Quantifying physiologic parameters of the gastroesophageal junction during robotic sleeve gastrectomy and identifying predictors of post-sleeve gastroesophageal reflux disease.

BACKGROUND: Sleeve gastrectomy is among the most commonly-performed procedures for morbid obesity. However, patients occasionally develop post-sleeve gastroesophageal reflux disease (GERD). Identifying patients most at risk for this complication remains difficult. We aimed to correlate intra-operative physiologic measurements of the lower esophageal sphincter (LES) at the gastroesophageal junction (GEJ) during robotic sleeve gastrectomy in an attempt to identify predictors of post-sleeve GERD symptoms. METHODS: A retrospective chart review of a prospectively maintained database identified 28 patients in whom robotic sleeve gastrectomy was performed utilizing EndoFLIP™ technology between January and September 2021. Intraoperative LES measurements at the GEJ including cross-sectional area (CSA), distensibility index (DI), intra-balloon pressure, and high-pressure zone (HPZ length) were correlated with post-operative GERD. RESULTS: GEJ CSA, pressure, and DI increased over the course of the surgery (CSA pre-op: 31 (IQR 19.3-39.5) mm2 vs. post-op: 67 (IQR 40.8-95.8) mm2, p < 0.001; pressure: 25.8 (IQR 20.2-33.1) mmHg vs. 31.5 (IQR 28.9-37.0) mmHg, p = 0.007; DI 1.1 (IQR 0.8-1.8) mm2/mmHg vs. 2.0 (IQR 1.2-3.0) mm2/mmHg, p = < 0.001), whereas HPZ length decreased (2.5 (IQR 2.5-3) cm vs. 2.0 (IQR 1.3-2.5) cm, p = 0.022). Twenty-three patients (82.1%) completed a post-operative GERD questionnaire. Fifteen (65.2%) had no GERD symptoms before or after surgery; 5 (21.7%) reported new post-sleeve GERD symptoms; 3 (13.0%) reported exacerbation of pre-existing GERD symptoms. Patients with new or worsening GERD symptoms had higher post-sleeve DIs (3.2 (IQR 1.9-4.5) mm2/mmHg vs. 1.5 (IQR 1.2-2.4) mm2/mmHg, p = 0.024) and lower post-sleeve LES pressures (29.9 (IQR 26.3-32.9) mmHg vs. 35.2 (IQR 31.0-38.0) mmHg, p = 0.023) than those without. CONCLUSIONS: An increase in GEJ CSA, pressure, and DI, and a decrease in GEJ length can be expected during robotic sleeve gastrectomy. Patients with new or worsening post-sleeve GERD symptoms have higher post-sleeve DI and lower post-sleeve LES pressure than their asymptomatic counterparts.

Minimally invasive versus open duodenal switch: a nationwide retrospective analysis.

INTRODUCTION: This study aims to characterize the variability in clinical outcomes between open, laparoscopic, and robotic Duodenal Switch (DS). METHODS: From the Metabolic and Bariatric Surgery and Accreditation Quality Improvement Program, patients who underwent DS (2015-2018) were identified. Open DS was compared to laparoscopic and robotic approaches with for patients factors, perioperative characteristics, and 30-day postoperative outcomes. Logistic regression estimates were used to characterize variables associated with surgical site infections, bleeding, reoperation, readmission, and early discharge (hospital stay of ≤ one day). RESULTS: Of 7649 cases, 411 (5.4%) were open, 5722 (74.8%) were laparoscopic, and 1515 (19.8%) were robotic DS. Open DS patients were more often older (≥ 65 years:4.7% vs. 4.3% vs. 2.1%, p < 0.01) and had lower body mass index (< 40 kg/m2:16.3% vs. 10.5% vs. 9.9%, p < 0.01). The co-morbidities were mainly comparable between the three groups. Open DS was more often without skilled assistance (35.3% vs. 12.1% vs. 5.3%, p < 0.01), revisional (41.4% vs. 20.5% vs. 21.3%, p < 0.01), and performed concurrently with other operations. Robotic DS surgery was more often longer (≥ 140 min:64.4% vs. 39.2% vs. 86.9%, p < 0.01). Post-operatively, open DS was associated with higher rates of surgical site infection (7.1% vs. 2% vs. 2.8%, p < 0.01), bleeding (2.4% vs. 0.7% vs. 0.9%, p = 0.001), reoperation (6.6% vs. 3.6% vs. 4.4%, p = 0.01), and readmission (12.4% vs. 6.8% vs. 8.3%, p = < 0.01). Patients undergoing robotic DS were more often discharged early (0.5% vs. 1% vs. 7.8%, p < 0.01). In the regression analyses, minimally invasive DS was associated with lower odds for wound infections (OR = 0.3,CI = [0.2-0.5]), bleeding (OR = 0.4,CI = [0.2-0.8]), and readmission (OR = 0.6,CI = [0.4-0.8]), as well as greater likelihood of early discharge (OR = 5.6 CI = [1.3-23.0]). CONCLUSION: Open DS is associated with greater risk for complications and excessive resource utilization when compared to minimally invasive approaches. Laparoscopic and robotic techniques should be prioritized in performing DS, despite the complexity of the procedure.

