Realización de procedimientos bariátricos por residentes de cirugía general. ¿Compromete la efectividad de la intervención y los resultados postoperatorios? / Surgical resident training program to perform laparoscopic bariatric procedures: Are safety and postoperative outcomes compromised?

Introducción: El objetivo de este estudio es evaluar los resultados de nuestro programa de formación de residentes para la realización de bypass gástrico laparoscópico en Y de Roux (BGLYR). Material y métodos: Estudio retrospectivo en el que se incluyeron pacientes a los que se les realizó un BGLYR en nuestro centro durante el período comprendido entre enero de 2014 y diciembre de 2018. Los residentes de cuarto año de nuestro centro realizaron progresivamente distintos pasos de la intervención siempre tutorizados por cirujanos bariátricos expertos (CBE). Se compararon los resultados obtenidos en las intervenciones en las que el residente ha realizado algún paso o la totalidad del BGLYR (grupo I), con aquellas realizadas en su totalidad por CBE (grupo II). Se analizaron datos demográficos de los pacientes, comorbilidades, resultados intraoperatorios, morbimortalidad postoperatoria y resultados al año de la intervención. Resultados: Se incluyeron 208 pacientes en el estudio, 67 en el grupo I y 141 en el grupo II. Ambos grupos fueron comparables. No se objetivaron diferencias significativas en el tiempo operatorio (166,45min en el grupo I vs. 156,69min en el grupo II; p=0,156). La conversión a cirugía abierta, la estancia hospitalaria y la morbilidad postoperatoria tampoco presentaron diferencias estadísticamente significativas. No hubo mortalidad durante este período. Los resultados tras el primer año fueron similares en ambos grupos. Conclusiones: La realización de distintos procedimientos del BGLYR por residentes es segura y no compromete la efectividad ni los resultados postoperatorios, siempre que se realice bajo la supervisión de un CBE. (AU)

Introduction: Laparoscopic bariatric procedures such as laparoscopic Roux-en-Y gastric bypass (LRYGB) are technically demanding and require a long learning curve. Little is known about whether surgical resident (SR) training programs to perform these procedures are safe and feasible. This study aims to evaluate the results of our SR training program to perform LRYGB. Methods: We designed a retrospective study including patients with LRYGB between January 2014 and December 2018, comparing SR results to experienced bariatric surgeons (EBS). In our country, SR have a five-year surgical formative period, and in the fourth year they are trained for 6 months in our bariatric surgery unit, from January to June. In the beginning, they perform different steps of this procedure, to finally complete an LRYGB. We collected demographic data, comorbidities, intraoperative outcomes, and postoperative complications and outcomes after a one-year follow-up. Results: Two hundred and eight patients were eligible for inclusion: 67 in group I (SR), and 141 in group II (EBS). Both groups were comparable. There was no statistically significant difference in operating time (166.45min in group I vs. 156.69min in group II; P=0.156). Conversion to open surgery, hospital stay, postoperative complications, and short-term outcomes had no significant differences between the two groups. There was no mortality registered during this period. Conclusion: Implementation of LRYGB stepwise learning as part of an SR training program is safe, and results are comparable to EBS, without loss of efficiency. Therefore, it is feasible to train SR in bariatric surgery under EBS supervision. (AU)

Postpyloric Balloon Occlusion to Increase Technical Success during Pediatric Percutaneous Gastrostomy/Gastrojejunostomy Tube Placement.

Gastric distension through insufflation is a key step in creating a safe percutaneous window during gastrostomy/gastrojejunostomy (G/GJ) placement; however, poor or incomplete gastric distention can occur, despite the use of glucagon, and lead to rapid egress of air from the stomach into the duodenum. This report describes the adjunctive technique using postpyloric balloon occlusion in 29 patients to maximize gastric insufflation during G/GJ tube placement after failure of conventional methods. Balloon occlusion was successful in salvaging 23 of 29 (79.3%) of G/GJ tube placements without any complications.

