Faculty Bibliography

BACKGROUND:Sleeve gastrectomy has become a gold standard in addressing medically refractory obesity. Robotic platforms are becoming more utilized, however, data on its cost-effectiveness compared to laparoscopy remain controversial (1-3). At NYU Langone Health, many of the bariatric surgeons adopted robotic surgery as part of their practices starting in 2021. We present a retrospective cost analysis of laparoscopic sleeve gastrectomy (LSG) vs. robotic sleeve gastrectomy (RSG) at New York University (NYU) Langone Health campuses. METHODS:All adult patients ages 18-65 who underwent LSG or RSG from 202 to 2023 at NYU Langone Health campuses (Manhattan, Long Island, and Brooklyn) were evaluated via electronic medical records and MBSAQIP 30-day follow-up data. Patients with prior bariatric surgery were excluded. Complication-related ICD-10/CPT codes are collected and readmission costs will be estimated from ICD codes using the lower limit of CMS transparent NYU standard charges (3). Direct charge data for surgery and length of stay cost data were also obtained. Statistical T-test and chi-squared analysis were used to compare groups. RESULTS:Direct operating cost data at NYU Health Campuses demonstrated RSG was associated with 4% higher total charges, due to higher OR charges, robotic-specific supplies, and more post-op ED visits. CONCLUSIONS:RSG was associated with higher overall hospital charges compared to LSG, though there are multiple contributing factors. More research is needed to identify cost saving measures. This study is retrospective in nature, and does not include indirect costs nor reimbursement. Direct operating costs, per contractual agreement with suppliers, are only given as percentages. Data are limited to 30-day follow-up.

OBJECTIVE:With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries. MATERIALS AND METHODS/METHODS:The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG). RESULTS:AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB. CONCLUSIONS:As revisional bariatric surgery becomes more common, the best approach depends on the patient's indication for surgery and preexisting anatomy.

UNLABELLED:This perspective piece aims to examine the impact of the growing utilization of robotic platforms in general and minimally invasive surgery on surgical trainee experience, skill level, and comfort in performing general surgical and minimally invasive procedures following completion of training. We review current literature and explore the application of robotic surgery to surgical training, where minimum case thresholds and breadth distribution are well defined, and where development of surgical technique is historically gained through delicate tissue handling with haptic feedback rather than relying on visual feedback alone. We call for careful consideration as to how best to incorporate robotics in surgical training in order to embrace technological advances without endangering the surgical proficiency of the surgeons of tomorrow. KEY MESSAGE/UNASSIGNED:The large-scale incorporation of robotics into general and minimally invasive surgical training is something that most, if not all, trainees must grapple with in today's world, and the proportion of robotics is increasing. This shift may significantly negatively affect trainees in terms of surgical skill upon completion of training and must be approached with an appropriate degree of concern and thoughtfulness so as to protect the surgeons of tomorrow.

Background and Objective: With the advent of minimally invasive approaches, coronary artery bypass grafting (CABG) surgery has evolved to maintain good outcomes and improve patient experience. The increased use of robotic and hybrid platforms in cardiac surgery has allowed for smaller incisions, quicker recovery times, while maintaining acceptable outcomes. While minimally invasive techniques are growing in popularity, sternotomy remains the most common means of exposure. The following manuscript explores the opportunities that mini thoracotomy, robotic surgery, and hybrid coronary revascularization (HCR) provide to the modern cardiac surgeon. Methods: A comprehensive search strategy was constructed on minimally invasive approaches for CABG. All resulting articles were manually screened and selected for chapter review. Key Content and Findings: The chapter reviews the data on CABG via mini-Thoracotomy incision, robotic CABG, and HCR. It also discusses patient selection and cost analysis. With careful patient selection, minimally invasive approaches to CABG can provide equivalent or better outcomes to standard open CABG. Some limitations to the growth in its popularity may be the need for a higher patient volume in order for hospitals to justify investing in robotic technology. However, with equivalent survival outcomes and better patient recovery, minimally invasive CABG is the future of surgical treatment of coronary artery disease. Conclusions: Through smaller incisions and robotic platforms, minimally invasive CABG is a safe and effective option for cardiac surgery patients. Future research is required into how best to finance minimally invasive surgery (MIS) CABG modalities in order to make it more readily available to the general public.

