Bariatric Surgeon Perspective on Revisional Bariatric Surgery (RBS) for Weight Recurrence.

BACKGROUND: Weight recurrence (WR) after bariatric surgery occurs in nearly 20% of patients. Revisional bariatric surgery (RBS) may benefit this population but remains controversial among surgeons. OBJECTIVES: Explore surgeon perspectives and practices for patients with WR after primary bariatric surgery (PBS). SETTING: Web-based survey of bariatric surgeons. METHODS: A 21-item survey was piloted and posted on social media closed groups (Facebook) utilized by bariatric surgeons. Survey items included demographic information, questions pertaining to the definition of suboptimal and satisfactory response to bariatric surgery, and general questions related to different WR management options. RESULTS: One hundred ten surgeons from 19 countries responded to the survey. Ninety-eight percent responded that WR was multifactorial, including behavioral and biological factors. Failure of PBS was defined as excess weight loss < 50% by 31.4%, as excess weight loss <25% by 12.8%, and as comorbidity recurrence by 17.4%. Surgeon responses differed significantly by gender (P = .036). 29.4% believed RBS was not successful, while 14.1% were unsure. Nevertheless, 73% reported that they would perform RBS if sufficient evidence of benefit existed. Most frequently performed revisional procedures included conversion of sleeve gastrectomy to Roux-en-Y gastric bypass (RYGB), adjustable gastric band to RYGB, and RYGB revision (21.9% versus 18.2% versus 15.3%, respectively). CONCLUSIONS: This survey demonstrates significant variability in surgeon perception regarding causes and the effectiveness of RBS. Moreover, they disagree on what constitutes a nonsatisfactory response to PBS and to whom they offer RBS. These findings may relate to limited available clinical evidence on best management options for this patient population. Clinical trials investigating the comparative effectiveness of various treatment options are needed.

Patient perspectives on the usefulness of the MBSAQIP Bariatric Surgical Risk/Benefit Calculator: a randomized controlled trial.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Bariatric Surgical Risk/Benefit Calculator uses procedure-specific prediction models to generate individualized surgical risk/outcome estimates. This tool helps guide informed consent and operative selection. We hypothesized that calculator use would influence patient procedure choice. OBJECTIVE: To assess patient perspectives on the bariatric surgical calculator. SETTING: A randomized controlled trial at an MBSAQIP-accredited center. METHODS: During the preoperative bariatric surgical office consultation, patients were randomized into 2 groups: the control group received conventional surgeon-led counseling, whereas surgeons used the risk/benefit calculator to guide decision making for the calculator group. Surveys were completed by patients following consultations to evaluate satisfaction and perceived impact of the risk/benefit calculator on operative selection. RESULTS: Between 2020 and 2022, 61 patients were randomized to the calculator group and 68 patients to the control group. The percentage of patients whose procedure of choice changed following consultation was similar in the calculator versus control group (44.3% versus 41.2%; P = .723). However, calculator group patients were less likely to perceive surgeon counseling as very important for their decision making (43.3% versus 76.5%; P < .001). Eighty-five percent of calculator group patients rated the calculator as useful or very useful, and only 1.7% found it not very important. The reasons patients changed procedure choice were similar between the groups (P = .091); the most common cause was to improve their anticipated outcome (48.7% versus 54.8%). CONCLUSIONS: While the risk/benefit calculator was perceived as a helpful tool by most patients, its use did not influence their procedure choice. However, the patient-reported usefulness and importance of the calculator during surgeon counseling suggest that the information provided has weight in patient decision making.

Distal gastric bypass revision for weight recurrence or nonresponse to primary procedure: initial experience and outcomes in an academic practice.

BACKGROUND: Considerable weight recurrence (WR) after Roux-en-Y gastric bypass (RYGB) may occur in nearly 20% of patients. While several nonoperative, endoscopic, and surgical interventions exist for this population, the optimal approach is unknown. This study reports our initial experience with distal bypass revision (DGB) and provides a comparison with patients after primary RYGB. METHODS: Single-institution, retrospective review was conducted for patients who underwent DGB from 2018 to 2020. A Roux and common channel of 150 cm each were constructed (total alimentary limb 300 cm). A group of primary RYGB patients with similar demographics were selected as controls. Demographics, comorbidity resolution, surgical technique, complications, excess weight loss (EWL), total weight loss (TWL), BMI, and weight change data were compared. Patient postoperative weight loss (WL) was also compared after their primary and DGB operations. RESULTS: Sixteen DGB patients, all female, were compared with 29 controls. DGB was performed on average 12.3 years after primary RYGB. In the DGB group, mean BMI was 53.7 before primary RYGB, 31.9 at nadir, and 44.1 prior to DGB. Post-DGB, mean BMI was 40.5, 37.4, 34.8, and 34.4, at 3-, 6-, 12-, and 24-months, respectively. Five patients (31.3%) experienced complications and were readmitted within 30 days, with two of them (12.5%) requiring reintervention and one (6.3%) undergoing reoperation. Mean EWL and TWL up to 2 years after DGB were lower than that after the patient's original RYGB (52.3 ± 18.6 vs. 67.2 ± 33.2; p = 0.126 and 19.6 ± 13.3 vs. 29.6 ± 11.8; p = 0.027, respectively). CONCLUSIONS: DGB resulted in excellent WL up to 2 years after surgery but was associated with considerable postoperative complication rates. The magnitude of TWL was lower compared with the primary operation. Only a few patients experienced nutritional complications. Results of this study can help counsel patients pursuing DGB for WR or nonresponse to primary RYGB. The comparative effectiveness of this approach to other available options remains to be determined.

