A cost comparison of GLP-1 receptor agonists and bariatric surgery: what is the break even point?

BACKGROUND: With the prevalence of obesity rising in the US, medical management is of increasing importance. Two popular options for the treatment of obesity are bariatric surgery (e.g. sleeve gastrectomy and Roux-en-Y gastric bypass) and the increasingly popular GLP-1 Receptor Agonists (GLP-1 s). This study examines the initial and long-term costs of GLP-1 s compared to bariatric surgery. STUDY DESIGN: We compared average 2023 national retail prices for GLP-1 s to surgical cost estimates from 2015 adjusted for inflation. We then plotted the cumulative medication cost over time against the flat cost of each surgery, thus calculating "break-even points" (when medication costs equal surgery costs). The findings revealed a crucial insight, for some GLP-1 s like Saxenda and Wegovy, the high cost of ongoing use surpasses the cost of RYGB in less than a year and sleeve gastrectomy within nine months. Even the most affordable option, Byetta, becomes costlier than surgery after around 1.5 years. RESULTS: This highlights the importance of looking beyond the initial financial investment when considering cost-effectiveness. Additionally, while not directly assessed, this study acknowledges that GLP-1 s take time to reach full effectiveness, potentially delaying weight loss while accumulating costs. Concerns also exist about weight regain after discontinuing the medication. CONCLUSION: This study is limited by the real-world variation for individual treatment costs (e.g. insurance), a limited evaluation of long-term costs associated with either treatment modality and their co-morbidities, and the reality of patient preference providing subjective value to either modality. Overall, the study offers insights into the financial trade-offs between GLP-1 s and bariatric surgery.

Current trends and barriers to video management and analytics as a tool for surgeon skilling.

BACKGROUND: The benefits of intraoperative recording are well published in the literature; however, few studies have identified current practices, barriers, and subsequent solutions. The objective of this study was to better understand surgeon's current practices and perceptions of video management and gather blinded feedback on a new surgical video recording product with the potential to address these barriers effectively. METHODS: A structured questionnaire was used to survey 230 surgeons (general, gynecologic, and urologic) and hospital administrators across the US and Europe regarding their current video recording practices. The same questionnaire was used to evaluate a blinded concept describing a new intraoperative recording solution. RESULTS: 54% of respondents reported recording eligible cases, with the majority recording less than 35% of their total eligible caseload. Reasons for not recording included finding no value in recording simple procedures, forgetting to record, lack of access to equipment, legal concerns, labor intensity, and difficulty accessing videos. Among non-recording surgeons, 65% reported considering recording cases to assess surgical techniques, document practice, submit to conferences, share with colleagues, and aid in training. 35% of surgeons rejected recording due to medico-legal concerns, lack of perceived benefit, concerns about secure storage, and price. Regarding the concept of a recording solution, 74% of all respondents were very likely or quite likely to recommend the product for adoption at their facility. Appealing features to current recorders included the product's ease of use, use of AI to maintain patient and staff privacy, lack of manual downloads, availability of full-length procedural videos, and ease of access and storage. Non-recorders found the immediate access to videos and maintenance of patient/staff privacy appealing. CONCLUSION: Tools that address barriers to recording, accessing, and managing surgical case videos are critical for improving surgical skills. Touch Surgery Enterprise is a valuable tool that can help overcome these barriers.

The evidence behind robot-assisted abdominopelvic surgery: a meta-analysis of randomized controlled trials.