Metoclopramide Reduces Fluoroscopy and Procedure Time during Gastrojejunostomy Tube Placement: A Placebo-Controlled Trial.

PURPOSE: To determine whether a single 10-mg intravenous dose of the promotility agent metoclopramide reduces the fluoroscopy time, radiation dose, and procedure time required for gastrojejunostomy (GJ) tube placement. METHODS: This prospective, randomized, double-blind, placebo-controlled trial enrolled consecutive patients who underwent primary GJ tube placement at a single institution from April 10, 2018, to October 3, 2019. Exclusion criteria included age less than 18 years, inability to obtain consent, metoclopramide allergy or contraindication, and altered pyloric anatomy. Average fluoroscopy times, radiation doses, and procedure times were compared using t-tests. The full study protocol can be found at www.clinicaltrials.gov (NCT03331965). RESULTS: Of 110 participants randomized 1:1, 45 received metoclopramide and 51 received placebo and underwent GJ tube placement (38 females and 58 males; mean age, 55 ± 18 years). Demographics of the metoclopramide and placebo groups were similar. The fluoroscopy time required to advance a guide wire through the pylorus averaged 1.6 minutes (range, 0.3-10.1 minutes) in the metoclopramide group versus 4.1 minutes (range, 0.2-27.3 minutes) in the placebo group (P = .002). Total procedure fluoroscopy time averaged 5.8 minutes (range, 1.5-16.2 minutes) for the metoclopramide group versus 8.8 minutes (range, 2.8-29.7 minutes) for the placebo group (P = .002). Air kerma averaged 91 mGy (range, 13-354 mGy) for the metoclopramide group versus 130 mGy (range, 24-525 mGy) for the placebo group (P = .04). Total procedure time averaged 16.4 minutes (range, 8-51 minutes) for the metoclopramide group versus 19.9 minutes (range, 6-53 minutes) for the placebo group (P = .04). There were no drug-related adverse events and no significant differences in procedure-related complications. CONCLUSIONS: A single dose of metoclopramide reduced fluoroscopy time by 34%, radiation dose by 30%, and procedure time by 17% during GJ tube placement.

Jejuno-jejunal intussusception caused by a percutaneous endoscopic gastrojejunostomy tube in a pediatric patient: A case report.

RATIONALE: Although percutaneous endoscopic gastrojejunostomy (PEG-J) tubes are believed to reduce the side effect of aspiration, cautious catheter management is required. Intussusception is a serious complication of these tubes. PATIENT CONCERNS: A 7-year-old boy bedridden with hypoxic encephalopathy owing to drowning at the age of 1 year was admitted our hospital with urinary retention for 1 month. At the age of 4 years, a PEG-J tube was inserted. Concomitant with hyperaldosteronemia, an intestinal intussusception from the duodenum to the jejunum was observed via computed tomography (CT). The patient's condition worsened dramatically; gastrointestinal perforation was suspected, and laparotomy was performed. DIAGNOSIS: Jejuno-jejunal intussusception. INTERVENTIONS: Open surgery was performed to release the intussusception. By assessing the reduced intestinal tract, the intussusception starting from a 50 cm portion from the Treitz ligament had been extended to 100 cm from the Treitz ligament. The oral side jejunum was dilated. No evidence of intestinal perforation or strangulated ileus was observed, and the intussusception was manually remediable. OUTCOMES: Preoperative CT examination showed intussusception from the duodenum to the jejunum. Laparotomy showed intussusception on the anal side of the Treitz ligament. With regard to the CT findings associated with the progression of intussusception to the duodenal site, as a result of the telescope phenomenon extending to the duodenum due to the relaxation of the Treitz ligament through repeated intussusception, it was considered that CT examination revealed intussusception extending from the jejunum to the duodenum of oral side. After 3 postoperative weeks, the patient was finally able to return home. LESSONS: If the ileus is observed during the insertion of a PEG-J, clinicians should consider the possibility of intussusception even in the duodenum.

