Faculty Bibliography

Introduction: Laparoscopic Roux-en-Y gastric bypass (RYGB) is a common and effective form of bariatric weight loss surgery. However, a subset of patients will fail to achieve the expected total body weight loss (TBWL) greater than 20% after 12 months or experience significant weight regain despite dietary, psychiatric, and behavioral counseling. Although alternative procedural interventions exist for operative revision after suboptimal RYGB weight loss, laparoscopic adjustable gastric banding (LAGB) provides an option with short operative time, low morbidity, and effective results. We have previously demonstrated that short-term (12-month), and mid-term (24-month) weight loss is achievable with LAGB for failed RYGB. The objective of this study is to report the long term 5 year outcomes of LAGB after RYGB failure. Methods and Procedures: A retrospective review of prospectively collected data before and after RYGB when available, and before and after revision with LAGB was performed. The data included weight, height, body mass index, gender, race, age, operative time, length of stay, postoperative complications, and percentage of total body weight loss. Results: A total of 182 patients (81.3% female, 18.7% male) were included in this study. The mean age of patients undergoing LAGB after RYGB was 47+/-9.98 years old. The majority of patients (98.4%) underwent gastric band placement laparoscopically, with 2 patients requiring conversion to an open procedure, and 1 planned open approach. The mean preoperative weight was 319+/-64 lbs and BMI of 53+/-10 kg/m² before RYGB. After RYGB, patients experienced a mean %TBWL of 16+/-11%, had a weight of 264+/-50 lbs, and a BMI of 43+/-7 kg/m² before undergoing LAGB an average of 9 years after their first bariatric procedure. At the time of 5 year follow up after LAGB the patients had a %TBWL of 35+/-13%, weight of 201.9+/-46 lbs, and had a BMI of 33+/-7 kg/m². The mean operative time was 73+/-34 minutes and 85% of patients had a hospital length of stay less than 24 hours. Conclusion: The results of our study have shown that LABG had good long term data as a revi-sionary procedure for weight loss failure after RYGB. Patients experienced a satisfactory amount of total body weight loss with reduction in BMI and had a short operative time and length of stay

Introduction: We aimed to create a morbidity prediction score for patients undergoing RYGB using MBSA-QIP data. Methods and Procedures: We retrospectively analyzed all RYGB cases in MBSA-QIP during 2015, and identified factors associated with 30-day complications using chi-squared analysis. Multiple logistic regression identified pre-operative factors independently associated with 30-day complication to develop a prediction score, verified using a Cochran Armitage trend test. Results: For 42,849 procedures, there were 3034 (7.1%) with any 30-day complication. Preoperative patient characteristics independently associated with increased risk of morbidity are shown in Table 1. A scoring algorithm was formulated by assigning points based on strength of the odds ratio (Table 1), with the final score a summation of points accrued. The rate of any 30-day complication was evaluated across the range of scores (Table 2). Higher scores were associated with a higher rate of morbidity (p<0.0001 for each). [Figure Presented] Conclusion: We created and verified a morbidity prediction score for patients undergoing RYGB based on MBSA-QIP data

Aim: The literature supports comparable safety profiles in regard to performing one vs. two stage revisional conversions of laparoscopic adjustable gastric bands to sleeve gastrectomies. In this discussion, we compare weight loss differences between one and two stage gastric band removal to sleeve gastrectomy procedures. The reasoning behind this discussion is the question: can an appropriately sized sleeve be created at the same time as gastric band removal (assuming scar tissue and tissue swelling), and can that sleeve permit adequate weight loss? Methods: This is a retrospective review of patients who underwent gastric band removal and subsequent sleeve gastrectomies between 2008 and 2016. We reviewed each patient's BMI at the time of the revisional sleeve gastrectomy and compared the BMI reduction (BMIR) and percentage total body weight loss (%BWL) after one year between patients undergoing a concurrent gastric band removal and sleeve gastrectomy vs. those undergoing a gastric band removal with an interval sleeve gastrectomy (3 or more months after band removal). Results: Between 2008 and 2016 there were 259 patients who underwent surgery converting a gastric band to a sleeve gastrectomy (191 one stage, 68 two stage). We compared the weight loss parameters for those following up at one year for both one stage and two stage conversions (104 one stage, 38 two stage). One stage conversions exhibited a 16.95% total body weight loss while two stage conversions exhibited a 17.95% total body weight loss (p=0.08). BMI reduction was also reviewed at one year showing 7.49 for one stage and 7.95 for two stage procedures (p=0.81). Conclusions: The safety of one vs. two stage laparoscopic adjustable gastric band conversion to sleeve gastrectomy has been supported in the literature. We demonstrate that there is no statistical difference in weight loss, after one year, between patients having their conversion at the same time (one stage) or in an interval manner (two stage). Therefore, there appears to be no weight loss benefit favoring a one vs. two stage procedure-thus leaving the choice up to surgeon's level of operative comfort and preference