BACKGROUND: Despite recent advancements, the advantage of robotic surgery over other traditional modalities still harbors academic inquiries. We seek to take a recently published high-profile narrative systematic review regarding robotic surgery and add meta-analytic tools to identify further benefits of robotic surgery. METHODS: Data from the published systematic review were extracted and meta-analysis were performed. A fixed-effect model was used when heterogeneity was not significant (Chi2 p ≥ 0.05, I2 ≤ 50%) and a random-effects model was used when heterogeneity was significant (Chi2 p < 0.05, I2 > 50%). Forest plots were generated using RevMan 5.3 software. RESULTS: Robotic surgery had comparable overall complications compared to laparoscopic surgery (p = 0.85), which was significantly lower compared to open surgery (odds ratio 0.68, p = 0.005). Compared to laparoscopic surgery, robotic surgery had fewer open conversions (risk difference - 0.0144, p = 0.03), shorter length of stay (mean difference - 0.23 days, p = 0.01), but longer operative time (mean difference 27.98 min, p < 0.00001). Compared to open surgery, robotic surgery had less estimated blood loss (mean difference - 286.8 mL, p = 0.0003) and shorter length of stay (mean difference - 1.69 days, p = 0.001) with longer operative time (mean difference 44.05 min, p = 0.03). For experienced robotic surgeons, there were less overall intraoperative complications (risk difference - 0.02, p = 0.02) and open conversions (risk difference - 0.03, p = 0.04), with equivalent operative duration (mean difference 23.32 min, p = 0.1) compared to more traditional modalities. CONCLUSION: Our study suggests that compared to laparoscopy, robotic surgery may improve hospital length of stay and open conversion rates, with added benefits in experienced robotic surgeons showing lower overall intraoperative complications and comparable operative times.

Endoscopic closure techniques of bariatric surgery complications: a meta-analysis.

BACKGROUND: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure. METHODS: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines. RESULTS: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%. CONCLUSION: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

Assessing the impact of enhanced hygiene precautions during the COVID-19 pandemic on surgical site infection risk in abdominal surgeries.

BACKGROUND: A surgical site infection (SSI) is a postoperative infection that occurs at or near the surgical incision. SSIs significantly increase morbidity, mortality, length of hospital stay, and healthcare costs. The World Health Organization (WHO) has established hospital hygiene precaution guidelines for the prevention of SSIs, which were enhanced during the COVID-19 pandemic. The current study aims to explore the effect of the COVID-19 pandemic on SSI incidence among initially uninfected postoperative patients. We hypothesize that these enhanced precautions would reduce the incidence of SSIs. MATERIALS AND METHODS: A retrospective study comparing surgical outcomes before and during the pandemic. Patients who had abdominal surgery between June and December 2019 (Non-COVID-19) or between February and June 2020 (COVID-19) were included. The two groups were matched in a 1:1 ratio based on age, Sex, acuity (elective or emergent), surgical approach, and comorbidities. Electronic medical records were reviewed to identify SSIs and hospital readmissions within 30 days after surgery. Pearson's chi-square test and Fisher's exact test were used. RESULTS: Data was collected and analyzed from 976 patients who had surgery before the COVID-19 pandemic (non-COVID group) and 377 patients who had surgery during the pandemic (COVID group). After matching, there were 377 patients in each group. In our study, we found 23 surgical site infections (SSIs) in both laparoscopic and open surgeries. The incidence of SSIs was significantly higher in the non-COVID period compared to the COVID period [17 cases (4.5%) vs. 6 cases (1.6%), respectively, p = 0.032], especially in non-COVID open surgeries. The incidence of SSIs in laparoscopic surgeries was also higher during the non-COVID period, but not statistically significant. CONCLUSIONS: Enhanced hygiene precautions during the COVID -19 pandemic may have reduced SSIs rates following abdominal surgery.

The Role of Hepatobiliary Scintigraphy as the Initial Investigative Modality for Significant Bile Leak following Laparoscopic Cholecystectomy.

INTRODUCTION: Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak. METHODS: We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments. RESULTS: Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients. CONCLUSIONS: Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.

Delayed diagnosis and subsequently increased severity of acute appendicitis (compatible with clinical-pathologic grounds) during the COVID-19 pandemic: an observational case-control study.

BACKGROUND: During a global crisis like the current COVID-19 pandemic, delayed admission to hospital in cases of emergent medical illness may lead to serious adverse consequences. We aimed to determine whether such delayed admission affected the severity of an inflammatory process regarding acute appendicitis, and its convalescence. METHODS: In a retrospective observational cohort case-control study, we analyzed the medical data of 60 patients who were emergently and consecutively admitted to our hospital due to acute appendicitis as established by clinical presentation and imaging modalities, during the period of the COVID-19 pandemic (our study group). We matched a statistically control group consisting of 97 patients who were admitted during a previous 12-month period for the same etiology. All underwent laparoscopic appendectomy. The main study parameters included intraoperative findings (validated by histopathology), duration of abdominal pain prior to admission, hospital stay and postoperative convalescence (reflecting the consequences of delay in diagnosis and surgery). RESULTS: The mean duration of abdominal pain until surgery was significantly longer in the study group. The rate of advanced appendicitis (suppurative and gangrenous appendicitis as well as peri-appendicular abscess) was greater in the study than in the control group (38.3 vs. 21.6%, 23.3 vs. 16.5%, and 5 vs. 1% respectively), as well as mean hospital stay. CONCLUSIONS: A global crisis like the current viral pandemic may significantly affect emergent admissions to hospital (as in case of acute appendicitis), leading to delayed surgical interventions and its consequences.

