUSIONS: The LTRS can stratify the short- and long-term outcomes of LT recipients at the time of their evaluations irrespective of their gender, ethnicity, and primary cause of liver disease.

Minimally Invasive Sleeve Gastrectomy as a Surgical Treatment for Nonalcoholic Fatty Liver Disease in Liver Transplant Recipients.

BACKGROUND: Obesity is a major public health burden that affects the transplant community because of its key role in fatty liver disease and transplantation outcomes. OBJECTIVES: To evaluate the role of sleeve gastrectomy in treating recurrent and de novo nonalcoholic fatty liver disease (NAFLD) in liver transplant recipients. SETTING: A university hospital. METHODS: We describe 2 obese liver transplant recipients with recurrent and de novo NAFLD who underwent minimally invasive metabolic and bariatric surgery. RESULTS: The surgery was performed successfully, with much of the operative time consumed by enterolysis. There were no intraoperative or postoperative complications. At last follow-up appointment (16 months postoperatively), there was a mean reduction in weight (31.98 kg), body mass index (10.2 kg/m2), glycosylated hemoglobin (1.05%), alanine aminotransferase (38 IU/L), steatosis score (0.34), and fibrosis score (0.05). The mean decrease in 6-month postoperative hepatic fat quantification was 6%. CONCLUSIONS: These cases show that metabolic and bariatric surgery in obese, posttransplant recipients with recurrent and de novo nonalcoholic steatohepatitis lead to improved steatosis and reduced obesity and obesity-associated comorbidities.

Technical Aspects of Bile Duct Evaluation and Exploration: An Update.

Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.

Recipient obesity does not affect survival after deceased donor liver transplantation for hepatocellular carcinoma. A national retrospective cohort study in the United States.

BACKGROUND: The oncological effects of obesity on liver transplant (LT) patients with hepatocellular carcinoma (HCC) remains unclear. We investigated patient overall survival and tested two-way interactions between donor and recipient obesity status. METHODS: Using the UNOS database, a total of 8352 LT recipients with HCC were included. Donors and recipients were stratified in normal weight (NW), overweight (OW) and obese (OB). Hazard ratios (HR) for any cause of death and interactions between recipient and donor BMI were estimated by multivariate flexible parametric models. RESULTS: Five-year overall survival was 66% for NW, 67% for OW and 68% for OB recipients. The HRs of death from all causes were 0.96 (95% CI: 0.86-1.08) for OW and 0.93 (95% CI: 0.82-1.05) for OB recipients when compared to NW patients. At multivariate analysis, predictors of inferior survival were recipient age (≥65 years), donor age (≥45 years), need for pre-operative dialysis, HCV infection, transplants performed before 2007, and UNOS regions 2,3,9,10, and 11. The lowest adjusted HR was measured for recipients with BMI between 25 and 35 and there were no interactions between recipient and donor BMI. CONCLUSIONS: the overall survival of LT recipients with HCC was not affected by donor or recipient obesity.

Robot-Assisted Repair of E1 Biliary Ductal Injury with Roux-en-Y Hepaticojejunostomy.

Background: Common bile duct (CBD) injury is a serious complication of laparoscopic and open cholecystectomy. Early identification and minimally invasive repair, when possible, can prevent much of the morbidity associated with this injury. Materials and Methods: A 36-year-old woman referred in the immediate perioperative period for CBD injury at the time of laparoscopic cholecystectomy. We present a case of early robot-assisted repair of a Strasberg class E1 bile duct injury with Roux-en-Y hepaticojejunostomy. Results: Total console time of 4 hours with minimal blood loss and no requirement for transfusion with length of stay of 3 days. No intra- or perioperative complications of the surgery were noted. Conclusion: The degrees of freedom and stability of the robotic platform were instrumental during several key steps, including exposure of the hepatic hilum, positioning of the Roux limb, and suturing of the CBD. Successful minimally invasive repair of this patient's CBD injury minimized the morbidity of the index operation, blood loss, hospital length of stay, and potential legal consequences.

Societal reintegration following cadaveric orthotopic liver transplantation.

BACKGROUND: Studies on patients' societal reintegration following orthotopic liver transplantation (OLT) are scarce. METHODS: Between September 2006 and January 2008, all adults who were alive after 3 years post OLT were included in this prospective cohort study. Validated questionnaires were administered to all candidates with the primary aim of investigating the rate of their social re-integration following OLT and potential barriers they might have encountered. RESULTS: Among 157 eligible patients 110 (70%) participated. Mean participants' age was 57 years (SD 11.4) and 43% were females. Prior to OLT, 75% of patients were married and 6% were divorced. Following OLT there was no significant difference in marital status. Employment rate fell from 72% to 30% post-OLT. Patients who had been employed in either low-skill or advanced-skill jobs were less likely to return to work. After OLT, personal income fell an average of 4,363 Canadian dollars (CAN$) (SD 20,733) (P=0.03) but the majority of recipients (80%) reported high levels of satisfaction for their role in society. CONCLUSIONS: Although patients' satisfaction post-OLT is high, employment status is likely to be negatively affected for individuals who are not self-employed. Strategies to assist recipients in returning to their pre-OLT jobs should be developed to improve patients' economical status and societal ability to recoup resources committed for OLT.