Background and Objective: The use of robot technology has greatly expanded the field of general surgery. While robot technology has become almost standard for many general surgeons, there is an increasing interest in how this same technology may be utilized within more specialized fields. We sought to explore the advances and current uses of robot technology within the field of vascular surgery. We evaluated this topic broadly in the context of both the open and endovascular approach. Methods: A comprehensive literature search was employed using the following search strategy on PubMed: ("Robotic Surgical Procedures"[Mesh]) AND ("Vascular Surgical Procedures"[Mesh]). A total of 381 articles were identified. No filters were applied. All articles were then screened manually for applicability. Articles relating to cardiothoracic and neurosurgery were excluded (n=366), as the authors were most interested in performing this literature review from the focus of the vascular surgeon, and procedures involving the heart and brain are outside his or her scope of practice. The remaining (n=15) articles were then utilized to provide a synopsis of the advances made in robotic-assisted procedures within the field of vascular surgery. Key Content and Findings: Robot technology is currently being utilized by vascular surgeons to assist in both open and endovascular procedures. Some typical open procedures wherein the robot has shown to be most effective are in complex aortic reconstruction, first rib resection, venous thrombectomy and venous reconstruction following oncologic resection. In addition to open procedures, there is also evidence that robot technology may offer some benefits in purely endovascular ones, such as in inferior vena cava (IVC) filter retrieval and in standard angiograms. Conclusions: This work highlights that robot technology is greatly expanding the field of vascular surgery. In addition to offering a less invasive approach for both major and minor procedures, robot technology has also led to significant increases in team members"™ safety by decreasing radiation exposure. This review will hopefully act as a catalyst to further expand the use of robot technology in vascular procedures, and by effect increase the value that the vascular surgeon brings to the health care system.

BACKGROUND:New York University Langone Health has three accredited bariatric centers, with 10 different bariatric surgeons. This retrospective analysis compares surgeon techniques in laparoscopic or robotic sleeve gastrectomy (SG) to identify associations with perioperative morbidity and mortality. METHODS:All adults who underwent SG between 2017 and 2021 at NYU Langone Health were evaluated via EMR and MBSAQIP 30-day data. We also surveyed all 10 bariatric surgeons and compared their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression. RESULTS:86 (2.77%) out of 3,104 patients who underwent SG encountered an adverse event. Lower adverse outcomes were observed with a laparoscopic approach, 40-Fr bougie, buttressing, not oversewing the staple line, using hemostatic agents, stapling 3-cm from pylorus, and no routine UGI series. Lower bleeding rates were observed in a laparoscopic approach, 40-Fr bougie, buttressing, not oversewing the staple line, using hemostatic agents, stapling 3-cm from pylorus, no routine UGI series, and not proceeding with SG if hiatal hernia is present. Lower SSI rates were observed with ViSiGi™ bougie, no hemostatic agents, and routine EGD. Lower readmission rates were observed with 40-Fr bougie, buttressing, not oversewing, and stapling 3-cm from pylorus. Hemostatic agents had higher reoperation rates. It was not feasible to test for mortality given the low incidence. CONCLUSION:Certain surgical techniques in SG among our bariatric surgeons had a significant effect on the rates of adverse outcomes, bleeding, readmission, reoperation, and SSI. Our findings warrant further investigation into these techniques via multivariate regression or prospective design. LIMITATIONS:This study was limited by its retrospective and univariate design. We did not account for interaction. The sample size was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.

BACKGROUND:New York University Langone Health has three accredited bariatric centers, with altogether ten different bariatric surgeons. This retrospective analysis compares individual surgeon techniques in laparoscopic or robotic Roux-en-Y gastric bypass (RYGB) to identify potential associations with perioperative morbidity and mortality. METHODS:All adult patients who underwent RYGB between 2017 and 2021 at NYU Langone Health campuses were evaluated via electronic medical records and MBSAQIP 30-day follow-up data. We surveyed all ten practicing bariatric surgeons to analyze the relationship between their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression. RESULTS:54 (7.59%) out of 711 patients who underwent laparoscopic or robotic RYGB encountered an adverse outcome. Lower adverse outcomes were observed with laparoscopic approach, creating the JJ anastomosis first, flat positioning, division of the mesentery, Covidien™ laparoscopic staplers, gold staples, unidirectional JJ anastomosis, hand-sewn common enterotomy, 100-cm Roux limb, 50-cm biliopancreatic limb, and routine EGD. Lower bleeding rates were observed with flat positioning, gold staples, hand-sewn common enterotomy, 50-cm biliopancreatic limb, and routine EGD. Lower readmission rates were observed in laparoscopic, flat positioning, Covidien™ staplers, unidirectional JJ anastomosis, and hand-sewn common enterotomy. Gold staples had lower reoperation rates. Otherwise, there was no statistically significant difference in SSI. CONCLUSION/CONCLUSIONS:Certain surgical techniques in RYGB within our bariatric surgery group had significant effects on the rates of total adverse outcomes, bleeding, readmission, and reoperation. Our findings warrant further investigation into the aforementioned techniques via multivariate regression models or prospective study design. LIMITATIONS/CONCLUSIONS:This study was limited by the inherent nature of its retrospective and univariate statistical design. We did not account for the interaction between techniques. The sample size of surgeons was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.