Challenges in abdominal re-exploration for war casualties following on-site abdominal trauma surgery and subsequent delayed arrival to definitive medical care abroad - an unusual scenario.

BACKGROUND: During the Syrian civil war, patients were initially treated on-site in Syria and later transferred to medical centers in Israel. Relevant details concerning the exact nature of injury and medical/surgical care received in Syria were unavailable to clinicians in Israel. Many of these patients required abdominal re-exploration for obvious or suspected problems related to their injury. Our aim is to present our approach to abdominal trauma patients who survived initial on-site surgery and needed subsequent abdominal re-exploration abroad, in our medical center. METHODS: Clinical data from all medical records were retrospectively analyzed. Each patient underwent total body computerized tomography on arrival, revealing diverse multi-organ trauma. We divided the patient population who had abdominal trauma into 4 sub-groups according to the location in which abdominal surgical intervention was performed (abdominal surgery performed only in Syria, surgery in Syria and subsequent re-laparotomy in Israel, abdominal surgery only in Israel, and management of patients without abdominal surgical intervention). We focused on missed injuries and post-operative complications in the re-laparotomy sub-group. RESULTS: By July 2018, 1331 trauma patients had been admitted to our hospital, of whom 236 had suffered abdominal trauma. Life-saving abdominal intervention was performed in 138 patients in Syria before arrival to our medical center. A total of 79 patients underwent abdominal surgery in Israel, of whom 46 (33%) required re-laparotomy. The absence of any communication between the surgical teams across the border markedly affected our medical approach. Indications for re-exploration included severe peritoneal inflammation, neglected or overlooked abdominal foreign bodies, hemodynamic instability and intestinal fistula. Mortality occurred in 37/236 patients, with severe abdominal trauma as the main cause of fatality in 10 of them (4.2%), usually following urgent re-laparotomy. CONCLUSIONS: Lack of information about the circumstances of injury in an environment of catastrophe in Syria at the time and the absence of professional communication between the surgical teams across the border markedly dictated our medical approach. Our concerns were that some patients looked deceptively stable while others had potentially hidden injuries. We had no information on who had had definitive versus damage control surgery in Syria. The fact that re-operation was not performed by the same team responsible for initial abdominal intervention also posed major diagnostic challenges and warranted increased clinical suspicion and a change in our standard medical approach.

The volume of general surgery emergency cases in a government hospital during the COVID-19 pandemic and two other periods: a comparative, retrospective study.

BACKGROUND: During March and April 2020, reductions in non-COVID-19 hospital admissions were observed around the world. Elective surgeries, visits with general practitioners, and diagnoses of medical emergencies were consequently delayed. OBJECTIVE: To compare the characteristics of patients admitted to a northern Israeli hospital with common surgical complaints during three periods: the lockdown due to the COVID-19 outbreak, the Second Lebanon War in 2006, and a regular period. METHODS: Demographic, medical, laboratory, imaging, intraoperative, and pathological data were collected from electronic medical files of patients who received emergency treatment at the surgery department of a single hospital in northern Israel. We retrospectively compared the characteristics of patients who were admitted with various conditions during three periods. RESULTS: Patients' mean age and most of the clinical parameters assessed were similar between the periods. However, pain was reportedly higher during the COVID-19 than the control period (8.7 vs. 6.4 on a 10-point visual analog scale, P < 0.0001). During the COVID-19 outbreak, the Second Lebanon War, and the regular period, the mean numbers of patients admitted daily were 1.4, 4.4, and 3.0, respectively. The respective mean times from the onset of symptoms until admission were 3, 1, and 1.5 days, P < 0.001. The respective proportions of surgical interventions for appendiceal disease were 95%, 96%, and 69%; P = 0.03. CONCLUSIONS: Compared to a routine period, patients during the COVID-19 outbreak waited longer before turning to hospitalization, and reported more pain at arrival. Patients during both emergency periods were more often treated surgically than non-operatively.