Robotic-assisted surgery enhances the learning curve while maintaining quality outcomes in sleeve gastrectomy: a preliminary, multicenter study.

BACKGROUND: The frequency of robotic-assisted bariatric surgery has been on the rise. An increasing number of fellowship programs have adopted robotic surgery as part of the curriculum. Our aim was to compare technical efficiency of a surgeon during the first year of practice after completing an advanced minimally invasive fellowship with a mentor surgeon. METHODS: A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted sleeve gastrectomy between 2015 and 2019 at a tertiary-care bariatric center (mentor group) and between 2018 and 2019 at a semi-academic community-based bariatric program (mentee 1 group) and 2019-2020 at a tertiary-care academic center (mentee 2 group). RESULTS: 257 patients in the mentor group, 45 patients in the mentee 1 group, and 11 patients in the mentee 2 group were included. The mentee operative times during the first year in practice were significantly faster than the mentor's times in the first three (mentee 1 group) and two (mentee 2 group) years (P < 0.05) but remained significantly longer than the mentor's times in the last two (mentee 1 group) and one (mentee 2 group) years (P < 0.05). There was no significant difference in venothromboembolic events (P = 0.89) or readmission rates (P = 0.93). The mean length of stay was 1.8 ± 0.5 days, 1.3 ± 0.5 days, and 1.5 ± 0.5 days in the mentor, mentee 1, and mentee 2 groups, respectively (P < 0.0001). There were no reoperations, conversion to laparoscopy or open, no staple line leaks, strictures, or deaths in any group. CONCLUSIONS: This is one of the first series to show that the robotic platform can safely be taught and may translate into outcomes consistent with surgeons with more experience while mitigating the learning curve as early as the first year in practice. Long-term follow-up of mentees will be necessary to assess the evolution of fellowship training and outcomes.

Robotic-assisted approaches to GERD following sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is the most common bariatric operation in the United States but increases the incidence of gastroesophageal reflux disease (GERD). The aim of our study was to describe our experience with robotic-assisted management of intractable GERD after SG. METHODS: A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted magnetic sphincter augmentation placement after sleeve gastrectomy (MSA-S group) or conversion to Roux-en-Y gastric bypass (RYGB group) for GERD from 2015 to 2019 at our tertiary- care bariatric center. These were compared to a consecutive group of patients undergoing robotic-assisted magnetic sphincter augmentation placement (MSA group) for GERD without a history of bariatric surgery from 2016 to 2019. The primary outcome was perioperative morbidity. Secondary outcomes were operative time (OT), 90-day re-intervention rate, length of stay, symptom resolution and weight change. RESULTS: There were 51 patients included in this study; 18 patients in the MSA group, 13 patients in the MSA-S group, and 20 patients in the RYGB group. There was no significant difference in age, gender, ASA score, preoperative endoscopic findings, or DeMeester scores (P > 0.05). BMI was significantly higher in patients undergoing RYGB compared to MSA or MSA-S (P < 0.0001). There were significant differences in OT between the MSA and RYGB groups (P < 0.0001) and MSA-S and RYGB groups (P = 0.009), but not MSA group to MSA-S group (P = 0.51). There was no significant difference in intraoperative and postoperative morbidity (P = 1.0 and P = 0.60, respectively). 30-day morbidity: 5.6% (MSA), 15.4% (MSA-S) and 15% (RYGB). There was no difference on PPI discontinuation among groups, with more than 80% success rate in all. CONCLUSIONS: The use of the robotic platform in the different approaches available for treatment of GERD after SG appears to be a feasible option with low morbidity and high success rate. Further data is needed to support our findings.

