The performance of artificial intelligence large language model-linked chatbots in surgical decision-making for gastroesophageal reflux disease.

BACKGROUND: Large language model (LLM)-linked chatbots may be an efficient source of clinical recommendations for healthcare providers and patients. This study evaluated the performance of LLM-linked chatbots in providing recommendations for the surgical management of gastroesophageal reflux disease (GERD). METHODS: Nine patient cases were created based on key questions addressed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines for the surgical treatment of GERD. ChatGPT-3.5, ChatGPT-4, Copilot, Google Bard, and Perplexity AI were queried on November 16th, 2023, for recommendations regarding the surgical management of GERD. Accurate chatbot performance was defined as the number of responses aligning with SAGES guideline recommendations. Outcomes were reported with counts and percentages. RESULTS: Surgeons were given accurate recommendations for the surgical management of GERD in an adult patient for 5/7 (71.4%) KQs by ChatGPT-4, 3/7 (42.9%) KQs by Copilot, 6/7 (85.7%) KQs by Google Bard, and 3/7 (42.9%) KQs by Perplexity according to the SAGES guidelines. Patients were given accurate recommendations for 3/5 (60.0%) KQs by ChatGPT-4, 2/5 (40.0%) KQs by Copilot, 4/5 (80.0%) KQs by Google Bard, and 1/5 (20.0%) KQs by Perplexity, respectively. In a pediatric patient, surgeons were given accurate recommendations for 2/3 (66.7%) KQs by ChatGPT-4, 3/3 (100.0%) KQs by Copilot, 3/3 (100.0%) KQs by Google Bard, and 2/3 (66.7%) KQs by Perplexity. Patients were given appropriate guidance for 2/2 (100.0%) KQs by ChatGPT-4, 2/2 (100.0%) KQs by Copilot, 1/2 (50.0%) KQs by Google Bard, and 1/2 (50.0%) KQs by Perplexity. CONCLUSIONS: Gastrointestinal surgeons, gastroenterologists, and patients should recognize both the promise and pitfalls of LLM's when utilized for advice on surgical management of GERD. Additional training of LLM's using evidence-based health information is needed.

Robotic surgery across Latin America: a bibliometric analysis of research trends from 2009 to 2022.

The rise of robotic surgery throughout the world, particularly in Latin America, justifies an objective evaluation of research in this field. This study aimed to use bibliometric techniques to identify the research trends and patterns of robotic surgery in Latin America. The research strategy used the terms "Robotic," "Surgery," and the name of all the Latin American countries, in all fields and collections of Web of Science database. Only original articles published between 2009 and 2022 were included. The software Rayyan, Bibliometric in the R Studio, and VOSViewer were used to develop the analyses. After screening, 96 articles were included from 60 different journals. There was a 22.51% annual increase in the scientific production of robotic surgery in the period studied. The more frequent topics by specialty were: Urology (35.4%), General Surgery (34.4%), and Obstetrics and Gynecology (12%). International cooperation was observed in 65.62% of the studies. The Latin American institution with the highest production of manuscripts was the Pontificia Universidad Católica de Chile. Mexico, Chile, and Brazil were, in descending order, the nations with the highest number of corresponding authors and total citations. When considering the total number of articles, Brazil ranked ahead of Chile. Scientific production regarding robotic surgery in Latin America has experienced accelerated growth since its beginning, supported by the high degree of collaboration with leading countries in the field.

Feasibility of robotic cholecystectomy at an academic center with a young robotic surgery program: a retrospective cohort study with umbrella review.

Laparoscopic cholecystectomy (LC) has been standard of care for surgical treatment of benign gallbladder pathology for decades. With the advent of robotic surgical technology, robotic cholecystectomy (RC) has gained attention as an alternative to conventional laparoscopy. This study introduces a single-surgeon experience with laparoscopic versus robotic cholecystectomy and an umbrella systematic review of the outcomes of both approaches. A retrospective chart review was performed at a single institution on a prospectively maintained database of patients undergoing laparoscopic or robotic cholecystectomy for benign gallbladder pathology. An umbrella systematic review was conducted using PRISMA methodology. A total of 103 patients were identified; 61 patients underwent LC and 42 underwent RC. In the RC cohort, 17 cases were completed using a four-port technique while 25 were completed using a three-port technique. Patients undergoing RC were older compared to the LC group (44.78 vs 57.02 years old; p < 0.001) and exhibited lower body mass index (29.37 vs 32.37 kg/m2, p = 0.040). No statistically significant difference in operative time or need for postoperative ERCP was noted. Neither this series nor the umbrella systematic review revealed significant differences in conversion to open surgery or readmissions between the LC and RC cohorts. Three-port RC was associated with reduced operative time compared to four-port RC (101.28 vs 150.76 min; p < 0.001). Robotic cholecystectomy is feasible and safe at a young robotic surgery program in an academic center setting and comparable to laparoscopic cholecystectomy clinical outcomes.