Aims: Our institution implemented a Value-Based Medicine (VBM) clinical pathway to standardize the pre-, peri-, and post-operative management of longitudinal sleeve gastrectomy (LSG) patients. The goal of the program was to decrease patient length of stay (LOS) while maintaining the same clinical outcomes seen prior to initiation. Methods: The VBM pathway was instituted in September of 2014. A retrospective review was performed of all primary LSG cases from 2011-2015. Pre-VBM LSG patients were matched to post-VBM patients in a 1:1 ratio. Matching criteria were age within five years, body-mass index (BMI) within 5 kg/m, expected LOS within 0.5 days, same sex, and same status for prior abdominal surgery. Patients < 18 years of age, body mass index (BMI) < 35, and those with prior bariatric surgery were excluded from analysis. Primary outcomes were LOS, LOS > 2 days, operating room (OR) time, and cost per admission. Secondary outcomes included 30-day readmissions and reoperations. Results: There were 426 pre-VBM and 507 post-VBM patients. After matching for age, sex, BMI, expected LOS and previous abdominal surgery, there were 330 patients in each of the pre-VBM and post-VBM groups. There were no clinically significant demographic differences between the two groups. The post-VBM group had shorter mean OR time (75.1 vs 95.8 min, p<.0001), shorter LOS (1.50 vs 1.94 days, p<.0001), lower cost (median cost $792 less than pre-VBM group, p<.0001), and lower reoperation rate (0.0% vs 2.1%, p=.015). Readmission rate was lower in the post-VBM group, but did not reach statistical significance (2.7% vs 4.9%, p=.154). After controlling for hospital trends over time, LOS > 2 days (p=.008) and median cost (p=.019) remained significant. OR time (p=.058) and mean LOS (p=.338) still showed an improved trend, but could not be directly correlated to VBM implementation. Conclusions: Standardization of clinical care for LSG patients is feasible and effective. Patient length of stay and hospital cost were successfully decreased with no negative impact seen on 30-day post-operative outcomes

Introduction: Endoscopic stent placement after sleeve gastrectomy (LSG) leak is usually considered part of the treatment algorithm. We have experienced varying success with stents and have also seen patients who have difficulty tolerating the stent or who have experienced worsening leak with the stent. The purpose of this study is to review our experiences with these stents to contribute to the growing literature of the effectiveness in the management of sleeve leaks. Setting: Academic medical center. Methods: A retrospective review of all reported sleeve leaks between 2 high-volume bariatric surgery centers were reviewed. Data was collected on the presentation of these leaks as well as the entire post-operative course. Cases spanned from 2006 to 2016. Information was collected on clinical presentation, radiographic findings, endoscopic findings, stent placement, stent complications, re-intervention rate, and re-operation rate. Stent complications were defined as any persistent leak, PO intolerance, nausea/vomiting, radiographic evidence of migration, or abdominal pain that required either replacement/repositioning or removal of the stent. Results: 32 sleeve leaks were identified across our institutions. Two cases were excluded for lack of post-operative course data. 18 (60%) of 30 were treated at some point with an endoscopic stenting procedure. Complications that could be attributed directly to the stent were identified in 14 of the 18 cases (78%).The average number of interventions in the stent group was 3.7 compared to 0.75 in the no stent group (p<0.005).The average number of total admitted days was significantly higher in the stent group with 25.5 days versus 12.58 (p = 0.006). Conclusion: Patients who undergo stenting for the management of leak following a sleeve gastrectomy appear to require more interventions and have higher length of stay. Further studies are needed in order to better identify those patients who may benefit from endoscopic interventions and those who should be managed alternatively

