Evaluation of endoscopic gastrojejunostomy revision after Roux-en-Y gastric bypass for treatment of dumping syndrome.

BACKGROUND AND AIMS: Gastrojejunostomy stomal dilation is a frequent cause of weight regain after Roux-en-Y gastric bypass and may be a contributing cause of dumping syndrome. This study aims to evaluate the long-term durability of endoscopic gastrojejunostomy revision (EGJR) to resolve dumping syndrome. METHODS: A retrospective chart review was performed of patients undergoing EGJR at a single institution from January 1, 2013 to December 1, 2018. The primary endpoint, dumping symptom resolution, was measured at 1 month and at the most recent postoperative follow-up. Continuous data are reported as mean and standard deviations and categorical data as percentages. The Fisher exact test was used to assess associations between categorical variables. RESULTS: Ninety-eight patients underwent EGJR for dumping syndrome. Mean patient age was 51 years (standard deviation [SD], 9.9), and mean body mass index (BMI) was 36.2 kg/m2 (SD, 7.1), with most patients (53%) presenting with BMIs ≥35 kg/m2. Thirty-two patients (32%) reported severe dumping (≥3 symptoms). All patients were followed-up for 1 month, and 83% had a long-term follow-up at a mean of 3.45 years (SD, 1.7) after EGJR. In addition, 88% had initial symptom resolution at 1 month, and 85% reported symptom resolution 3 years postoperatively. Patients with GERD had a statistically significant improvement in dumping syndrome at 3 years compared with those without GERD (69% vs 62%, P = .03). Long-term weight loss averaged 2.1 pounds after EGJR. CONCLUSIONS: EGJR is associated with effective and durable resolution of dumping syndrome at 3 years postoperatively, with a minimal long-term impact on weight loss. The presence of GERD preoperatively correlates with a statistically significant resolution of dumping syndrome.

Technique and outcomes of laparoscopic bulge repair after abdominal free flap reconstruction.

INTRODUCTION: Bulges and hernias after abdominal free flap surgery are uncommon with rates ranging from as low as 0-36%. In the free flap breast reconstruction population, there are no clear guidelines or optimal strategies to treating postoperative bulges. We describe our minimally invasive technique and outcomes in managing bulge complications in abdominal free flap breast reconstruction patients. METHODS: A retrospective review was performed on all abdominal free flap breast reconstruction patients at Albany Medical Center from 2011 to 2014. All patients with bulges on clinical exam underwent abdominal CT imaging prior to consultation with a minimally invasive surgeon. Confirmed symptomatic bulges were repaired laparoscopically and patients were monitored regularly in the outpatient setting. RESULTS: Sixty-two patients received a total of 80 abdominal free flap breast reconstructions. Flap types included 41 deep inferior epigastric perforator (DIEP), 36 muscle-sparing transverse rectus abdominus myocutaneous (msTRAM), 2 superficial inferior epigastric artery, and 1 transverse rectus abdominus myocutaneous flap. There were a total of 9 (14.5%) bulge complications, with the majority of patients having undergone msTRAM or DIEP reconstruction. There were no complications, revisions, or recurrences from laparoscopic bulge repair after an average follow-up of 181 days. CONCLUSION: Although uncommon, bulge formation after abdominal free flap reconstruction can create significant morbidity to patients. Laproscopic hernia repair using composite mesh underlay offers an alternative to traditional open hernia repair and can be successfully used to minimize scarring, infection, and pain to free flap patients who have already undergone significant reconstructive procedures. © 2016 Wiley Periodicals, Inc. Microsurgery 36:367-371, 2016.

Reverse alignment "mirror image" visualization as a laparoscopic training tool improves task performance.

Reverse alignment (mirror image) visualization is a disconcerting situation occasionally faced during laparoscopic operations. This occurs when the camera faces back at the surgeon in the opposite direction from which the surgeon's body and instruments are facing. Most surgeons will attempt to optimize trocar and camera placement to avoid this situation. The authors' objective was to determine whether the intentional use of reverse alignment visualization during laparoscopic training would improve performance. A standard box trainer was configured for reverse alignment, and 34 medical students and junior surgical residents were randomized to train with either forward alignment (DIRECT) or reverse alignment (MIRROR) visualization. Enrollees were tested on both modalities before and after a 4-week structured training program specific to their modality. Student's t test was used to determine differences in task performance between the 2 groups. Twenty-one participants completed the study (10 DIRECT, 11 MIRROR). There were no significant differences in performance time between DIRECT or MIRROR participants during forward or reverse alignment initial testing. At final testing, DIRECT participants had improved times only in forward alignment performance; they demonstrated no significant improvement in reverse alignment performance. MIRROR participants had significant time improvement in both forward and reverse alignment performance at final testing. Reverse alignment imaging for laparoscopic training improves task performance for both reverse alignment and forward alignment tasks. This may be translated into improved performance in the operating room when faced with reverse alignment situations. Minimal lab training can account for drastic adaptation to this environment.

Gastrojejunal strictures after Roux-en-Y gastric bypass with a 21-MM circular stapler.