A unusual case of multifocal pyogenic abscess formation following ERCP procedure.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing biliary and pancreatic disorders. Infection is the most morbid complication of ERCP and among the most common causes of ERCP-related death. CASE PRESENTATION: A 69-year-old man presented with right upper quadrant abdominal pain, obstructive jaundice and abnormal liver function tests. Ultrasound revealed cholelithiasis without bile duct dilation. After receiving intravenous antibiotics for acute cholecystitis, the patient was discharged. Two weeks later, an endoscopic ultrasound demonstrated gallstones and CBD dilation of up to 6.4 mm with 2 filling defects. An ERCP was performed with a papillotomy and stone extraction. Twenty-four hours post-ERCP the patient developed a fever, chills, bilirubinemia and elevated liver function tests. Ascending cholangitis was empirically treated using Ceftriaxone and Metronidazole. However, the patient remained febrile, with a diffusely tender abdomen and elevated inflammatory markers. A CT revealed a very small hypodense lesion in the seventh liver segment. Extended-spectrum beta-lactamase positive Klebsiella Pneumonia and Enterococcus Hirae were identified, and the antibiotics were switched to Imipenem and Cilastatin. The hypodense lesion in the liver increased to 1.85 cm and a new hypodense lesion was seen in the right psoas. At day 10 post-ERCP, the patient started having low back pain and difficulty walking. MRI revealed L4-L5 discitis with a large epidural abscess, spanning L1-S1 and compressing the spinal cord. Decompressive laminectomy of L5 was done and Klebsiella pneumonia was identified. Due to continued drainage from the wound, high fever, we performed a total body CT which revealed increased liver and iliopsoas abscess. Decompressive laminectomy was expanded to include L2-L4 and multiple irrigations were done. Gentamycin and Vancomycin containing polymethylmethacrylate beads were implanted locally and drainage catheters were placed before wound closure. Multidisciplinary panel discussion was performed, and it was decided to continue with a non invasive approach . CONCLUSIONS: Early recognition of complications and individualized therapy by a multi-disciplined team is important for managing post-ERCP septic complications. Particular attention should be given to adequate coverage by empiric antibiotics.

Chylous ascites as a late complication of one anastomosis gastric bypass-minigastric bypass: case report.

BACKGROUND: One anastomosis gastric bypass- minigastric bypass (OAGB-MGB) is an emerging bariatric surgery that is being endorsed by surgeons worldwide. Internal herniation is a rare and dreaded complication after malabsorptive bariatric procedures, which necessitates early diagnosis and intervention. CASE PRESENTATION: We describe a 29-year-old male with chylous ascites caused by an internal hernia 8 months following laparoscopic one anastomosis gastric bypass. An abdominal CT showed enlargement of lymph nodes at the mesentery, with a moderate amount of liquid in the abdomen and pelvis. An emergent exploratory laparoscopic surgery demonstrated an internal hernia at the Petersen's space with a moderate quantity of chylous ascites. The patient made an uneventful recovery after surgery. CONCLUSIONS: Internal herniation can occur after OAGB-MGB and in extremely rare cases lead to chylous ascites. To our knowledge, this is the first reported case of chylous ascites following one anastomosis gastric bypass.

Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia.

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the failure of the LES to relax. Patients typically complain of dysphagia, chest pain, and regurgitation. They often report drinking liquids with solids intake to help propel food boluses into the stomach. The diagnosis of achalasia is typically confirmed with an esophagogram and a motility study (esophageal manometry). An esophagogram classically shows the bird beak sign with tapering in the distal esophagus. The treatment for achalasia includes both surgical and non-surgical options. Surgical treatment is associated with a lower rate of recurrences, high clinical success rate, and durability of symptom relief. The current gold standard of surgical technique is myotomy, or the dividing of the muscle fibers of the distal esophagus. Surgical myotomy can be accomplished via a laparoscopic or robotic technique; per-oral endoscopic myotomy is a new alternative intervention. Due to the theoretical risk of gastroesophageal reflux following a myotomy, an antireflux procedure is sometimes performed. We reviewed the approach to a robotic heller myotomy for the treatment of achalasia.