ASMBS statement on metabolic and bariatric surgery for beneficiaries of Centers for Medicare and Medicaid Services with a review of the literature.

This position statement is issued by the American Society for Metabolic and Bariatric. Surgery in response to inquiries made to the Society by patients, physicians, Society members, hospitals, health insurance payors, the media, and others regarding the access and outcomes of metabolic and bariatric surgery for beneficiaries of Centers for Medicare and Medicaid Services. This position statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. This statement will be revised in the future as additional evidence becomes available.

Optimizing aortic valve prosthesis selection in patients with obesity: Institutional experience with multidisciplinary perspective.

BACKGROUND: Aortic valve diseases are life-threatening conditions with increasing prevalence worldwide. Risk factors include gender, age, hypertension, dyslipidemia, and type 2 diabetes. Obesity is closely related to these risk factors and has been linked to a higher risk of developing aortic valve diseases. However, there is no specific guideline for managing aortic valve disease in patients with obesity, and the choice of valve type remains uncertain. METHODS: A total of 130 patients with obesity who met the inclusion criteria underwent surgical aortic valve replacement. The patients were divided into two groups based on the type of prosthesis used. Among the study cohort, 50 patients received a bioprosthetic valve, while 80 patients received a mechanical valve. We compared these groups in terms of perioperative characteristics and follow-up results. Statistical significance was determined using a p-value threshold of 0.05. RESULTS: There were no significant differences in age, gender, body mass index, or cardiac comorbidities between the two groups. Preoperative blood results and echo findings also showed no significant differences. Intraoperative characteristics and postoperative outcomes, including mortality and acute kidney injury, did not differ significantly between the groups. In addition, BHVG patients had shorter ICU stays compared to MHVG patients without significance. CONCLUSION: Deliberate consideration is crucial when selecting valves for obese patients, particularly those with class II obesity. This is due to the potential influence of obesity on valve types, as well as the need to account for the possibility of bariatric surgery and its potential effects.

Three-port laparoscopic cholecystectomy is safe and efficient in the treatment of surgical biliary disease: a retrospective cohort study.

Multiple studies have suggested that three-port laparoscopic cholecystectomy is both feasible and safe. However, this approach has failed to gain acceptance outside of clinical trials, leaving adopters of this approach vulnerable to medico-legal scrutiny. We hypothesized that the three-port approach to laparoscopic cholecystectomy (LC) is safe and efficient in experienced hands. All LC (including robotic) cases were performed on patients 18 years and older between November 2018 and March 2020. Operations utilizing three ports were compared to those performed using more than three ports. The primary outcomes measured were total operative time, conversion-to-open rate, and the complication rate. A two-sample test was performed to compare operative times, and a Fisher's exact test was used to compare conversion-to-open and complication rates. Linear regression models were used to account for the effect of confounders. 924 total LCs were performed by 30 surgeons in the study period (71 three-port, 853 four or more ports). The mean operative time was 10 min shorter in the three-port group in comparison (64.1 ± 1.4 min vs. 74.4 ± 1.8 min, p < 0.01), despite a threefold higher rate of intraoperative cholangiogram in these cases (23.0% vs. 7.9%, p < 0.001). There was no significant difference in either the conversion-to-open rate (1.6% vs. 5.1%, p = 0.35), or the overall complication rate (7.1% vs. 8.7%, p = 0.82). Operative time for LC performed through three ports was significantly less than those performed through the traditional four port approach, despite utilizing intraoperative cholangiogram nearly three times as often. There was no difference in the conversion-to open rate or complication rate. These results provide considerable evidence that three-port laparoscopic cholecystectomy is comparable to four-port laparoscopic cholecystectomy in operative duration, conversion-to-open rate, and complication rate.