INTRODUCTION: Intraluminal staplers for gastrojejunostomy construction during Roux-en-Y gastric bypass (RYGBP) may be associated with postoperative strictures. We analyzed outcomes of a transabdominal circular-stapled RYGBP with evaluation of short- and long-term anastomotic complications. METHODS: All laparoscopic RYGBPs performed between January 2004 and December 2005 at an academic institution were reviewed. The gastrojejunostomy was created by using the transabdominal passage of a 21-mm intraluminal circular stapler into an antecolic, antegastric Roux limb. This retrospective chart review analyzes patient demographics, anastomotic complications, and weight loss. RESULTS: Between January 2004 and December 2005, 159 patients underwent transabdominal circular-stapled RYGBP. Fifteen patients developed a stenosis at the gastrojejunostomy, all requiring endoscopic balloon dilatation. One of these patients required laparoscopic revision of the gastrojejunostomy. Eleven strictures occurred after 30 days, whereas only 4 strictures occurred within 30 days of surgery. Two marginal ulcerations were seen within 1 year of surgery. CONCLUSION: Our 9.4% stricture rate parallels what has been reported in the literature. The majority of strictures were amenable to one endoscopic treatment session. Transabdominal circular-stapled gastrojejunostomy is a reproducible construct for use in bariatric surgery.

Towards a virtual basic laparoscopic skill trainer (VBLaST).

Surgical skill training is a long and tedious process of acquiring fine motor skills. To overcome the drawbacks of the existing toolbox trainer systems, we develop, for the first time, a virtual basic laparoscopic skill trainer (VBLaST) whereby tasks, such as the ones available in the FLS toolbox system, may be performed on the computer.

Development of the VBLaST: a virtual basic laparoscopic skill trainer.

BACKGROUND: The FLS training tool box has now been adopted by the Society of Gastrointestinal Endoscopic Surgeons (SAGES) as an official training tool for minimally invasive procedures. METHODS: To overcome the limitations of the physical FLS training tool box, we have developed a Virtual Basic Laparoscopic Skill Trainer (VBLaSTTM) system, which is a 3D simulator that will allow trainees to acquire basic laparoscopic skill. RESULTS: The outcome of this work is the development of an integrated visio-haptic workstation environment including force feedback devices and a stereo display interface whereby trainees can practice on virtual versions of the FLS. Realistic graphical rendering and high fidelity haptic interactions are achieved. CONCLUSIONS: Surgical skill training is a long and tedious process of acquiring fine motor skills. It is expected that residents would start on trainers such as VBLaSTTM and after reaching a certain level of competence would progress to the more complex trainers for training on specific surgical procedures.

Early robotic experience with paraesophageal hernia repair and Nissen fundoplication: short-term outcomes.

The applications of robot-assisted surgery continue to expand. Several recent studies have examined the use of robotic Nissen fundoplication (RF) for treatment of gastroesophageal reflux disease (GERD). Our experience with RF has led us to introduce this technology for the treatment of paraesophageal hernias (PEH). There is little information about the short-term outcomes of patients undergoing robotic paraesophageal hernia repair (RPEH). The goal of our study was to summarize the short-term outcomes of patients who underwent either RF or RPEH. We conducted a retrospective review of all patients who underwent RPEH and RF by a single surgeon between June, 2005 and August, 2006. Data collected included age, gender, body mass index (BMI), co-morbidities and prior operations, and ASA class. Outcomes included operating times, length of stay, pain medication use, and perioperative complications. We performed a comparison of the two groups using the Mann-Whitney U test for statistical significance. Seven patients underwent RPEH, and 19 patients underwent RF alone. Four patients were excluded from the RF group. Patients in the RPEH group had a significantly higher BMI (33 vs. 26 kg/m(2), P = 0.007) and significantly more comorbidities (6 vs. 4, P = 0.004). There was no calculated statistical difference between the two groups in regards to age, ASA class, operating times, length of stay, or complications. Patients undergoing RPEH have similar short-term outcomes when compared to patients undergoing RF. The skills necessary for RF can be easily applied to RPEH, despite technical differences between the two operations. Similar morbidity can be anticipated between the two groups.

The impact of obesity in renal transplantation: an analysis of paired cadaver kidneys.

BACKGROUND: Previous studies indicate that obesity is a risk factor in renal transplantation. However, these analyses did not control for variable donor factors that may strongly influence outcome. To control for donor variables such as age, cause of death, procurement techniques, preservation methods, cold ischaemia time and implantation technique, we analysed patient and graft survival in recipients of paired kidneys, derived from the same procurement procedure, preserved in the same manner, subjected to similar cold ischaemia time and implanted by the same surgical team. Between June 1992 and August 1999, 28 procurement procedures provided kidneys which were transplanted into one obese and one non-obese recipient. Body mass index (BMI) was calculated as kg/m2. Recipients were classified as obese (BMI > 30) or non-obese (BMI < 30). Immunotherapy for all recipients consisted of a triple therapy regimen of cyclosporine or prograf, azathioprine or cellcept, and prednisone. Patients with delayed graft function (DGF), defined as the need for dialysis within 72 h of the transplant procedure, were treated with anti-thymocyte globulin (ATG) or thymoglobulin (TMG) induction for 5-7 d. The rate of DGF (7.1 versus 10.7%) and acute rejection (39.3 versus 35.7%) were similar in the obese and non-obese recipient groups. Patient survival was similar at 1, 3 and 5 yr in both groups. In addition, graft survival was similar at 1 yr. However, a trend toward decreased medium-term graft survival, which reached significance at 5 yr, was observed in the obese group. Furthermore, mean serum creatinine at 1 yr was higher in the obese group (2.0) compared with the non-obese group (1, 4) (p=0.12). This analysis of paired cadaver kidneys indicated that obesity is not a risk factor for DGF, acute rejection, and 1-yr graft survival. However, a decreased medium- and long-term graft survival trend, which reached statistical significance at 5 yr, was observed in obese recipients.