Percutaneous Gastrojejunostomy Catheter Placement Using a Slow-Leak Balloon through the Reconstructed Gastric Tube after Esophagectomy.

Twelve patients who had undergone esophageal reconstruction because of cancer and in whom conventional percutaneous radiologic or endoscopic gastrostomy was considered difficult are reported. These patients underwent placement of a percutaneous gastrojejunostomy catheter through the reconstructed gastric tube using a slow-leak balloon that had been developed for percutaneous transesophageal gastrotubing. Retrospective evaluation showed successful outcomes without severe complications in all patients. Eight (66.6%) were able to resume oral intake, which allowed gastrojejunostomy catheter withdrawal in 3 (25%). This technique is feasible with acceptable clinical outcomes for patients who have undergone gastric tube reconstruction after esophagectomy.

Further Development of Magnetic Compression for Gastrojejunostomy in Rabbits.

BACKGROUND: Technical improvement of gastrojejunostomy is critical in bariatric and metabolic surgery. In this study, a novel magnetic compression approach for gastrojejunostomy was evaluated. MATERIALS AND METHODS: Both cylindrical and rectangular magnets were used in rabbits, and the magnets were named according to their location. All the magnets were perorally introduced into the stomach. The position of the jejunal magnet was controlled by a connecting line. When the jejunal magnet spontaneously entered the jejunum, the gastric magnet was introduced into the stomach. An extracorporeal magnet was used to guide these two magnets together, and the magnet pair was left to create a side-to-side anastomosis. The state of the animals and extrusion time of the magnets were observed. The anastomoses were evaluated by burst pressure and histology. RESULTS: Gastrojejunostomy was successfully established in all animals. Cylindrical and rectangular magnets spontaneously entered the jejunum through the pylorus within 2.4 ± 0.5 and 6.0 ± 0.8 d, respectively (P < 0.01). The cylindrical and rectangular magnet pairs fell off within 15.3 ± 0.8 and 11.9 ± 1.1 d, respectively (P < 0.01). The burst pressures were statistically similar between the two types of magnets (P > 0.05). Histological examination showed sealed anastomoses with mild inflammation of the mucosa and fibrosis within the submucosa. CONCLUSIONS: The feasibility and efficacy of establishing gastrojejunostomy by guidewire introduction of magnets, which were guided together with an extracorporeal magnet, were confirmed in rabbits. In humans, with the clinical use of this procedure, surgery would be greatly simplified.

Comparison of Two Types of Liver Retractors in Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity.

BACKGROUND: Retraction of the left lobe of the liver is an important step in most bariatric surgical procedures. Bariatric patients may have enlarged, fatty livers and retraction can be complicated with injuries, haematoma, or necrosis. The aim of this study was to compare the effects of two standard liver retractors, Nathanson and PretzelFlex on patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: All consecutive patients undergoing LRYGB in our center from April 2017 to January 2019 were analysed. The type of retractor used was dependent on the surgeon's preference and the availability of instruments. Patients were divided into two groups, based on the type of liver retraction device used. Each group was assessed and compared for postoperative pain score, presence of nausea or vomiting, blood test results (liver function tests and C-reactive protein), and length of hospital stay. RESULTS: LRYGB was performed on 167 patients in which Nathanson was used in 93 patients and PretzelFlex in 74 patients. The duration of surgery was similar in both groups. Alanine transaminase (ALT) levels and C-reactive protein (CRP) were significantly higher in the group where Nathanson's retractor was used. The postoperative pain score and length of stay were also higher when Nathanson's retractor was used but it did not reach statistical significance. CONCLUSION: The PretzelFlex liver retractor causes significantly less measurable liver damage and is associated with less postoperative pain and nausea when compared with Nathanson's retractor.

Trocar site closure with a novel anchor-based (neoClose®) system versus standard suture closure: a prospective randomized controlled trial.