Foregut Malignancy After Metabolic Surgery: a Literature Review.

Obesity is known to be epidemiologically associated with malignancy. Although there is an increasing global number of bariatric surgeries, the relationship between bariatric surgery and esophagogastric cancers is not well understood. Diagnosis of esophagogastric cancers following bariatric surgery is challenging because the presentation tends to be nonspecific and may be perceived as usual postoperative symptoms in bariatric patients. Therefore, the early diagnosis requires a high index of suspicion. In addition, endoscopic investigation of the excluded stomach after a Roux-en-Y gastric bypass or a one-anastomosis gastric bypass is technically challenging, which further complicates the diagnosis. The aim of this study is to review the current evidence in the literature on esophagogastric cancers following bariatric surgery.

Predictors of morbidity in revisional bariatric surgery and bariatric emergencies at an MBSAQIP-accredited community hospital.

INTRODUCTION: Bariatric surgery revisions and emergencies are associated with higher morbidity and mortality compared to primary bariatric surgery. No formal outcome benchmarks exist that distinguish MBSAQIP-accredited centers in the community from unaccredited institutions. METHODS: A retrospective chart review was conducted on 53 bariatric surgery revisions and 61 bariatric surgical emergencies by a single surgeon at a high-volume community hospital accredited program from 2018 to 2020. Primary outcomes were complications or deaths occurring within 30-days of the index procedure. Secondary outcomes included operative time, leaks, surgical site occurrences (SSOs), and deep surgical site infections. RESULTS: There were no significant differences in the demographic characteristics of the study groups. Mean operative time was significantly longer for revisions as compared to emergency operations (149.5 vs. 89.4 min). Emergencies had higher surgical site infection (5.7% vs. 21.3%, p < 0.05) and surgical site occurrence (SSO) (1.9% vs. 29.5%, p < 0.05) rates compared to revisions. Logistic regression analysis identified several factors to be predictive of increased risk of morbidity: pre-operative albumin < 3.5 g/dL (p < 0.05), recent bariatric procedure within the last 30 days (p < 0.05), prior revisional bariatric surgery (p < 0.05), prior duodenal switch (p < 0.05), and pre-operative COPD (p < 0.05). CONCLUSION: Bariatric surgery revisions and emergencies have similar morbidity and mortality, far exceeding those of the primary operation. Outcomes comparable to those reported by urban academic centers can be achieved in community hospital MBSAQIP-accredited centers.

RYGB-Induced Gut Dysmotility and Retrograde Intussusception: an Unusual Phenomenon. A Narrative Literature Review.

Intussusception following Roux-en-Y gastric bypass (RYGB) is a rare complication of bariatric surgery with an unclear etiology. The pathogenesis underlying intussusception after gastric bypass is likely different from that in the general population. Post-RYGB intussusception might be related to motility issues in the divided small bowel, thinning of the mesentery following rapid weight loss, or anastomotic sutures/staple line acting as the lead point. This condition can cause obstruction with subsequent strangulation and bowel necrosis if not recognized and treated promptly. Clinical presentation is vague and nonspecific, and computerized tomography scan represents the diagnostic test of choice. Surgical treatment consists of reduction with or without anastomosis resection and reconstruction. This literature review provides an extensive overview of this condition, based on multiple studies involving 120 patients.

Literature review on antiobesity medication use for metabolic and bariatric surgery patients from the American Society for Metabolic and Bariatric Surgery Clinical Issues Committee.

The following literature search is in response to inquiries made to the American Society for Metabolic and Bariatric Surgery (ASMBS) regarding antiobesity medication (AOM) use in patients who are having or have already had metabolic and bariatric surgery (MBS). These recommendations are based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. This paper is not intended to establish a local, regional, or national standard of care. The paper will be revised in the future as additional evidence becomes available.

Robotic Roux en Y gastric bypass can be safe and cost-effective in a rural setting: clinical outcomes from a community hospital bariatric program.