Early postoperative weight loss predicts nadir weight and weight regain after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

BACKGROUND: Weight regain (WR) post bariatric surgery affects almost 20% of patients. It has been theorized that a complex interplay between physiologic adaptations and epigenetic mechanisms promotes WR in obesity, however, reliable predictors have not been identified. Our study examines the relationship between early postoperative weight loss (WL), nadir weight (NW), and WR following laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG). METHODS: A retrospective review of prospectively collected data was conducted for LRYGB or LSG patients from 2012 to 2016. Demographics, preoperative BMI, procedure type, and postoperative weight at 6, 12, 24, 36, and 48 months were recorded. WR was defined as > 20% increase from NW. Univariate and multivariate linear and logistic regression models were used to determine the association between early postoperative WL with NW and WR at 4 years. RESULTS: Thousand twenty-six adults were included (76.8% female, mean age 44.9 ± 11.9 years, preoperative BMI 46.1 ± 8); 74.6% had LRYGB and 25.3% had LSG. Multivariable linear regression models showed that greater WL was associated with lower NW at 6 months (Coef - 2.16; 95% CI - 2.51, - 1.81), 1 year (Coef - 2.33; 95% CI - 2.58, - 2.08), 2 years (Coef - 2.04; 95% CI - 2.25, - 1.83), 3 years (Coef - 1.95; 95% CI - 2.14, - 1.76), and 4 years (Coef - 1.89; 95% CI - 2.10, - 1.68), p ≤ 0.001. WR was independently associated with increased WL between 6 months and 1 year (Coef 1.59; 95% CI 1.05,2.14; p ≤ 0.001) and at 1 year (Coef 1.24; 95% CI 0.84,1.63;p ≤ 0.001) postoperatively. The multivariable logistic regression model showed significantly increased risk of WR at 4 years for patients with greater WL at 6 months (OR 1.20, 95% CI 1.08,1.33; p = 0.001) and 1 year (OR 1.14; 95% CI 1.06,1.23; p ≤ 0.001). CONCLUSION: Our findings demonstrate that higher WL at 6 and 12 months post bariatric surgery may be risk factors for WR at 4 years. Surgeons may need to follow patients with high early weight loss more closely and provide additional treatment options to maximize their long-term success.

Gender equity in ergonomics: does muscle effort in laparoscopic surgery differ between men and women?

BACKGROUND: Women surgeons may experience more ergonomic challenges while performing surgery. We aimed to assess ergonomics between men and women surgeons. METHODS: Laparoscopic surgeons from a single institution were enrolled. Demographics and intraoperative data were collected. Muscle groups were evaluated objectively using surface electromyography (EMG; TrignoTM, Delsys, Inc., Natick, MA), and comprised upper trapezius (UT), anterior deltoid, flexor carpi radialis (FCR), and extensor digitorum (ED). Comparisons were made between women (W) and men (M) for each muscle group, assessing maximal voluntary contraction (MVC) and median frequency (MDF). The Piper Fatigue Scale-12 (PFS-12) was used to assess self-perceived fatigue. Statistical analyses were performed using SPSS v26.0, α = 0.05. RESULTS: 18 surgeries were recorded (W:8, M:10). Women had higher activation of UT (32% vs 23%, p < 0.001), FCR (33% vs 16%, p < 0.001), and ED (13% vs 10%, p < 0.001), and increased effort of ED (90.4 ± 18.13 Hz vs 99.1 ± 17.82 Hz). Comparisons were made between W and M for each muscle group, assessing MVC and MDF. CONCLUSIONS: After controlling for surgeon's height and duration of surgery, an increase in muscle activation was seen for women laparoscopic surgeons. Since poor ergonomics could be a major cause of work-related injuries, we must understand differences in ergonomics between men and women and evaluate which factors impact these variations.

Elective robotic-assisted bariatric surgery: Is it worth the money? A national database analysis.