Safety and Efficacy of Bedside Peritoneal Dialysis Catheter Placement in the COVID-19 Era: Initial Experience at a New York City Hospital.

INTRODUCTION: Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is common in critically ill patients with COVID-19. Unparalleled numbers of patients with AKI and shortage of dialysis machines and operative resources prompted consideration of expanded use of urgent-start peritoneal dialysis (PD) and evaluation of the safety and efficacy of bedside surgical placement of PD catheters. STUDY DESIGN: Bedside, open PD catheter insertions were performed in early April 2020, at a large academic center in New York City. Patients with SARS-CoV-2 infection and AKI and ambulatory patients with chronic kidney disease and impending need for RRT were included. Detailed surgical technique is described. RESULTS: Fourteen catheters were placed at the bedside over 2 weeks, 11 in critically ill COVID-19 patients and three in ambulatory patients. Mean patient age was 61.9 years (43-83), and mean body mass index was 27.1 (20-37.6); four patients had prior abdominal surgery. All catheters were placed successfully without routine radiographic studies or intraoperative complications. One patient (7%) experienced primary nonfunction of the catheter requiring HD. One patient had limited intraperitoneal bleeding while anticoagulated, which was managed by mechanical compression of the abdominal wall and temporarily holding anticoagulation. All other catheters had an adequate function at 3-18 days of follow-up. CONCLUSIONS: Bedside placement of PD catheters is safe and effective in ICU and outpatient clinic settings. Our surgical protocols allowed for optimization of critical hospital resources, minimization of hazardous exposure to healthcare providers and a broader application of urgent-start PD in selected patients. Long-term follow-up is warranted.

Lessons Learned From Developing a Mobile App to Assist in Patient Recovery After Weight Loss Surgery.

BACKGROUND: Weight loss surgery is safe and effective, but fluid and electrolyte balance remains problematic postoperatively. We developed a mobile app to help patients recover after weight loss surgery. MATERIAL AND METHODS: Single-center prospective, mixed-methods, participatory research design study of eligible English-speaking adults undergoing weight loss surgery was used. Patients used the app for 30 d after surgery. We developed and refined the app from July 2017 to October 2018. The principal component of the app is a daily survey designed to assess patients' recovery. The app was revised based on patient feedback, and we compared app utilization between initial and updated versions of the app. Primary outcome was successful patient engagement, which we defined as 80% of patients completing at least 70% of the surveys. RESULTS: Ten patients completed the trial period, four with the initial version of the app, and six with the updated version. All patients expressed satisfaction with the app and most frequently reported that push notifications were helpful. We found that one (25%) patient completed at least 70% of the surveys in the initial version of the app. In the updated version, five (83.3%) of patients completed at least 70% of the surveys, passing our criteria for successful engagement. CONCLUSIONS: Participatory research design in app development requires continuous evaluation and refinement to patient and clinician needs. This effort is essential as we observed significant improvement in app utilization. Our next step is to pilot the app in a larger set of patients to assess utility and feasibility.

Successful Cholecystectomy After Endoscopic Ultrasound Gallbladder Drainage Compared With Percutaneous Cholecystostomy, Can it Be Done?

BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage (EGBD) with a lumen apposing metal stent is becoming a widely accepted alternative to percutaneous gallbladder drainage (PTGD) for patients who are not candidates for cholecystectomy (CCY). In some patients, medical comorbidites can improve, allowing them to undergo CCY. We compare feasibility and outcomes of interval CCY after EGBD versus PTGD. METHODS: We conducted a multicentered international cohort study of patients who underwent EGBD or PTGD and then underwent interval CCY. Baseline patient demographics, procedural details, and follow-up data were recorded and compared. RESULTS: In total, 34 patients were included. Thirteen patients underwent EGBD followed by CCY (mean age, 53.77±17.27, 46.15% male), and 21 patients underwent PTGD followed by CCY (mean age, 62.14±13.06, 61.9% male). There was no statistically significant difference in mean Charlson Comorbidity Index (P=0.12) or etiology of cholecystitis (P=0.85) between the 2 groups. All patients had a technically successful CCY. There was no difference between rates of open versus laparoscopic CCY (P=1). In addition, there was no difference in postsurgical adverse events (P=0.23). CONCLUSIONS: Surgical CCY after EGBD with lumen apposing metal stent is safe and feasible for the management of cholecystitis. If patient's underlying medical conditions improve, previous EUS-GLB drainage should not preclude patients from undergoing CCY as part of standard of care.

Nasal positive pressure with the SuperNO2VA™ device decreases sedation-related hypoxemia during pre-bariatric surgery EGD.

INTRODUCTION: Pre-operative esophagogastroduodenoscopy (EGD) is becoming routine practice in patients undergoing bariatric surgery. Many patients with morbid obesity have obstructive sleep apnea (OSA), which can worsen hypoxia during an EGD. In this study, we report our outcomes using the SuperNO2VA™ device, a sealed nasal positive airway pressure mask designed to deliver high-fraction inhaled oxygen and titratable positive pressure compared to conventional nasal cannula. METHODS: Between June 2016 and August 2017, we conducted a prospective observational study that included 56 consecutive patients who presented for EGD prior to bariatric surgery. Airway management was done using either the SuperNO2VA™ (N = 26) device or conventional nasal cannula (N = 30). Patient demographics, procedure details, and outcomes were compared between the two groups. RESULTS: The SuperNO2VA™ group had a lower median age compared to the control group (38.5 vs. 48.5 years, p = 0.04). These patients had a higher body mass index (BMI) (47.4 vs. 40.5, IQR, p < 0.0001), higher ASA class (p = 0.03), and were more likely to have OSA (53.9% vs. 26.7%, p = 0.04). Desaturation events were significantly lower in the SuperNO2VA™ group (11.5% vs. 46.7%, p = 0.004) and the median lowest oxygen saturation was higher in the SuperNO2VA™ group (100% vs. 90.5%, p < 0.0001). DISCUSSION: This is the first study to report on the use of the SuperNO2VA™ device in bariatric patients undergoing pre-operative screening EGD. The use of the SuperNO2VA™ device offers a clinical advantage compared to the current standard of care. Our data demonstrate that patients with higher BMI, higher ASA classification, and OSA were more likely to have the SuperNO2VA™ device used; yet, paradoxically, these patients were less likely to have issues with desaturation events. Use of this device can optimize care in this challenging patient population by minimizing the risks of hypoventilation.

Predicting Survival and Response to Treatment in Gastroesophageal Neuroendocrine Tumors: An Analysis of the National Cancer Database.

BACKGROUND: Neuroendocrine tumors (NETs) of the esophagus and stomach are rare neoplasms with variable behavior. We aim to describe their epidemiology and response to treatment. METHODS: NETs of the stomach and the esophagus were selected from the National Cancer Database (2004-2013) and classified by location. Survival analyses were performed with respect to tumor characteristics and treatment variables. RESULTS: NETs of the stomach (n = 2700; 92.8%) and esophagus (n = 210, 7.2%) were identified. Gastric cardia NETs had demographics and behavior similar to esophageal tumors and were associated with worse overall survival than NETs of the noncardia stomach independent of grade (p < 0.001). Poorly differentiated histology [hazard ratio (HR) 4.14, 95% confidence interval (CI) 2.26-7.57; p < 0.001] and distant metastases (HR 3.28, 95% CI 1.94-5.56; p < 0.001) were the greatest independent predictors of survival. For patients with poorly differentiated NETs, surgery was the only treatment to have benefit on overall survival (HR 0.38, 95% CI 0.27-0.54; p < 0.001) regardless of extent of disease. There was no additional benefit to adjuvant chemotherapy or radiation in patients undergoing resection (p = 0.39), even for patients with lymph node metastases (surgery alone versus surgery plus adjuvant therapy, p = 0.46), distant metastases (p = 0.19), or positive margins (p = 0.33). CONCLUSIONS: Esophageal and gastric cardia NETs have worse survival than those of the noncardia stomach. Surgery offers the only survival benefit for poorly differentiated tumors, with no additional survival advantage to adjuvant chemotherapy or radiation.