Robotic Roux en Y gastric bypass (R-RYGB) is becoming more common due to the shifting trend toward robotic gastrointestinal surgery. The goal of this study is to determine if R-RYGB can be safely implemented at a robotic bariatric surgery program in a community hospital with similar results to laparoscopic RYGB (L-RYGB) in a cost-effective manner. A total of 50 R-RYGB procedures were performed with the Xi and the X da Vinci systems and compared with 50 L-RYGB cases by a single surgeon from October 2018 to January 2020 at an acute-care community hospital in a rural setting with a high-volume MBSAQIP-accredited program. A retrospective chart review was conducted with IRB approval and statistical analysis of 30-day morbidity, mortality, re-interventions, and resolution of co-morbidities, with financial analysis of cost reduction. Both groups were similar in age, gender, ASA class, co-morbidities, and body mass index (BMI). There was no mortality or anastomotic leak. The 30-day morbidity for R-RYGB was 10.0% with a re-operation rate of 4.0%. There were no conversions to open, and the mean hospital length of stay was 2.22 ± 1.19 days. There were no statistically significant differences between R-RYGB and L-RYGB with respect to any measured outcome, including intraoperative time (121.94 vs. 113.52, respectively; p = 0.1495). However, when incidences and percentages were used, R-RYGB had improved performance for most of the outcomes measuring safety. There was an average cost reduction of $816.90 per case (total saving of $40,845.00 for 50 cases) in the R-RYGB by transitioning from a hybrid approach to a totally robotic approach. R-RYGB appears to be as safe as L-RYGB and can be performed in a rural community hospital while maintaining a low complication rate, achieving a high co-morbidity resolution rate, and saving costs with a totally robotic approach.

Laparoscopic Duodenal Switch Versus Roux-en-Y Gastric Bypass at a High-Volume Community Hospital: a Retrospective Cohort Study from a Rural Setting.

BACKGROUND: The classic duodenal switch (DS) represents a minority of bariatric procedures due to its high complexity and potential for complications. METHODS: A retrospective chart review was conducted on 100 laparoscopic DS cases from 2014 to 2018 at an accredited program in a rural community hospital and compared to 100 laparoscopic Roux-en-Y gastric bypasses (RYGB). Primary outcomes were 30-day morbidity and mortality. Secondary outcomes included anastomotic leak and remission of type 2 diabetes. RESULTS: There were more demographic risk factors for DS. The 30-day morbidity was higher for DS compared to RYGB (31% vs 13%, respectively; p = 0.0037). There was one mortality for DS and none for RYGB. There were statistically significant longer intraoperative times, greater EBL, and greater decrease in BMI for DS. The DS had a lower incidence of anastomotic ulcers (4% vs 13%, respectively; p = 0.0289), with a higher incidence of subsequent surgery beyond 30 days (21% vs 8%, respectively; p = 0.0160). There were 3 anastomotic leaks for DS and none for RYGB, although not statistically significant (p = 0.2463). The DS was more likely to eradicate hypertension, but the RYGB was more likely to eradicate GERD. There were no statistically significant differences for type 2 diabetes remission (92.1% vs 89.5%, respectively; p = 0.7239). CONCLUSION: Laparoscopic DS offers greater weight loss and hypertension remission, with lower incidence of anastomotic ulcers, but at the expense of greater morbidity and need for subsequent surgery, with no significant differences in type 2 diabetes remission when compared to RYGB in a rural community hospital program.

Robotic Ventral Hernia Repair and Endoscopic Component Separation: Outcomes.

BACKGROUND AND OBJECTIVES: Robot-assisted hernia repair, combined with endoscopic component separation, has reduced recurrence and complication rates and allowed immediate intervention in obese patients. We sought to study surgical outcomes in this high-risk group of patients in a community hospital. METHODS: We conducted a retrospective chart review of ventral, incisional, and umbilical hernia repairs performed at a small community hospital by a single surgeon from March 2014 through November 2016, with statistical analysis of the surgical outcomes. Patients included were those who underwent hernia repair during the study period and had a body mass index (BMI) >30. Patients were followed up for a minimum of 6 months (range, 6-37). RESULTS: Forty-seven hernia repairs were performed, including 33 combined and 14 control cases. The demographics of each group were comparable when comparing sex, age, BMI, and ASA classification. Mean follow-up was 19.39 months in the study group and 28.64 months in the control group. There were no significant differences in total operative time, estimated blood loss, conversion rates, or hospital length of stay. Two complications occurred in each of the study and control groups, with no recurrences in the study group and 3 in the control group and no mortalities. CONCLUSION: Robotic laparoscopic repair of abdominal wall defects offers significant advantages, including easier primary defect closure. Our analyses showed that combining robot-assisted hernia repair with mesh and endoscopic component separation is an effective intervention in obese patients.