BACKGROUND: Patients with obesity have a higher risk of trocar site hernia. The objective of the present study was to compare a standard suture passer versus the neoClose® device for port site fascial closure in patients with obesity undergoing laparoscopic bariatric surgery. METHODS: This is a randomized, controlled trial with two parallel arms. Thirty five patients with BMI ≥ 35 kg/m2 and undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass were randomized to each group. Port site fascial closure for trocars ≥ 10 mm was performed with the neoClose® device in the study group and the standard suture passer in the control group. Primary outcomes were time required to complete closure and intensity of postoperative pain at the fascial closure sites. Secondary outcomes were intraabdominal needle depth and incidence of trocar site hernia. RESULTS: The use of the neoClose® device resulted in shorter closure times (20.2 vs 30.0 s, p = 0.0002), less pain (0.3 vs 0.9, p = 0.002) at port closure sites, and decreased needle depth (3.3 cm vs 5.2 cm, p < 0.0001) compared to the standard suture passer. There was no trocar site hernia at the one-year follow-up in either group. CONCLUSIONS: Use of the neoClose® device resulted in faster fascial closure times, decreased intraoperative needle depth, and decreased postoperative abdominal pain at 1 week as compared to the standard suture passer. These data need to be confirmed on larger cohorts of patients with longer follow-up.

Hybrid fluorescent magnetic gastrojejunostomy: an experimental feasibility study in the porcine model and human cadaver.

BACKGROUND: Laparoscopic gastrojejunostomies are time consuming and require a specific training. Alternatively, sutureless anastomosis can be achieved using endoscopically delivered magnetic rings. Our aim was to assess the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using a pair of magnets coated with a near-infrared fluorescent biocompatible polymeric material. METHODS: Five pigs (3 acute and 2 survival models) and one human anatomical specimen were included. In the survival models, the distal ring was inserted into the duodenum endoscopically, and it was fixed to a thread clipped to the gastric mucosa. Twenty-four hours later, a two-port laparoscopy was performed using a near-infrared (NIR) laparoscope. The magnet position in the jejunum was detected with the transluminal fluorescence of the dye. Magnetic interaction with the metallic tip of the laparoscopic grasper allowed to capture the ring and bring the bowel loop to the future anastomotic site on the gastric wall. The proximal magnet was inserted into the stomach endoscopically and released when magnetic interaction started, allowing for a precise connection with the distal ring. The animals were followed up for 12 days and underwent control endoscopies and radiograms. In the acute animals, the anastomotic procedure was repeated 24 times. Finally, the procedure was performed in the human anatomical specimen. RESULTS: There were no technical problems, and magnetic connection could be precisely directed at both the anterior and posterior gastric walls. No complications occurred during the survival period and the anastomoses were patent on day 5. Transluminal fluorescence enabled a rapid detection of the magnet. CONCLUSIONS: Hybrid-reduced port magnetic gastrojejunostomy using a pair of fluorescently coated magnetic rings was feasible, reproducible, and easy to perform in both porcine and cadaver models.

Effectiveness of different recruitment strategies in an RCT of a surgical device: experience from the Endobarrier trial.

Recruiting participants into clinical trials is notoriously difficult and poses the greatest challenge when planning any investigative study. Poor recruitment may not only have financial ramifications owing to increased time and resources being spent but could adversely influence the clinical impact of a study if it becomes underpowered. Herein, we present our own experience of recruiting into a nationally funded, multicentre, randomised controlled trial (RCT) of the Endobarrier versus standard medical therapy in obese patients with type 2diabetes. Despite these both being highly prevalent conditions, there were considerable barriers to the effectiveness of different recruitment strategies across each study site. Although recruitment from primary care proved extremely successful at one study site, this largely failed at another site prompting the implementation of multimodal recruitment strategies including a successful media campaign to ensure sufficient participants were enrolled and the study was adequately powered. From this experience, we propose where appropriate the early engagement and investment in media campaigns to enhance recruitment into clinical trials. Trial Registration: ISRCTN30845205.