Pancreatic manifestations in von Hippel-Lindau disease: A case report.

INTRODUCTION: Pancreatic manifestations in Von Hippel-Lindau (VHL) disease can present as a multitude of forms, and their management can be challenging. PRESENTATION OF THE CASE: A 66-year-old woman presented with increasing abdominal girth without other associated symptoms of nausea, vomiting, abdominal pain, weight-loss, and jaundice. Her medical and surgical histories were significant for type II diabetes, cerebral tumor resection, bilateral nephrectomies, and laser photocoagulation of retinal hemangiomas. Computed tomography (CT) of the abdomen showed a massive multi-cystic lesion in the pancreas and the patient was referred to our hepatopancreatic biliary center. DISCUSSION: The findings on the subsequent cross-sectional MRI imaging signified pancreatic manifestations in VHL disease. CONCLUSION: The management of VHL disease-associated benign pancreatic cystic lesions involves interval monitoring with cross-sectional imaging for malignant changes/development.

Laparoscopic, hybrid, and totally robotic Roux-en-Y gastric bypass.

The laparoscopic approach to Roux-en-Y gastric bypass (RYGB) is a highly regarded and frequently used bariatric procedure. We review our experience with robotic approaches to RYGB. We hypothesized that the robotic approach is safe and may produce similar outcomes to previously reported laparoscopic surgery. We conducted our study at the University Hospital, USA. Data regarding RYGB procedures performed in 2006-2013 were retrospectively reviewed from a prospectively maintained, dedicated database. Procedures were categorized into three groups: laparoscopic, hybrid robotic (HR), and total robotic (TR). Patient characteristics, operative variables, and postoperative short- and long-term outcomes were compared between groups and to recently published larger laparoscopic series. Our study included 192 RYGB consecutive patients who underwent laparoscopic, HR, or TR surgery. Mean patient age, preoperative body mass index, and preoperative weight were 40.4 ± 9.3 years (range 22-64), 46. 2 ± 5.9 kg/m(2) (range 35-64), and 130. 3 ± 22.1 kg (range 76.7-193.4) respectively. Ninety-two patients (47.9 %) had undergone previous abdominal surgery. Mean operative time, estimated blood loss, and length of stay were 223.4 ± 39.2 min (range 130-338), 21.9 ± 18.8 mL (range 5-10), and 2.6 ± 1.1 days (range 2-15), respectively. There were 248 concomitant procedures such as upper endoscopy, cholecystectomy, etc., 7 revisional surgeries, and 2 conversions to open surgery. Intraoperative complications included one liver laceration and one bowel injury. There were two cases each of bowel obstruction, transfusions, and deep vein thrombosis/pulmonary embolus, but no deaths or anastomotic leaks. Early experience with TR approach for RYGB is safe, with similar outcomes to the laparoscopic approach.

Obesity and liver transplantation.

The percentage of overweight and obese patients (OPs) waiting for a liver transplant continues to increase. Despite the significant advances occurred in bariatric medicine, obesity is still considered a relative contraindication to liver transplantation (LT). The main aim of this review is to appraise the literature on the outcomes of OPs undergoing LT, treatments that might reduce their weight before, during or after surgery, and discuss some of the controversies and limitations of the current knowledge with the intent of highlighting areas where future research is needed.

Vitamin D, inflammation, and relations to insulin resistance in premenopausal women with morbid obesity.

OBJECTIVE: In this study, the associations between vitamin D, insulin sensitivity, and inflammation and their relationships with adipose tissue expression of vitamin D receptor (VDR) and inflammatory markers in women with morbid obesity were determined. METHODS: An oral glucose tolerance test prior to surgery was completed by healthy premenopausal women (n = 76) seeking bariatric surgery. Abdominal subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were collected during surgery. RESULTS: Approximately, 70% of our subjects were vitamin D sufficient or optimal, and 80% had normal glucose tolerance. No significant association between serum 25-hydroxyvitamin D [25(OH)D] with circulating inflammatory markers or insulin sensitivity was identified. In subjects with waist circumference of <139 cm (n = 42), log25(OH)D positively predicted VAT logIL-6 mRNA expression (P = 0.003). LogVDR expression was positively correlated with the expression of inflammatory markers in both SAT (logIL-1ß mRNA: r = 0.95, P < 0.0001; logTNF mRNA: r = 0.82, P < 0.0001) and VAT (logIL-1ß mRNA: r = 0.89, P < 0.0001; logTNF mRNA: r = 0.75, P < 0.0001). VAT logVDR expression positively predicted logHOMA-IR in non-African American subjects (P = 0.05). CONCLUSIONS: The beneficial effects of vitamin D on inflammation and insulin sensitivity were not supported by our findings. VDR does not appear to possess a protective effect in adipose tissue.