Emergency splenectomy for trauma in the setting of splenomegaly, axillary lymphadenopathy, and incidental B-cell chronic lymphocytic leukemia: A case report.

INTRODUCTION: The spleen is the most commonly injured intra-abdominal solid organ following blunt trauma. B-cell chronic lymphocytic leukemia (CLL) is the most common leukocytic dyscrasia affecting adults in Western countries. Splenomegaly with axillary and retroperitoneal lymphadenopathy are common physical findings. This case investigates an emergency splenectomy in a community hospital involving a 45-year-old man with blunt abdominal trauma following an assault with incidental splenomegaly and axillary lymphadenopathy, with surgical pathology findings of B-cell CLL. PRESENTATION OF CASE: A 45- year-old man without past medical or family history who was the victim of an assault presented to the emergency department 6h later with left upper quadrant pain and radiation to the left flank and a positive Kehr sign. An elevated absolute lymphocyte count above 7×109 and CT confirmation of a Grade V splenic laceration with splenomegaly, axillary lymphadenopathy, with hemodynamic compromise led to an exploratory laparotomy and emergency splenectomy regardless of the potential for malignancy. DISCUSSION: Hemoperitoneum with blunt splenic injury (BSI) caused by abdominal trauma with hemodynamic instability should be treated with exploratory laparotomy and splenectomy even in the face of potential malignancy with splenomegaly and axillary lymphadenopathy. An appropriate oncologic work up and treatment can be provided after the emergency intervention. CONCLUSION: An emergency splenectomy is an appropriate operative intervention for a grade V splenic laceration with hemoperitoneum, splenomegaly, and axillary lymphadenopathy regardless of the potential for a neoplastic process such as B-cell CLL. Post-splenectomy vaccinations and oncologic follow-up for systemic chemotherapy should be facilitated after recovery.

Emergency incarcerated obturator hernia repair with biologic mesh in a male patient after ipsilateral hip disarticulation: A case report.

INTRODUCTION: An obturator hernia is an uncommon form of abdominal hernia that is difficult to diagnose due to its non-distinct presentation. This case investigates an emergency treatment of an obturator hernia presenting in a patient with an ipsilateral hip disarticulation in a 266-bed community hospital. PRESENTATION OF CASE: A 53-year old man with a history of a left hip disarticulation 3-weeks prior presented to the emergency department with fever, nausea, vomiting, and diarrhea for the past 5-days. An elevated WBC and presence of gas within the hip stump on CT led to an emergency operation to rule out necrotizing fasciitis within the stump. Opening of the stump incision revealed two herniated loops of small bowel corresponding to the left obturator foramen, revealing the diagnosis of an incarcerated obturator hernia. The bowel was reduced and secured within the hip stump and the defect was covered with Strattice biologic mesh. DISCUSSION: Obturator hernias are rare and can involve vague symptoms, but it is essential to make an accurate diagnosis and repair the defect on an emergency basis. Obturator hernias may appear in the setting of a hip disarticulation, being caused by iatrogenic anatomic alteration, and can be treated in a community acute care hospital. CONCLUSION: Being aware of the possibility of obturator foramen herniation and bowel incarceration as part of the differential diagnosis for patients with abdominal pain after a prior hip disarticulation can facilitate prompt diagnosis and reduce morbidity and mortality.

First 101 Robotic General Surgery Cases in a Community Hospital.

