Faculty Bibliography

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

BACKGROUND:Laparoscopic cholecystectomy is still fraught with bile duct injuries (BDI). A number of methods such as intra-operative cholangiography, use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS) have been suggested to ensure safer Laparoscopic cholecystectomy (LC).To these, we add posterior infundibular dissection as the initial operative maneuver during LC. Here, we report specific technical details of this approach developed over 30 years with no bile duct injuries and update our experience in 1402 LC. METHODS:In this manuscript, we present a detailed and illustrated description of a posterior infundibular dissection as the initial approach to laparoscopic cholecystectomy (LC). This technique developed after thirty years of experience with LC and have used it routinely over the past ten years with no bile duct injury. RESULTS:Between January of 2010 and December 2019, 1402 Laparoscopic cholecystectomies were performed using the posterior infundibular approach. Operations performed on elective basis constituted 80.3% (1122/1402) and 19.97% were emergent (280/1402). One intra-operative cholangiogram was performed after a posterior sectoral duct was identified. There was one conversion to open cholecystectomy due to bleeding. There were 4 bile leaks that were managed with endoscopic retrograde cholangio-pancreatography (ERCP). There were no bile duct injuries. CONCLUSION/CONCLUSIONS:Adopting an initial posterior mobilization of the gallbladder infundibulum lessens the need for medial and cephalad dissection to the node of Lund, allowing for a safer laparoscopic cholecystectomy. In fact the safety of the technique comes from the initial dissection of the lateral border of the infundibulum. The risk of BDI can be reduced to null as was our experience. This approach does not preclude the use of other intra-operative maneuvers or methods.

BACKGROUND:Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8 cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade. METHODS:Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded. RESULTS:Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3 days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction. CONCLUSION/CONCLUSIONS:Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.

Introduction: The preoperative workup for the bariatric patient varies from institution to institution and uncertainty exists in the literature as to the utility of certain aspects of the workup; such as routine esophagogastroduodenoscopy (EGD), screening adults and adolescence for obstructive sleep apnea (OSA), and management of asymptomatic cholelithiasis. In this submission we review the literature on controversial aspects of the bariatric preoperative workup, discuss the issues, and offer our institutional recommendations.
Method(s): PUBMED search terms: 'EGD bariatric surgery,' 'cholecystectomy bariatric surgery,' 'obstructive sleep apnea bariatric surgery'. 850 total articles were returned and 20 from each category were selected by the authors for their direct relevance to the preoperative workup before bariatric surgery.
Result(s): After a review of the literature, we recommend OSA screening of adult bariatric patients with an approved questionnaire and treatment with continuous positive airway pressure therapy (CPAP) for 30 days preoperatively and continuation postoperatively. We recommend against routine screening and treatment of adolescence for OSA. We recommend against synchronous cholecystectomy with bariatric procedures for asymptomatic cholelithiasis. We recommend for the use of ursodeoxycholic acid pre and postoperatively for cholelithiasis prophylaxis. We recommend for the use of preoperative EGD in mucosal altering procedures, such as the Roux-en-Y gastric bypass, gastric sleeve, or duodenal switch. We recommend against a routine EGD before the gastric banding. We recommend routine proton pump inhibitor (PPI) use preoperatively when symptomatic.
Conclusion(s): When current literature is equivocal, clinical decision making and institutional guidelines target the best preoperative workup for each bariatric patient. The recommendations for our preoperative workup and algorithm for testing is driven by our clinical experience and best interpretation of available data

Case Presentation: Patient is a 22 year old female with no significant past medical or surgical history presented to the emergency department with a 2 day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and PO intolerance. The pain started a few months prior, however it was self-limited with diet modifications. An ultrasound demonstrated a contracted gallbladder with a 15 mm gallbladder wall. White blood cell count was within normal limits and total bilirubin was slightly elevated to 1.8 mg/dL. No palpable mass was noted on physical exam. An MR cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring 11.5 x 2.5 cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. The patient proceeded with a laparoscopic cholecystectomy. Intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. The gallbladder was subsequently removed without any complications. Patient's remaining hospital course was uncomplicated. Surgical pathology returned demonstrating acute on chronic cholecystitis.
Discussion(s): Cholecystomegaly or 'Giant Gallbladder' disease is a rare pathology encountered in the surgical world. There have been few reported cases, most of which occurred in the elderly ([65 years). Kuznetsov et al. defined an enlarged gallbladder to have a volume of 200-300 cc and a giant gallbladder as exceeding 1500 cc (the average weight of the liver). The etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. Preoperative imaging, such as MR cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. Removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. The cause of cholecystomegaly still remains uncertain and warrants further research. The management and treatment remains similar to acute cholecystitis

Background: We present a case of a 33-year-old female that underwent a laparoscopic Roux-En-Y gastric bypass 5 months prior that subsequently developed a gastrojejunostomy stricture treated with endoscopic balloon dilation. Following her third balloon dilation she developed severe abdominal pain and was found to have free air on an upright abdominal x-ray. The patient was immediately brought to the operating room for a diagnostic laparoscopy which demonstrated an anterior perforation of the gastrojejunostomy anastomosis. The decision was made to revise the anastomosis by performing a stricturoplasty where the perforation was extended longitudinally and closed transversely with interrupted silk sutures to both repair the perforation and resolve the anastomotic stricture. The patient had an uncomplicated postoperative course. Gastrojejunostomy strictures are a common complication after laparoscopic Roux-En-Y gastric bypass. There are multiple factors that may lead to the formation of a stricture including marginal ulcers or technical error. Anastomotic strictures are often managed endoscopically with serial balloon dilations. However, if endoscopy fails to relieve the stricture, the patient may need to undergo a laparoscopic gastrojejunostomy revision, which can be morbid. Additionally, anastomotic perforation represents a surgical emergency that warrants immediate exploration. This case presents a unique situation where both situations are present and more conservative measures such as endoscopic stenting are not feasible. By performing a revision stricturoplasty, we attempted to repair the perforation as well as lengthen the anastomosis to relieve the stenotic area. [Figure presented]
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Introduction: Even though the benefits of bariatric surgery are clear, patients often become fatigued with a process that can take 4-6 months. This leads to high attrition rates. We surveyed bariatric patients to identify barriers and increase retention.
Method(s): A total of 208 patients who did not undergo definitive bariatric procedure were identified and surveyed for specific barriers to completion during a 1-year period from January 1st to December 31st. Patients were called and asked an open-ended question regarding barriers. The responses were recorded and analyzed by 1 faculty member.
Result(s): We identified 9 specific barriers to completion of bariatric surgery: 17.8% due to medical issues, 28.4% change of heart, 15.7% insurance/financial issues, 12% tedious process, 2.4% pregnant/trying, 2% relocated, 8.7% unhappy with surgeon, 12% lost weight without operation, 1% exceeded institutional weight limit. Among medical barriers, cardiac (21.6%) and acute illness or medical emergency (48.6%) were the 2 most common. A total of 28.4% were afraid of surgical complications or unsure of the efficacy of bariatric surgery, 12% felt the clearance process was too tedious and fatigued before completion, 5 patients became pregnant, 4 relocated, 8.7% were unhappy with surgeon, or office staff, and 12% lost weight without operation.
Conclusion(s): In order to break the barriers to bariatric surgery, our institution has increased prime-time educational sessions for patients and outreach for referring providers. We have also acquired a medical weight loss specialist for retention of patients with borderline BMIs, and we offer less invasive techniques for patients who are wary of surgery.
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In 2014 the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias". Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.