Perioperative outcomes and anesthetic considerations of robotic bariatric surgery in a propensity-matched cohort of super obese and super-super obese patients.

BACKGROUND: The use of the robotic platform has not been well established in patients with super obesity (SO; body mass index, BMI ≥ 50) and super-super obesity (SSO, BMI ≥ 60). We aimed to determine safety and feasibility of robotic bariatric surgery in this cohort. METHODS: Review of a prospectively maintained database was performed of consecutive patients undergoing robotic bariatric surgery between 2015 and 2017. Propensity score analysis with 1:2 nearest neighbor matching was performed to control for baseline characteristics and procedure type. RESULTS: A propensity-matched cohort of 47 SO patients (median BMI 55.3, range 50.1-92.5) and 94 morbidly obese (MO; median BMI 41.8, range 35.1-48.8) patients were analyzed. After matching, there were no difference in baseline characteristics including age, American Society of Anesthesiologists (ASA) score, or preoperative comorbidities. Most patients in each group underwent sleeve gastrectomy (81% of SO patients versus 76% of MO patients) or Roux-en-Y gastric bypass (13% vs. 18%, respectively), p = 0.66. There were no differences in operative time, intraoperative complications, postoperative complications, or re-admissions between groups. Length of stay was slightly longer in the MO group (2.2 days, IQR 1.8-3.2 vs. 1.8 days, IQR 1.2-2.7; p = 0.01). A subset of SSO patients (n = 11, median BMI 67, range 60-92) was analyzed; there was no increase in operation time, and zero intraoperative complications, conversions to open, or postoperative complications in this subset. CONCLUSIONS: Robotic bariatric surgery can safely be performed on patients with SO or SSO with low perioperative morbidity and no increase in operating time.

Robotic Reoperative Anti-reflux Surgery: Low Perioperative Morbidity and High Symptom Resolution.

BACKGROUND: Laparoscopic reoperative anti-reflux surgery (ARS) has a significantly higher morbidity than laparoscopic primary ARS; however, it is not known whether the same pattern exists within the robotic approach. We aimed to evaluate the safety and efficacy of robotic reoperative ARS in comparison with primary robotic ARS. METHODS: A retrospective review of patients undergoing primary or reoperative robotic ARS at a tertiary referral center between 2012 and 2017 was performed. Perioperative outcomes and long-term symptom resolution were evaluated. RESULTS: A total of 200 patients were included (38 reoperative and 162 primary ARS). Baseline characteristics were comparable across groups. Seven (18.4%) of the reoperative patients had two or more prior foregut operations. Patients in the reoperative group had a longer operative time (226 vs. 180 min, p < 0.001). There were no conversions to open technique, and one patient in the reoperative group (2.6%) had an intraoperative perforation. Twenty of the 38 reoperative patients (52.6%) were discharged within 24 h as compared to 109/162 primary patients (64.9%) (p = 0.09). The readmission rate and postoperative complication rates were 6 and 3%, respectively, and did not differ between groups. At a mean follow-up of 1 year, complete or partial resolution of preoperative symptoms was achieved in 97% of primary patients and 100% of reoperative patients (p = 0.4). CONCLUSION: The robotic approach allows for minimal morbidity, short length of stay, and excellent functional outcomes in patients undergoing reoperative ARS when compared to patients undergoing primary ARS.

Laparoscopic Appendectomy: Minimally Invasive Surgery Training Improves Outcomes in Basic Laparoscopic Procedures.