BACKGROUND:Many insurance companies mandate medically supervised weight loss programs (MSWLPs) prior to bariatric surgery. This retrospective study aims to elucidate whether the average 6-month preoperative medical-management period decreases preoperative BMI for those with BMI ≥ 50. METHODS:All adult patients with bariatric consultation at any time at the New York University Langone Health campuses during the period 2015 to 2021 were evaluated via electronic medical records. Only patients with ≥ BMI 50, without previous bariatric surgeries, and those with 6-month insurance-mandated medical visits were included. A paired t-test was performed on the difference in BMI and percent-weight loss among the subjects at least 6 months before surgery and on the day of surgery. RESULTS:Of the 130 patients with BMI ≥ 50, undergoing preoperative 6-month office weigh-ins, the mean difference in BMI was - 1.51 (P < 0.01). The mean total body weight loss was 4.8% (P < 0.01). There were no intraoperative complications nor 30-day complications or mortality in the group. CONCLUSIONS:We found that there was weight loss during the 6-month insurance-mandated medical management prior to surgery, but the amount (4.8%) did not reach the goal target of 10% of body weight. We found that there were no complications and question the need for prolonged delay to surgery.

Techniques for laparoscopic Roux-en-Y gastric bypass vary in the creation of the jejuno-jejunostomy and the gastro-jejunostomy. Here we share the principles of the key steps in our long experience with this procedure and the evolution to its present-day form. First, patient positioning involves supine position without the need for steep reverse Trendelenburg. In conjunction, subcostal port placements play a critical role for exposure, including one for liver retraction using a grasper holding the diaphragm from the subxiphoid port to give adequate exposure. In case of poor visualization due to size of the liver, mobilization of the left lateral segment of the liver allows work to be done anterior to it. Second, starting with the creation of the jejuno-jejunostomy allows for freedom of movements and fluid creation of the anastomosis. Critical to this step is no division of the mesentery, to reduce risk of internal hernia. No stay sutures are needed. Common enterotomy is closed in a single layer hand-sewn anastomosis. Mesentery is closed with interrupted sutures with the inclusion of the "Brolin stitch" to prevent intussusception. Third, the G-J anastomosis has evolved in the past 20 years, starting with the laparoscopic retrocolic retrogastric anastomosis with the EEA 21 mm with a short biliary limb in 1997. Between 2000-2001, the technique shifted to retrocolic retrogastric side-to-side anastomosis with the GIA and handsewn entero-enterostomy (with a longer biliary limb of 100 cm). Since 2004, the technique now involves antecolic antegastric single-layer handsewn anastomosis without any division of mesentery. Vagus nerve is left intact during dissection and pouch creation. With 857 cases using this current technique, there has been 1 anastomotic leak, 1 leak from pouch due to infected hematoma, 1 internal hernia, 16 marginal ulcers (1.87%), 1 mortality, and 1 aborted case

Introduction: Many insurance companies mandate a minimum of a 6-month preoperative medical intervention prior to bariatric surgery. It has been conventional experience that this does not make a difference in BMI prior to surgery. This cross-sectional study is an effort towards elucidating whether or not a 6-month preoperative medical intervention makes any difference in preoperative BMI.
Method(s): All adult patients with bariatric consultation at any time at the New York University Langone Health campuses during the period 2015 to 2021 were evaluated via electronic medical records. Only patients with>BMI 50 on initial visit and those without previous bariatric surgeries at other institutions were included. Along with BMI and weight, baseline characteristics were obtained during this perioperative period. A paired t-test was performed on the difference in BMI and percent-weight loss among the subjects at least 6 months before surgery and the same subjects right before surgery. Additionally, sub-group analysis was performed on those that had>5% weight loss.
Result(s): Of the 130 super-morbidly obese patients undergoing preoperative medical intervention, by the time of surgery there was a statistically significant mean difference in BMI of-1.51, standard deviation 3.26 with a p-value of<0.01. There was also a statistically significant mean difference in percent-weight loss of 0.048, standard deviation 0.11 with a p-value of<0.01. Furthermore, there were no observed intraoperative complications nor 30-day mortality.
Conclusion(s): We found that BMI and percent-weight loss is present and is statistically significant, but these small differences have little clinical significance given that the goal target of medical preoperative weight-loss is typically 5-10% body weight. This study provides additional data to suggest that mandatory preoperative medical interventions in the super morbidly obese may make no difference in BMI nor operative outcomes, and warrants further study in the form of cohort design