ROUTINE USE OF V-LOCK® SUTURE FOR BARIATRIC ANASTOMOSIS IS SAFE: COMPARATIVE RESULTS FROM CONSECUTIVE CASE SERIES.

BACKGROUND: In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist. AIM: To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery. METHODS: Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared. RESULTS: All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05). CONCLUSION: The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.

[New endoluminal and surgical methods for the treatment of morbid obesity]. / Neue endoluminale und chirurgische Verfahren für die Behandlung der morbiden Adipositas.

New endoluminal and surgical methods for the treatment of morbid obesity Abstract. A number of endoluminal techniques to treat (morbid) obesity have been developed recently aiming at finding less invasive methods that may be more acceptable for patients. Through upper endoscopy changes are made to the gastro-intestinal tract. Welldesigned trials have to prove their effectiveness and safety. In the meantime they remain experimental and this has to be communicated to the patient. New operative techniques have also been developed. The One Anastomosis Gastric Bypass is a variation of the standard Roux-Y-Gastric Bypass. There is evidence supporting that it can also become an accepted standard bariatric procedure in Switzerland.

Simulation of gastric bypass effects on glucose metabolism and non-alcoholic fatty liver disease with the Sleeveballoon device.

BACKGROUND: Gastric bypass surgery is a very effective treatment of obesity and type 2 diabetes. However, very few eligible patients are offered surgery. Some patients also prefer less invasive approaches. We aimed to study the effects of the Sleeveballoon - a new device combining an intragastric balloon with a connecting sleeve, which covers the duodenal and proximal jejunal mucosa - on insulin sensitivity, glycemic control, body weight and body fat distribution. METHODS: We compared the effects of Sleeveballoon, Roux-en-Y Gastric-Bypass (RYGB) and sham-operation in 30 high-fat diet (HFD) fed Wistar rats. Whole body and hepatic insulin sensitivity and insulin signaling were studied. Transthoracic echocardiography was performed using a Vevo 2100 system (FUJIFILM VisualSonics Inc., Canada). Gastric emptying was measured using gastrografin. FINDINGS: Hepatic (P = .023) and whole-body (P = .011) insulin sensitivity improved in the Sleeveballoon and RYGB groups compared with sham-operated rats. Body weight reduced in both Sleeveballoon and RYGB groups in comparison to the sham-operated group (503.1 ±â€¯8.9 vs. 614.4 ±â€¯20.6 g, P = .006 and 490.0 ±â€¯17.7 vs. 614.4 ±â€¯20.6 g, P = .006, respectively). Ectopic fat deposition was drastically reduced while glycogen content was increased in both liver and skeletal muscle. Gastric emptying (T1/2) was longer (157.7 ±â€¯29.2 min, P = .007) in the Sleeveballoon than in sham-operated rats (97.1 ±â€¯26.3 min), but shorter in RYGB (3.5 ±â€¯1.1 min, P < .0001). Cardiac function was better in Sleeveballoon and RYGB versus sham-operated rats. INTERPRETATION: The Sleeveballoon reduces peripheral and hepatic insulin resistance, glycaemia, body weight and ectopic fat deposition to a similar level as RYGB, although the contribution of gastric emptying to blood glucose reduction is different.

Efficacy and Safety of Novel, Disposable Endoscopic Scissors in Patients with Roux-en-Y Gastric Bypass: a Single-Center Feasibility Study.