BACKGROUND: To determine whether minimally invasive surgery (MIS) training improves outcomes in laparoscopic appendectomy, a procedure that is commonly performed in general surgery training. METHODS: Retrospective review was conducted of all patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2014 and 2015 at a single-center, tertiary-care academic institution. Patients operated on by MIS-trained surgeons (MIS group) were compared to those operated on by general surgeons (GS group). Single-incision and multiport laparoscopic appendectomies were included; open approach, known malignancy, and interval appendectomies were excluded. RESULTS: A total of 507 patients were included in the study: 181 patients in the MIS group and 326 in the GS group. There were no differences in patient demographics or medical comorbidities between groups and most patients were ASA class 1 or 2. Patients operated on by MIS-trained surgeons had significantly shorter operative time (43 min, IQR 32-60 vs. 58 min, IQR 44-81; p < 0.001) and fewer intra-operative adverse events (0/181 vs. 8/326, 2.5%; p = 0.03). There was no difference in number of postoperative adverse events between groups (6/181, 3.3% vs. 21/326, 6.4%; p = 0.13). In the MIS group, subgroup analysis of single-incision versus multiport appendectomy showed no differences in intra-operative or postoperative adverse events. On multivariable linear regression, lack of MIS training and traditional multiport approach had the greatest effects on prolonging operative time (11.2 and 12.8 min, respectively; p = 0.001). CONCLUSIONS: MIS fellowship improves operative metrics and patient outcomes even in basic laparoscopy.

General surgery training and robotics: Are residents improving their skills?

BACKGROUND: While robotic-assisted operations have become more prevalent, many general surgery residencies do not have a formal robotic training curriculum. We sought to ascertain how well current general surgery training permits acquisition of robotic skills by comparing robotic simulation performance across various training levels. STUDY DESIGN: Thirty-six participants were categorized by level of surgical training: eight medical students (MS), ten junior residents (JR), ten mid-level residents (MLR), and eight senior residents (SR). Participants performed three simulation tasks on the da Vinci (®) Skills Simulator (MatchBoard, EnergyDissection, SutureSponge). Each task's scores (0-100) and cumulative scores (0-300) were compared between groups. RESULTS: There were no differences in sex, hand dominance, video gaming history, or prior robotic experience between groups; however, SR was the oldest (p < 0.001). The median overall scores did not differ: 188 (84-201) for MS, 183 (91-234) for JR, 197 (153-218) for MLR, and 205 (169-229) for SR (p = 0.14). The median SutureSponge score was highest for SR (61, range 39-81) compared to MS (43, range 26-61), JR (43, range 11-72), and MLR (55, range 36-68) (p = 0.039). However, there were no significant differences in MatchBoard (p = 0.27) or EnergyDissection (p = 0.99) scores between groups. There was a positive correlation between SutureSponge score and number of laparoscopic cases logged (p = 0.005, r(2) = 0.21), but this correlation did not exist for the MatchBoard or EnergyDissection tasks. Lastly, there was no correlation between total lifetime hours of video gaming and overall score (p = 0.89, R(2) = 0.0006). CONCLUSIONS: Robotic skillsets acquired during general surgery residency show minimal improvement during the course of training, although laparoscopic experience is correlated with advanced robotic task performance. Changes in residency curricula or pursuit of fellowship training may be warranted for surgeons seeking proficiency.

BRAVO esophageal pH monitoring: more cost-effective than empiric medical therapy for suspected gastroesophageal reflux.

INTRODUCTION: Early referral for catheter-based esophageal pH monitoring is more cost-effective than empiric proton-pump inhibitor (PPI) therapy to diagnose gastroesophageal reflux disease (GERD). We hypothesize that BRAVO wireless pH monitoring will also demonstrate substantial cost-savings compared to empiric PPI therapy, given its superior sensitivity and comfort. METHODS: We reviewed 100 consecutive patients who underwent wireless pH monitoring for suspected GERD at our institution. A cost model and a cost equivalence calculation were generated. Cost-saving analyses were performed for both esophageal and extraesophageal symptoms. RESULTS: Eighty-seven patients were available for analysis. Median PPI use prior to referral was 215 weeks (range 0-520). Forty-three patients (49 %) had BRAVO results diagnosing GERD; 98 % of these had esophageal symptoms. Patients with negative BRAVO studies had a median of 113 (0-520) weeks of unnecessary PPI therapy. Cost-savings ranged from $1048 to $15,853 per patient, depending on sensitivity (75-95 %), PPI dosage, and brand. Maximum cost-savings occurred in patients with extraesophageal symptoms ($2948-$31,389 per patient). The PPI cost equivalence of BRAVO placement was 36 and 6 weeks for low- and high-dose therapy, respectively. CONCLUSIONS: BRAVO wireless pH testing is more cost-effective than prolonged empiric medical management for GERD and should be incorporated early in the treatment algorithm.