BACKGROUND: This study sought to evaluate surgical outcomes, cost, and opiate utilization between patients who underwent either laparoscopic or robotic-assisted bariatric procedures, including sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). METHODS: The Vizient administrative database was queried for patients admitted with mild to moderate severity of illness scores who underwent elective laparoscopic (L) and robotic-assisted (R) SG or RYGB from October 2015 through December 2018. Patients were grouped according to surgical approach for each bariatric procedure. Rates of overall complications, mortality, 30-day readmission, LOS, total direct cost, and opiate utilization were collected. Comparisons were performed within each bariatric procedure, between laparoscopic and robotic approaches, using IBM SPSS v.25.0, α = 0.05. RESULTS: For SG, a total of 84,034 patients were included (LSG:N = 78,405; RSG:N = 5639). There was no significant difference in rates of overall complications (LSG:0.5%, RSG:0.4%; p = 0.872), mortality (LSG:<0.01%, RSG:<0.01%; p = 0.660), and 30-day readmissions (LSG: 0.5%, RSG:0.5%; p = 0.524). Average LOS was 1.65 ± 1.07 days for LSG and 1.77 ± 1.29 days for RSG (p=<0.001). Robotic approach had a significantly higher direct cost (LSG: $6505 ± 3,200, RSG: $8018 ± 3849; p=<0.001). Rate of opiate use was 97.3% for both groups (p=>0.05). For RYGB, 36,039 patients met the inclusion criteria (LRYGB:N = 33,053; RRYGB:N = 2986). There was no significant difference in rates of overall complications (LRYGB: 1.4%, RRYGB:1.3%; p = 0.414) or mortality (LRGYB:<0.01%, RRYGB: <0.01%; p = 0.646). Robotic approach was associated with a lower 30-day readmission rate (LRYGB: 1.3%, RRYGB:<0.01%; p=<0.001). Average LOS was 2.1 ± 2.18 days for LRYGB and 2.18 ± 3.78 days for RRYGB (p = 0.075). Robotic approach had a significantly higher direct cost (LRYGB:$8564 ± 5,350, RRYGB: $10,325 ± 7689; p=<0.001) and rate of opiate use (LRYG:95.75%, RRYGB:96.85%; p = 0.005). CONCLUSION: Our study found the direct cost of RSG to be significantly higher than LSG with no added clinical benefit, therefore, universal use of the robotic platform for routine SG cases remains difficult to justify. While the direct cost of RRYGB was also higher than LRYGB, the significantly lower readmission rate associated with robotic approach may help to offset the financial discrepancy and warrant its use.

Current state of robotic use in inguinal hernia repair: a survey of minimally invasive hernia surgeons.

Little is known about how robot technology is employed by surgeons in minimally invasive surgery (MIS). We evaluated the needs of established robotic surgeons and of those who are new to this technology. A survey was designed and sent electronically to MIS surgeons. Questions included fellowship training, area of expertise, experience with robotic simulation and in clinical use, mentorship, likelihood of switching to a different approach, and expectations for the robot. Descriptive analysis was conducted using STATA/MP 15.1. 189 interviewees self-identified as hernia surgeons. 73.8% had additional fellowship, with majority practicing for 3-6 years (54%). Nearly 40% were MIS surgeons (N = 73), followed by general surgery (34.4%), and bariatrics (13.8%). 146 interviewees (77.7%) have used the daVinci® in clinical scenarios. Among robotic surgeons, majority were performing less than ten robotic cases per month. Inguinal hernia repairs were the leading procedures (49%), followed by foregut-related (19.5%), and colorectal-related surgeries (17.5%). Nearly 40% of surgeons stated inguinal hernia repairs to be the most often performed procedure using the robot. Nearly 40% of open and laparoscopic hernia surgeons are willing to adopt robotic-assisted procedures for their inguinal hernia repairs. Level 1 evidence (47.9%) and cost (24.1%) were the most pressing needs for robotic research. Majority of interviewees have used the daVinci® in clinical settings. Hernia repair remains the primary application of the robot in general surgery, among specialized surgeons. Over 40% of hernia surgeons are interested in switching to robotic technology over its open or laparoscopic counterparts.

Patients undergoing intragastric balloon achieve approximately 50% of their target weight loss in the first month postoperatively: an MBSAQIP analysis.