Correlation between the Beck Depression Inventory and bariatric surgical procedures.

BACKGROUND: The Beck Depression Inventory (BDI) is a psychosocial screen for depression in obese patients seeking bariatric surgery. Gastric bypass improves postsurgical BDI scores due to weight loss, which predicts future weight loss. The effect of different bariatric procedures with differences in weight loss on BDI scores is unknown. OBJECTIVE: To evaluate the relationship between different bariatric procedures and changes in the BDI scores, adjusting for the initial BDI score, and to consider the impact of psychosocial variables. The secondary objective was to assess the relationship between changes in BDI scores and weight loss at 6 to 12 months. SETTING: University Hospital, United States. METHODS: Bariatric surgical patients were prospectively enrolled and retrospectively reviewed. We assessed changes in BDI after adjusting for the presurgical BDI and analyzed the relationship between patient demographic characteristics/psychological disorders and changes in BDI. RESULTS: We enrolled 137 patients who underwent a gastric band procedure, sleeve gastrectomy, or gastric bypass. We found a significant decrease in BMI and BDI scores across the full sample. Unlike BDI, change in BMI varied with procedure. Normalizing for baseline BDI, change in BDI did not significantly correlate with change in BMI. Patients who were employed and those without psychiatric history experienced even greater improvement in BDI scores. No statistically significant correlation was found between the change in BDI and weight loss at 6-12 months. CONCLUSIONS: BDI scores were independent of the type of bariatric procedure and the amount of weight loss. Advantageous psychosocial parameters were associated with greater improvement in BDI scores.

Combined Robot-assisted Kidney Transplantation and Sleeve Gastrectomy in a Morbidly Obese Recipient.

BACKGROUND: Kidney transplantation confers a well-documented survival advantage for patients with end-stage renal disease (ESRD) over dialysis, regardless of body mass index (BMI). However, obese patients with ESRD have limited access to kidney transplantation. In most transplant centers, a patient with a BMI above 35 to 40 kg/m is either completely excluded from transplantation or is required to lose weight before being considered for transplantation. MATERIALS AND METHODS: Herein, we present the first case of a 35-year-old woman with a BMI of 42 kg/m (96.8 kg) and ESRD, who underwent combined robot-assisted kidney transplant and sleeve gastrectomy. RESULTS: The total operative time was 318 minutes with an estimated blood loss of 125 mL. At 24 months after transplantation, the patient's weight, BMI, creatinine, and estimated glomerular filtration rate were 81.9 kg, 35.1 kg/m, 0.79 mg/dL, and 81.2 mL/min per 1.73 m, respectively. CONCLUSIONS: Combined robot-assisted kidney transplant and sleeve gastrectomy is feasible in morbidly obese patients and adds little additional operative time.

Robotic revisional bariatric surgery: single-surgeon case series.

BACKGROUND: Bariatric surgery is the only effective treatment for the long-term maintenance of significant weight loss. Minimally invasive revisional procedures are on the rise. Data is lacking in terms of safety, feasibility and outcomes with robotic revisional procedures. METHODS: Robotic revisional bariatric procedures (RRBPs) of gastric band to Roux-en-Y gastric bypass and sleeve gastrectomy, revision of gastro-jejunal anastomosis and stricturoplasty performed during 2009-2013 were retrospectively reviewed. RESULTS: RRBPs were performed on 14 patients with mean age, pre-operative body mass index (BMI) and weight of 45.2 ± 11.4 years, 40.1 ± 8.7 kg/m2 and 109.4 ± 26 kg, respectively. The mean operative time, estimated blood loss and length of hospital stay were 220.6 ± 64.3) min, 31 ± 22.7 ml and 3.3 ± 1.5 days, respectively. There were no conversions, blood transfusions, gastrointestinal leaks, intraoperative complications or mortalities. CONCLUSION: RRBP can be performed safely without increased morbidity and with the added benefit of a minimally invasive approach. Copyright © 2014 John Wiley & Sons, Ltd.