Quality of Life in Patients Undergoing Revisional Bariatric Surgery: From Sleeve Gastrectomy to Roux-en-Y Gastric Bypass.

Sleeve gastrectomy (SG) is the most performed bariatric surgery worldwide. However, this surgery may be associated with long-term weight regain and severe gastroesophageal reflux disease (GERD), sometimes necessitating conversion to Roux-en-Y gastric bypass (RYGB) to improve quality of life (QoL). We conducted a systematic review on QoL measures following the conversion of SG to RYGB. We searched various databases for studies conducted between January 2005 and September 2023. Four studies, involving 196 participants in total, met the inclusion criteria. Different assessment methods were used to evaluate QoL following the conversion. In the included studies, we observed that GERD symptoms and proton pump inhibitor (PPI) use both decreased following conversion to RYGB. Excess weight loss (EWL) was also observed in all studies.

Double Digest: A Rare Case Report of Amphicrine Gastric Carcinoma Co-occurring With Papillary Thyroid Carcinoma.

With improved cancer treatments and patient lifespans, the incidence of a second cancer diagnosis in a person's lifetime is increasing. While dual cancer diagnoses during one's lifetime are becoming more common, diagnosis with two separate cancers simultaneously is less so. In this report we present a 55-year-old obese woman with a history of chronic lymphocytic thyroiditis and a non-specific family history of thyroid cancer who received synchronous diagnoses of amphicrine carcinoma (AC) and papillary thyroid carcinoma (PTC) during work-up for bariatric surgery. AC is a very rare form of gastric cancer characterized by the presence of both endocrine and epithelial cell components within the same cell with only a few case reports in the literature. This is the first case report to present the co-occurrence of AC with PTC.

Incidentally Diagnosed Low-Grade Primary Peritoneal Serous Carcinoma Within the Umbilical Hernia Sac in a Male: A Report of an Extremely Rare Case and Review of the Literature.

Primary peritoneal serous carcinoma (PPSC) is a rare tumor that develops in the peritoneum. PPSC originates from embryonic nests of Müllerian cells in the peritoneum, which are also present in the epithelium of the ovary. This similarity explains the histopathological resemblance between PPSC and low-grade serous ovarian carcinoma. While PPSC primarily affects women, it is an extremely rare occurrence in males, and it is believed that the significant difference in diagnosis rates between males and females is due to the inhibition of Müllerian system growth by substances produced by male Sertoli cells. These substances are present at higher levels in males, which may prevent the development of Müllerian system-derived tumors in men. We describe a 65-year-old male patient who presented for elective bariatric surgery and umbilical hernia repair, and an incidental finding of low-grade PPSC was made based on hernia sac pathology. The patient underwent further management, including tumor debulking and hyperthermic intraperitoneal chemotherapy (HIPEC), with positive outcomes. Long-term follow-up and oral letrozole treatment are planned.

To Dor or Not to Dor? Heller Myotomy, a Retrospective Study.

Achalasia is a neurodegenerative disorder affecting esophageal sphincter function. Treatment options include non-surgical and surgical approaches, such as Heller myotomy (HM). Combining Dor fundoplication with HM is controversial but may prevent gastroesophageal reflux disease (GERD). This retrospective cohort study aimed to assess whether HM with Dor fundoplication reduces GERD rates and increases dysphagia rates. Eighty patients who underwent HM between January 2018 and August 2023 were included. Sixty-four patients had Dor fundoplication and were matched 4:1 to 16 patients without fundoplication. Records were reviewed for GERD and achalasia symptoms at various postoperative time points. No significant differences in GERD or dysphagia symptoms were found between the two groups at any time point. Similarly, there were no significant differences in chest pain or dysphagia treatment. In conclusion, this study suggests that the addition of Dor fundoplication to HM does not significantly impact postoperative GERD or achalasia-related symptoms.

The Financial Implications of a Single-Use Device Reprocessing Program at a Tertiary Referral Center Surgical Department.