BACKGROUND: Intragastric balloon (IGB) placement can provide a mean percent total weight loss (%TWL) of 10.2% at 6-month follow-up. OBJECTIVES: We aimed to evaluate 30-day outcomes and safety of patients undergoing IGB placement. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. METHODS: The 2016 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program was queried for adult patients who underwent primary IGB placement. Demographic characteristics and preoperative risk factors were collected. Postoperative outcomes included %TWL, percent excess weight loss, and complications rates and causes. Subset analysis was done for outcomes comparison between surgeons or gastroenterologists performing the procedure. Statistical analysis was performed using SPSS 25.0. RESULTS: A total of 1221 patients were included. The majority was female (81.9%), Caucasian (81.2%), with a mean age of 48 ± 11.3 years and a mean preoperative body mass index of 34.9 ± 11.2 kg/m2. Of patients, 98.8% were discharged within 24 hours of the procedure. Two patients were admitted to the intensive care unit, and 7.2% received postoperative treatment for dehydration. Reoperation and readmission rates were 1.1% and 7.2%, respectively, mainly due to nausea, vomiting, and poor nutritional status (n = 22). The intervention rate was 6.2%. Patients in this cohort achieved a mean %TWL of 6.2% (standard deviation, 5.52%) and mean TWL of 6.8 kg within 30 days postoperatively (n = 147; 24-30 d). CONCLUSIONS: Our data show patients met approximately 50% of their target weight loss 30 days after IGB placement. Nausea, vomiting, and poor nutrition status were the most common complications within 30 days of the procedure. Long-term follow-up is necessary to determine if these patients are able to sustain their weight loss and for how long.

Robot-assisted cholecystectomy is a safe but costly approach: A national database review.

BACKGROUND: This study sought to evaluate surgical outcomes, cost, and opiate utilization of patients who underwent laparoscopic (LC) or robotic cholecystectomy (RC). METHODS: The Vizient database was queried for patients admitted with mild to moderate severity of illness (SOI) scores who underwent LC or RC from January 2015 through December 2017. Rates of overall complications, postoperative infection, mortality, LOS, cost, and opiate utilization were compared between groups using IBM SPSS v.25.0, α = 0.05. RESULTS: 91,849 patients (LC:N = 89,878; RC:N = 1,971) met the inclusion criteria. Robotic approach was associated with more complications (LC:0.9%, RC:1.7%; p < 0.001), postoperative infections (LC:0.2%, RC:0.4%; p = 0.033) and a higher direct cost (LC:$6782 ±â€¯3421, RC:$9354 ±â€¯5497; p < 0.001). Opiates were prescribed more frequently in the laparoscopic group (LC:98.3%, RC:97.2%; p = 0.002). CONCLUSION: The direct cost of RC is significantly higher than LC with no added benefit. Routine use of the robotic platform for cholecystectomy should be discouraged until costs are reduced.

Predictors of Hiatal Hernia Recurrence After Laparoscopic Anti-reflux Surgery with Hiatal Hernia Repair: a Prospective Database Analysis.

BACKGROUND: The aim of this study is to identify factors that can predict hiatal hernia recurrence (HHR) in patients after anti-reflux surgery with hiatal hernia (HH) repair. METHODS: A single-institution, prospectively collected database was reviewed (January 2002-October 2015) with inclusion criteria of GERD and laparoscopic anti-reflux (AR) surgery with HH repair. Demographics, esophageal symptom scores, and pre- and post-upper gastrointestinal imaging (UGI) were collected. Mesh usage, HH type (sliding, paraesophageal (HH) or type IV), and size were evaluated, and patients who had HHR versus those who did not (NHHR) were compared. Statistical analysis was performed using IBM SPSS v.23.0.0, with α = 0.05. RESULTS: Three hundred twenty-two patients met inclusion criteria. Mean age was 56.9 ± 14.8 years (60.9% female), and mean follow-up was 19.9 ± 23.8 months. 88.2% underwent total fundoplication and 11.8% underwent partial fundoplication. HHR rate was 15.5%. HHR patients had larger HH than the NHHR group. There was no significant difference between groups for age, gender, BMI, race, and mesh usage. Only 3 patients (10.3%) with HHR reported mild-to-moderate heartburn, regurgitation, and solid or liquid dysphagia at 12-month follow-up. Overall reoperation rate was 1% in this population. CONCLUSIONS: HHR is correlated with large hernia size. Mesh use and patient BMI were not predictors, and no correlation was identified between HHR and presence of GERD symptoms. Recurrence after repair is not uncommon, but is asymptomatic in most cases. Reoperation is rare and mesh is not routinely needed. Large asymptomatic HHs in the elderly often do not require intervention.

Laparoscopic endoscopic combined surgery for removal of migrated coil after embolization of ruptured splenic artery aneurysm.

Splenic artery aneurysm is the most common visceral arterial aneurysm. Rupture of aneurysm is a rare event but associated with a high mortality. Endovascular coil embolization of bleeding splenic artery aneurysm has emerged as a promising minimal invasive treatment and considered safer than open surgery in selected patients. Nevertheless, several complications related to coils have been reported, the rarest being coil migration and erosion. We report a case of splenic artery coil migration into the stomach and its successful removal by laparoscopic endoscopy combined surgery.