BACKGROUND AND OBJECTIVES: The general surgeon's robotic learning curve may improve if the experience is classified into categories based on the complexity of the procedures in a small community hospital. The intraoperative time should decrease and the incidence of complications should be comparable to conventional laparoscopy. The learning curve of a single robotic general surgeon in a small community hospital using the da Vinci S platform was analyzed. METHODS: Measured parameters were operative time, console time, conversion rates, complications, surgical site infections (SSIs), surgical site occurrences (SSOs), length of stay, and patient demographics. RESULTS: Between March 2014 and August 2015, 101 robotic general surgery cases were performed by a single surgeon in a 266-bed community hospital, including laparoscopic cholecystectomies, inguinal hernia repairs; ventral, incisional, and umbilical hernia repairs; and colorectal, foregut, bariatric, and miscellaneous procedures. Ninety-nine of the cases were completed robotically. Seven patients were readmitted within 30 days. There were 8 complications (7.92%). There were no mortalities and all complications were resolved with good outcomes. The mean operative time was 233.0 minutes. The mean console operative time was 117.6 minutes. CONCLUSION: A robotic general surgery program can be safely implemented in a small community hospital with extensive training of the surgical team through basic robotic skills courses as well as supplemental educational experiences. Although the use of the robotic platform in general surgery could be limited to complex procedures such as foregut and colorectal surgery, it can also be safely used in a large variety of operations with results similar to those of conventional laparoscopy.

Emergency total proctocolectomy in an uninsured patient with Familial Adenomatous Polyposis Syndrome and acute lower gastrointestinal hemorrhage in a community hospital: A case report.

INTRODUCTION: Rectal bleeding is the most common symptom of Familial Adenomatous Polyposis (FAP). This case investigates the efficacy of emergency surgery for FAP with total proctocolectomy end ileostomy for recurrent lower gastrointestinal (GI) hemorrhage in an uninsured patient in a 266-bed community hospital. The optimal treatment for FAP with acute lower GI hemorrhage and hemodynamic compromise unresponsive to conservative management is unclear. PRESENTATION OF CASE: A 41-year-old uninsured African American man with no past medical or family history presented to the emergency department with hematochezia lasting three days. A clinical diagnosis of FAP made on colonoscopy with biopsies revealed villous and tubulovillous adenomas without dysplasia. After blood products resuscitation, an emergency total proctocolectomy with end ileostomy was performed. A staged ileal J pouch to anal anastomosis and creation of protective loop ileostomy was performed months later after securing state funding. A final loop ileostomy reversal occurred six weeks later. His self reported quality of life is improved. DISCUSSION: Lower GI hemorrhage from FAP unresponsive to blood products may require emergency total proctocolectomy and end ileostomy with a staged ileal J pouch to anal anastomosis, which can be done in a community acute care hospital for an uninsured patient. CONCLUSION: A total proctocolectomy is feasible in the emergency setting in an uninsured patient with lower GI bleeding and FAP. A staged ileal J pouch-anal anastomosis is easier to justify to the hospital compared to a staged completion colectomy with proctectomy. It is essential to monitor the ileo-anal anastomosis with anoscopy.

Achalasia: A case report on its effect during surgical decision making for laparoscopic sleeve gastrectomy in the young morbidly obese patient.

INTRODUCTION: Achalasia is a condition that occurs when the lower esophageal sphincter (LES) fails to properly relax, combined with slowing/failure of esophageal peristalsis. This is seen clinically by not allowing solids and liquids to pass easily into the stomach. Achalasia is not historically associated with morbid obesity, yet dual treatment of morbid obesity and achalasia is becoming more prominent due to the worldwide obesity epidemic. PRESENTATION OF CASE: Achalasia is typically a disease that affects non-obese adults over the age of 55, which makes the discussion of this case report unique in that our patient is a 23 year-old woman who successfully underwent per-oral endoscopic myotomy (POEM) in preparation for a future laparoscopic sleeve gastrectomy. There is sparse literature on combining laparoscopic Heller myotomy (LHM) and partial fundoplication versus POEM with either restrictive or malabsorptive minimally invasive bariatric procedures. DISCUSSION: LHM and partial fundoplication have long been considered the gold standard surgical treatment for achalasia by disrupting both the longitudinal and circular muscle layers of the LES. The newer, less invasive, POEM technique will be compared to the gold standard LHM and Dor fundoplication in this uncharacteristically young morbidly obese achalasia patient. The decision to pursue a laparoscopic sleeve gastrectomy over a laparoscopic Roux-en-Y gastric bypass was multifactorial due to the patient's concerns regarding malabsorption of vitamins and nutrients in the event of a future pregnancy. CONCLUSION: The patient has already undergone a POEM procedure, which was chosen to maintain the gastric fundus, cardia, and gastroesophageal junction (GEJ) architecture as opposed to a LHM with Dor fundoplication, which would have altered the anatomy, thus making a concomitant laparoscopic sleeve gastrectomy an unfeasible option.