The operating room has been identified as one of the primary contributors to waste and energy expenditure in the health care system. The primary objective of our study was to evaluate the efficacy of single-use device reprocessing and report the cost savings, waste diversion, and reduction in carbon emissions. Data was collected from January 2021 to April 2023. Medline collected the data for analysis and converted it from an Excel file format to SPSS (Version 27) for analysis. Descriptive frequencies were used for data analysis. We found a mean monthly cost savings of $16,051.68 and a mean 700.68 pounds of waste a month diverted, resulting in an estimated yearly saving of $2354.29 in disposal costs and a reduction of 1112.65 CO2e emissions per month. This program has made significant contributions to cost savings and environmental efforts.

Temporary Mechanical Circulatory Support During Bariatric Surgery: A Novel Bridge to Durable Left Ventricular Assist Device and Cardiac Transplantation.

Advanced heart failure (HF) with comorbid severe obesity presents a unique surgical dilemma: bariatric surgery may help patients meet cardiac transplantation body mass index (BMI) criteria, but poor cardiac function puts them at increased intraoperative risk. Per International Society for Heart and Lung Transplantation (ISHLT) guidelines BMI > 35 is a contraindication for orthotopic heart transplantation. Temporary mechanical circulatory support (MCS) with Impella 5.5 during bariatric surgery, as presented in this report, may help solve this dilemma for some patients. We present three patients with severe obesity and advanced heart failure (HF) who underwent successful bariatric surgery while supported by Impella 5.5 (Abiomed, Inc., Danvers, MA).

Surgical Complications in Hepatitis C Patients Undergoing Cholecystectomy.

BACKGROUND: Hepatitis C (HCV) affects over 2.2 million people in the United States and is associated with liver cirrhosis and gallstone formation. However, cholecystectomy outcomes of HCV patients compared to non-HCV patients are not well studied. This study aims to examine differences in cholecystectomy outcomes among patients with untreated, treated, and no HCV history. STUDY DESIGN: A retrospective cohort study was conducted at a single institution including data over a 12-year period. Patients were excluded if they had a prior chronic hepatitis B or HIV diagnosis. Non-HCV patients were matched to HCV patients based on age, sex, and race/ethnicity. RESULTS: We identified 66 patients with untreated HCV and 33 patients with treated HCV. 324 non-HCV patients were matched to the HCV cohort. The overall postoperative complication rate was 10.9%. There was no statistically significant difference in postoperative complication rates between groups (p=0.71). There was no significant difference in the level of intervention required to treat these complications based on the Clavien-Dindo classification (p=0.97), postoperative ICU admission (p=0.43), or reoperation rate (p=0.45). CONCLUSION: Despite having a longer average length of stay and increased risk for intraoperative blood product transfusion, both untreated and treated HCV patients have similar rates of postoperative complications and complication severity compared to controls. These findings suggest that HCV patients tolerate cholecystectomy at a comparable level to non-HCV patients. The lack of difference in postoperative complication rates between untreated and treated HCV patients indicates that lack of antiviral treatment should not delay cholecystectomy.

Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy.

BACKGROUND: Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed. STUDY DESIGN: PubMed, EMBASE, and SCOPUS databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool. Assessed outcomes included intra- and postoperative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random-effects model to report odds ratio (OR) and 95% CIs and continuous data to report mean difference and 95% CIs. RESULTS: Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic and 168,335 laparoscopic patients) studies assessed HHR outcomes, whereas 9 (2,384 robotic and 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a nonsignificantly shorter length of hospital stay (LOS) (mean difference -0.41, 95% CI -0.87 to -0.05), fewer conversions to open (OR 0.22, 95% CI 0.03 to 1.49), and lower morbidity rates (OR 0.76, 95% CI 0.47 to 1.23). Robotic HM led to significantly fewer esophageal perforations (OR 0.36, 95% CI 0.15 to 0.83), reinterventions (OR 0.18, 95% CI 0.07 to 0.47) a nonsignificantly shorter LOS (mean difference -0.31, 95% CI -0.62 to 0.00). Both robotic HM and HHR had significantly longer operative times. CONCLUSIONS: Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the 2 methods, given the low-to-moderate quality of included studies.