Introduction: The impact of resident involvement on outcomes after bariatric procedures is not well understood. Prior studies have demonstrated increased complication rates with resident involvement in Roux-en-y gastric bypass (RYGB). These studies did not include data for laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric band (LAGB). At our institution, attending surgeons operate with both residents and physician assistants (PA) interchangeably, thus controlling for surgeon variability. Our objective was to demonstrate that resident involvement in complex bariatric surgeries does not increase complication rates when residents and PA's work with the same attending surgeons. Methods and Procedures: Patients undergoing bariatric procedures at our institution between 3/2012 and 3/2015 were identified using the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database. All patients under 18 years of age were excluded. Cases were stratified into four different categories- RYGB, LSG, LAGB, and LAGB revision (replacement, removal, or port revision). Data included patient demographics, comorbidities, length of stay, and 30-day complications. The primary outcomes of the study were operative time and 30-day overall complication rate. Secondary outcomes included length of stay, major complications and reoperation rates. Results: There were 2741 bariatric surgeries performed from 2012-2015. Of those, 2067 had resident involvement and 674 had PA involvement. 30-day complication rates for all surgery types, with and without residents, were 5.3 % and 6.1 %, respectively (p = .45). Complication rates for LSG (p = .716), LAGB (p = .694), LAGB revision (p = .493), and RYGB (p = .126) were also not significant. Operative duration for all surgery types was longer with residents (77.0 vs 60.6 min, p<.0001). Operative duration was longer with resident involvement for LSG (101.1 vs 76.6 min, p<.0001), LAGB (51.6 vs 42.4 min, p<.0001), and LAGB revision (63.0 vs 51.6 min, p = .007). After risk adjustment, OR time for RYGB was significantly longer as well (134.3 min vs 119.3 min, p = .038). Length of stay was also found to be significantly increased in the resident group (1.23 vs 1.09 days, p = .0007). Conclusion: Resident involvement as first assistant in the OR does not increase complication rates in bariatric surgery. Operative times and length of stay are prolonged, as shown in other studies, but no difference was seen in complication rates for cases involving a resident and cases involving a dedicated operative PA. Teaching advanced bariatric surgery techniques to residents is both safe and essential to their education

Aims: Laparoscopic Nissen fundoplication is the most commonly performed surgical procedure for severe gastroesophageal reflux. Recent studies, however, have shown the 180-degree anterior fundoplication to be equivalent in treating reflux and superior in treating dysphagia and gas-related symptoms. This video highlights the safe and effective laparoscopic revision of a Nissen to an anterior fundoplication for symptoms of obstructive dysphagia. Methods: A 56 y.o. male with refractory gastroesophageal reflux and a large hiatal hernia underwent an uncomplicated Nissen fundoplication with vagal preservation. After the operation, he developed symptoms of obstructive dysphagia, hiccups, and trapped air. Upper GI series demonstrated smooth narrowing of the gastroesophageal junction with delayed esophageal emptying and stasis. Endoscopic balloon dilation and medical therapy were unsuccessful and the symptoms persisted for over a year. The decision was made for reoperation to loosen the wrap. Intraoperatively, the Nissen fundoplication appeared to be in good position. The wrap was taken down and a portion of the fundus appeared damaged from the dissection and dense adhesions. The damaged fundus was resected with an Endo GIA linear stapler. An intraoperative methylene blue leak test did not identify any leaks. A 180-degree anterior fundoplication was performed to ensure suturing to healthy tissues. Operative time was 96 minutes and blood loss was 25cc. Results: The patient was discharged to home the same day and has had an uneventful recovery. At the 4-month follow-up, an upper GI series demonstrated normal appearance of the fundoplication, as well as normal esophageal emptying without delay or obstruction. The patient's dysphagia has improved and he has no reflux symptoms, but still has intermittent hiccups. Conclusion: In cases of severe dysphagia after Nissen fundoplication, laparoscopic conversion to a partial anterior fundoplication is a safe and feasible option. Complete takedown of the posterior wrap, recognition of normal anatomy, and avoidance of suturing to damaged tissues are essential components of this procedure

Aims: Gatstro-gastric fistula (GGF), a complication of roux-en-y gastric bypass (RYGB), has an occurrence rate of 1-2% and can result in weight regain, relapse of comorbidities, and marginal ulceration. Surgical management varies-revision of the bypass with concurrent remnant gastrectomy is often avoided for fear of complexity, while division of the fistula, remnant gastrectomy, and endoscopic repairs can result in recurrence of the GGF or marginal ulceration. Institutional data on GGF after RYGB and the step-by-step revision to an esophagojejunostomy are herein presented. Methods: This is a retrospective review of prospectively collected data at a single institution and video presentation. Results: Between 2005 and 2014, 13 patients presented with GGF after RYGB. The mean time to presentation was 4.4 years [range: 7 mos-16.4 years]. Surgical treatments included resection of GGF, remnant gastrectomy, and subtotal gastrectomy with either revision of gastrojejunostomy or esophagojejunostomy. Mean OR time was 191 minutes. Four patients required an additional reoperation for recurrent marginal ulcer (2), persistent GGF (1), and enterocutaneous fistula (1). Patients who underwent full resection of the gastric remnant and conversion to esophagojejunostomy did not develop postoperative complications. Video Presentation: A 47-year-old male s/p laparoscopic RYGB one year prior presented with 1 day of abdominal pain and was diagnosed with a GGF on CT scan. His weight loss was adequate and his BMI was 28.8. Marginal ulceration was presumed to be the source of his acute pain and the patient was taken to the OR for revisional surgery. Intraoperatively, the roux-limb and remnant stomach were divided. The GE junction was marked and divided proximally to the GGF and an endoscopic stapler created an end-to-side esophagojejunal anastomosis. The gastric remnant, gastrojejunostomy, and GGF were removed through the umbilical incision. Incidentally found internal and hiatal hernias were also repaired. Total operative time was 162 minutes. On 6 months follow-up the patient has no complications. Conclusion: Surgical treatment of GGF after RYGB should include revision to esophagojejunostomy with complete excision of the gastric remnant. In experienced hands, this operation is safe and effective and has a lower likelihood of recurrent GGF and marginal ulceration compared to other procedures