BACKGROUND: Retained suture material from primary Roux-en-Y gastric bypass or revisions may result in local inflammation, ulcer formation, and abdominal pain. The primary aim of this study was to evaluate the feasibility, efficacy, and safety of novel, disposable endoscopic scissors for suture removal. METHODS: This was a single-center, retrospective analysis of prospectively collected data from December 2016 to January 2019. Patients with history of Roux-en-Y gastric bypass and upper endoscopy utilizing this novel, disposable endoscopic scissors device were reviewed. Measured outcomes included endoscopy indication, technical success (as determined by ability to achieve adequate cut and suture removal), improvement in abdominal pain if present prior to procedure, and adverse events. RESULTS: Sixty-two patients were included in this analysis. Mean age was 54.69 ± 9.40 years. Eighty-eight percent of patients were female. Roux-en-Y gastric bypass occurred on average 142.43 ± 62.33 months prior to suture removal. Primary indications for endoscopy were evaluation of gastric pouch and gastrojejunal anastomosis for weight regain (37.10%) and abdominal pain (30.65%). Overall, technical success of these novel endoscopic scissors was 100% with a mean procedure duration of 23.00 ± 9.50 min. Symptom improvement post-suture removal occurred in approximately half of the patients (48.65%). Post-procedure bleeding was self-limited and occurred in 2 patients (3.23%). Two patients developed transient post-procedure abdominal pain. CONCLUSIONS: Novel, disposable endoscopic scissors appear to be highly effective and safe for removal of suture material with high technical success and minimal adverse events.

Conversion of Adjustable Gastric Banding to Adjustable Banded Roux-en-Y Gastric Bypass: Should We Leave the Band in Place?

OBJECTIVE: Laparoscopic adjustable gastric banding (LAGB) is rapidly becoming a deprecated bariatric procedure due to disappointing weight loss results and a high rate of band intolerance. Conversion to Roux-en-Y gastric bypass is a common revisional procedure after failed LAGB. The aim of this study was to evaluate the feasibility, safety, and risk profile of conversion to adjustable banded Roux-en-Y gastric bypass (ABRYGB). METHODS: A retrospective patient file review of all consecutive laparoscopic conversions of LAGB to ABRYGB 2008-2017. Pre/perioperative data, weight change, and long-/short-term complications were retrieved. RESULTS: Study population 98 patients. Mean BMI before revision was 40,15 kg/m2. Most revisional procedures were performed for band intolerance and/or weight regain or weight loss failure. All procedures were performed laparoscopically. During follow-up, 16 bands had to be removed due to one of the following reasons: infection, anastomotic leakage, anastomotic peptic perforation, adhesions around the anastomosis, internal hernia around the tubing, adhesions to the tubing, tubing failure, and erosion of the band. Three of those bands were replaced with a non-adjustable Silastic (Minimizer) ring. In total, issues with tubing requiring an intervention were found in 20 patients after conversion to ABRYGB. Seven revisional procedures had to be performed for symptomatic internal hernias not related to the tubing and incidental internal hernias were found in another 7 procedures. CONCLUSION: Although conversion of LAGB to ABRYGB is technically feasible, initially well-tolerated, and has good weight loss results, the number of additional procedures during follow-up is rather high, suggesting that leaving the band in place should not be advised.

A comparison of the da Vinci Xi vs. the da Vinci Si Surgical System for Roux-En-Y gastric bypass.

PURPOSE: The da Vinci Surgical System family remains the most widely used surgical robotic system for laparoscopy. Data about gastric bypass surgery with the Xi Surgical System are not available yet. We compared Roux-en-Y gastric bypass surgery performed at our institution with the da Vinci Xi and the da Vinci Si Surgical System. METHODS: All robotic gastric bypass procedures performed between January 2013 and September 2016 were analyzed retrospectively. Patient demographics and operative and postoperative outcomes up to 30 days were compared for the da Vinci Xi and Si Surgical System. Robotic costs per procedure were modeled including posts for a standard set of robotic instruments, capital investment, and yearly maintenance. RESULTS: One-hundred forty-four Xi Surgical System and 195 Si Surgical System procedures were identified. Mean age (p = 0.9), gender distribution (p = 0.8), BMI (p = 0.6), and ASA scores (p > 0.5) were similar in both cohorts. Operating room times were similar in both groups (219.4 ± 58.8 vs. 227.4 ± 60.5 min for Xi vs. Si, p = 0.22). Docking times were significantly longer with the Xi compared with the Si Surgical System (9 ± 4.8 vs. 5.8 ± 4 min, p < 0.0001). There was no difference in incidence of minor (13.9 vs. 10.3%, p = 0.3) and major complications (5.6 vs. 5.1%, p = 1 for Xi vs. Si). Costs were higher for the Xi Surgical System caused by higher capital investment and yearly maintenance. CONCLUSIONS: Roux-en-Y gastric bypass surgery can be safely performed with the Xi Surgical System, while drawbacks include longer docking times and higher costs.