Esophageal reinforcement with an extracellular scaffold during total gastrectomy for gastric cancer.

BACKGROUND: Esophagojejunal (EJ) anastomotic leaks after total gastrectomy (TG) for malignancy lead to significant morbidity and mortality, thus affecting long-term survival. Preclinical and clinical trials have shown promise in utilizing degradable extracellular matrix (ECM) scaffolds in buttressing anastomoses. We describe our experience buttressing the EJ anastomosis after TG with a ECM scaffold. METHODS: From February 2012 to January 2014, a total of 37 consecutive patients underwent TG buttressing of the EJ anastomosis with the degradable ECM scaffold composed of a porcine urinary bladder called MatriStem (ACell Inc.). The scaffold was circumferentially wrapped around the EJ anastomosis. The primary end point was the EJ leak rate, while the secondary end point was the EJ stricture rate. RESULTS: The mean ± SD age and body mass index were 59 ± 16 years and 28.1 ± 4.9 kg/m(2), respectively. Most patients were male (51 %), white (78 %), and former smokers (51 %). Over half (59 %) underwent neoadjuvant chemotherapy. A minimally invasive TG was performed in 70 % of patients. Signet ring was the most common tumor type (48 %), and most patients had midstage disease (59 %). The mean number of lymph nodes procured was 36 ± 16. Eighteen patients (49 %) experienced a complication, mostly minor. One patient (2.7 %) developed an EJ leak, while three patients (8 %) developed an EJ stricture. Median follow-up was 7 months (range 2-12 months). There was no operative or in-hospital mortality. DISCUSSION: The use of urinary bladder matrix scaffolds may be helpful in decreasing the incidence of EJ anastomotic leak and/or stricture. A prospective phase II trial at our institution is currently under way.

A prospective randomized controlled trial assessing the efficacy of omentopexy during laparoscopic sleeve gastrectomy in reducing postoperative gastrointestinal symptoms.

BACKGROUND: Patients undergoing sleeve gastrectomy experience a significant amount of postoperative gastrointestinal (GI) symptoms. The purpose of our study was to assess the efficacy of omentopexy during laparoscopic sleeve gastrectomy (LSG) in reducing postoperative food intolerance and GI symptoms. METHODS: Morbidly obese patients undergoing LSG were randomly assigned to have LSG with or without omentopexy from May 2012 to June 2013. A total of 60 patients were recruited with 30 patients in each group. Patients and the symptom scorer were blinded as to the assigned surgery. All procedures were performed by one of two surgeons utilizing the same surgical technique. Patients were administered standardized surveys, including the Rhodes Index survey, gastroesophageal reflux disease (GERD) impact survey, and Eating Assessment Tool (EAT) survey at various time points postoperatively to assess nausea, vomiting, retching, frequency of GI symptoms, and level of distress. RESULTS: There was no significant difference in patient age, percent decrease in BMI at any time point, or length of hospitalization between the two groups (P > 0.05). Furthermore, there was no significant difference in Rhodes Index scores, GERD impact scores, or EAT scores at any time point (P > 0.05). Patients in the LSG with omentopexy group required significantly more ondansetron perioperatively (16.1 ± 12.9 mg vs. 10.3 ± 10.2 mg, respectively; P = 0.04); however, there was no difference in metoclopramide requirement (P = 0.22). Surgical morbidity was not significantly different between the two groups (P > 0.05). Finally, there was no significant difference in number of postoperative clinic visits, office telephone encounters, total postoperative readmissions, or postoperative readmissions associated with GI symptoms (P > 0.05). CONCLUSION: Omentopexy did not significantly decrease postoperative food intolerance or GI symptoms in morbidly obese patients undergoing LSG. Other methods of mitigating postoperative intolerance to oral intake and GI symptoms should be investigated.