Aims: Although laparoscopic bariatric surgery is accepted as the most effective treatment for morbid obesity, some patients fail to lose weight, develop postoperative weight regain, or develop other complications. Revisional bariatric surgery can correct such complications. Our video highlights sleeve gastrectomy as a revisional procedure for failed laparoscopic adjustable gastric banding. Methods: This patient is a 36-year-old male with a BMI of 42 kg/m². Following a Lap- Band procedure three years ago, the patient failed to lose weight because dysphagia and reflux prevented him from tolerating Lap-Band adjustments. An upper GI series confirmed that the band was in good position. The decision was made to remove the Lap-Band and convert him to a sleeve gastrectomy. The operation began with lysis of adhesions and release of the gastrogastric plication, allowing removal of the band. The underlying pseudocapsule was excised in order to minimize the disparity in tissue thickness during stapling, as well as to relieve any constriction on the gastric tissue. The greater curvature of the stomach was mobilized proximally to the angle of His and distally to a point 2-3 cm proximal to the pylorus. A 40-French bougie was placed down to the duodenum and a longitudinal sleeve gastrectomy was performed with multiple firings of a linear stapler covered with bioabsorbable staple-line reinforcement material. The upper portion of the staple line was oversewn with omentum and the incisura was sutured down to the transverse mesocolon to prevent rotation. Operative time was 51 minutes and blood loss was 20 cc. Results: An esophagram on the first postoperative day demonstrated a normal sleeve gastrectomy without leak or obstruction. The patient was able to tolerate thin liquids, and was discharged home on the second postoperative day. Two months after surgery, the patient is doing well with no dysphagia or reflux and a current BMI of 38 kg/m². Conclusions: Laparoscopic sleeve gastrectomy is a safe and feasible solution for laparoscopic adjustable gastric band intolerance and failure of weight loss. The procedure can be safely performed in a single-stage with concurrent removal of the gastric band

Aims: Laparoscopic sleeve gastrectomy (LSG) is a commonly performed primary bariatric procedure. Although bariatric surgery is becoming increasingly recognized as an effective treatment option for diabetes, there remain concerns about the operative risks faced by diabetic patients. This study's Objective: was to determine the safety of bariatric surgery in the subset of diabetic patients who do not require insulin (NIDDM). Methods: Patients with a body mass index (BMI) = 35 kg/m2 who underwent LSG in 2012 in the ACS-NSQIP database were identified. Emergency cases were excluded from analysis. Data included patient demographics, comorbidity, hospital length of stay, and 30-day complications. The primary outcome was 30-day overall complication rate and secondary outcomes included major complications and reoperation rates. Chi-square, Fisher's exact, and two-sample t tests were used to evaluate differences between groups. Results: Of 6062 LSG performed in 2012, 4726 (83.4 %) were non-diabetic and 941 (16.6 %) were NIDDM. NIDDM were more likely to be male (28.9 % vs. 19.3 %, p<0.001), older (47.6 years vs. 42.5 years, p<0.001), and had a higher BMI (46.4 kg/m2 vs. 45.7 kg/m2, p = 0.027) when compared to non-diabetics. In addition to diabetes, NIDDM had a higher rate of COPD (2.8 % vs. 0.6 %, p<0.001). The NIDDM group had a slightly longer mean operative time, as well (101.1 vs. 96.9 minutes, p = 0.014). The overall 30-day complication rate did not differ between groups (6.5 % NIDDM vs. 5.6 % non-diabetic, p = 0.305). In sub-analyses of specific complications, NIDDM had a slightly higher rate of blood transfusions (1.8 % vs. 1.0 %, p = 0.037). Other postoperative complications, including wound infection, intraabdominal infection, sepsis, renal injury, urinary tract infection, postoperative myocardial infarction, cardiac arrest, deep vein thrombosis, reoperation, and readmission did not differ between groups. Conclusion: Laparoscopic sleeve gastrectomy is a safe procedure for non-insulin dependent diabetics with regards to early post-operative complications