Use of barbed sutures in robotic bariatric bypass surgery: a single-center case series.

BACKGROUND: Surgical robots are increasingly being used in bariatric surgery. While several studies describe the safety of using barbed sutures in laparoscopic gastric bypass surgery, no reports are available for robotic bariatric procedures. The aim of our article is to determine whether barbed sutures can be used safely in robotic Roux-en-Y bypass (RYGB) surgery. METHODS: This was a single-center, single-surgeon case series of RYGB procedures using the da Vinci® Xi Surgical System (Intuitive Surgery, Sunnyvale, CA, USA) in combination with the use of barbed sutures (Stratafix, Ethicon, Johnson & Johnson, Cincinnati, OH, USA). RESULTS: Fifty robotic proximal and distal RYGB surgeries were performed. A linear stapled, side-to-side gastrojejunostomy was carried out, whereby the enterotomy was completed with a running resorbable unidirectional barbed suture, Stratafix 2-0. In one case after robotic proximal RYGB, revision surgery was required due to omentum necrosis. Another patient was readmitted due to gastrointestinal bleeding from anastomosis. No anastomotic insufficiencies, no stenoses, or higher-grade complications according to Clavien-Dindo 4a-5 were found. CONCLUSIONS: We found that the use of self-fixing barbed sutures in robotic RYGB is safe. The self-fixing suture enables the robotic surgeon to perform a simple continuous suture without the need for recurrent retraction. Although we are the first to report this procedure, we had a low number of cases and no control group; thus, further studies with a higher level of evidence are required.

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Comparison of a Novel, Trocar-Free Internal Liver Retractor to Standard Liver Retraction in Bariatric Surgery.

INTRODUCTION: Adequate liver retraction is an essential step in bariatric surgery, with technical challenges due to an enlarged, fatty liver. Traditional methods utilize externally fixed, rigid retractors with inherent drawbacks including an extra incision, pain, scarring, and liver injury. Advancement of laparoscopic techniques for liver retraction methods has focused on simplicity, reproducibility, safety, and effective use to avoid patient comorbidity. Our study is a retrospective evaluation of the safety and efficacy of a totally internal, atraumatic bulldog liver retractor versus standard retraction in a large series of patients undergoing laparoscopic bariatric surgery. METHODS: A retrospective chart review was performed on all patients undergoing bariatric surgery from April 2010 to December 2017. Standard retraction was used in 108 subjects and a bulldog retractor system attached to the pars flaccida, and anterior abdominal wall was used in 483 subjects. Any operations with additional procedures, re-do operations, or missing data were excluded. RESULTS: Five hundred fifty-one procedures were included between 2010 and 2017. In unadjusted analysis, no significant differences were found in AST/ALT elevation, need for additional retraction, length of stay (LOS), or operative times between the bulldog and standard retraction. Adjustment for demographics and Roux-en-Y gastric bypass versus sleeve gastrectomy in a multivariable logistic regression model, the standard retractor showed higher odds of AST/ALT elevation post-op and higher odds of needing additional retraction compared with those of the bulldog retractor. DISCUSSIONS/CONCLUSION: The bulldog retractor system can be used safely and effectively to expose the gastroesophageal junction in morbidly obese patients with advancements on the customary approach.