Achalasia 5 years following Roux-en-y gastric bypass.

Oesophageal achalasia is a rare, but serious condition in which the motility of the lower oesophageal sphincter (LES) is inhibited. This disorder of idiopathic aetiology complicates the peristaltic function and relaxation of the LES that may cause symptoms such as dysphagia, epigastric pain, and regurgitation of an obstructed food. The following case describes achalasia in a patient 5 years following a laparoscopic Roux-en-Y gastric bypass (RYGB). The patient underwent a laparoscopic Heller myotomy without a fundoplication. Although achalasia seems to be a rare occurrence in obese patients, this is the third case documented in a patient who previously had an RYGB. The role of performing a fundoplication in these patients remains to be elucidated.

Obesity does not increase morbidity of laparoscopic cholecystectomy.

BACKGROUND: Obesity has historically been a positive predictor of surgical morbidity, especially in the morbidly obese. The purpose of our study was to compare outcomes of obese patients undergoing laparoscopic cholecystectomy (LC). METHODS: We reviewed 1382 consecutive patients retrospectively who underwent LC for various pathologies from January 2008 to August 2011. Patients were stratified based on the World Health Organization definitions of obesity: nonobese (body mass index [BMI] < 30 kg/m(2)), obesity class I (BMI 30-34.9 kg/m(2)), obesity class II (BMI 35-39.9 kg/m(2)), and obesity class III (BMI ≥ 40 kg/m(2)). The primary end points were conversion rates and surgical morbidity. The secondary end point was length of stay. RESULTS: There were significantly more females in the obesity II and III groups (P = 0.0002). American Society of Anesthesiologists scores were significantly higher in the obesity I, II, and III groups compared with the nonobese (P < 0.05; P < 0.01; and P < 0.0001, respectively). Independent predictors of conversion on multivariate analysis (MVA) included age (P = 0.01), acute cholecystitis (P = 0.03), operative time (P < 0.0001), blood loss (P < 0.0001), and fellowship-trained surgeons (P < 0.0001). Independent predictors of intraoperative complications on MVA included age (P = 0.009), white patients (P = 0.009), previous surgery (P = 0.001), operative time (P < 0.0001), and blood loss (P = 0.01). Independent predictors of postoperative complications on MVA included American Society of Anesthesiologists score (P < 0.0001), acute cholecystitis (P < 0.0001), and a postoperative complication (P < 0.0001). BMI was not a predictor of conversions or surgical morbidity. Length of stay was not significantly different between the four groups. CONCLUSIONS: This study demonstrates that overall conversion rates and surgical morbidity are relatively low following LC, even in obese and morbidly obese patients.

Laparoscopic liver resection: lessons at the end of the second decade.

Laparoscopic liver surgery has evolved over the last two decades. Advancements in surgical technology, surgical technique, and postoperative care have aided in lifting barriers to laparoscopic liver resection (LLR). In this review, the authors highlight the modern indications, benefits, safety, and feasibility of laparoscopic liver resections. Moreover, they analyze various studies comparing laparoscopic major hepatectomies to open surgery. Morbidity and mortality rates are at an all-time low in this era of laparoscopic liver surgery. The role of laparoscopy for oncologic resections is compared with open liver resections. Attention is given to oncologic margins and survival rates. In addition, the authors examine the safety and efficacy of LLR for nontraditional laparoscopic segments and tumors abutting major hepatic vasculature. Various resection techniques are reviewed including the use of the hanging-maneuver and modern stapling devices. Finally, they examine several novel techniques for laparoscopic liver resections including the hybrid technique, as is used in laparoscopic living donor hepatectomies, the use of hand-assistance to avoid conversion to open surgery, and the use of the robotic platform to aid in complex biliary or vascular reconstructions. Current barriers to laparoscopic liver surgery will continue to fall over the next decade.