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

BACKGROUND:With obesity continuing as a global epidemic and therapeutic technologies advancing, several novel endoscopic and minimally invasive interventions will likely become available as treatment options. With improved technologies and different treatment strategies, as well as different patient populations being targeted, there will be greater application in the treatment armamentarium of specialists dedicated to treating obesity. We sought to review the existing technology and provide a review. METHODS:Literature review was carried out for endoscopic and minimally invasive devices. Some of these products are not FDA approved, so limited data are available in their review. RESULTS:A summary of the device and data currently available on weight loss and safety profile is provided. Several products are in clinical trials or will be soon. Some of the technology has limited data and companies will be submitting their results for FDA evaluation. CONCLUSIONS:The obesity epidemic and associated weight-related diseases represent a tremendous burden to health care practitioners. As such, a multi-modal and progressive approach, with data and outcomes examined, is likely the best and most comprehensive method to care for these patients. SAGES endorses the benefits of minimally invasive and endoscopic approaches in the treatment of obesity and its related co-morbidities.

BACKGROUND: Portomesenteric vein thrombosis (PMVT) has been increasingly reported after laparoscopic sleeve gastrectomy (LSG). Factor VIII (FVIII) is a plasma sialoglycoprotein that plays an essential role in hemostasis. There is increasing evidence that FVIII elevation constitutes a clinically important risk factor for venous thrombosis. OBJECTIVES: To report the prevalence of FVIII elevation as well as other clinical characteristics in a multicenter series of patients who developed PMVT after LSG. SETTING: University hospitals. METHODS: A retrospective review was conducted of all patients that developed PMVT after laparoscopic bariatric surgery from 2006 to 2016 at 6 high-volume bariatric surgery centers. RESULTS: Forty patients who developed PMVT postoperatively, all after LSG, were identified. During this timeframe, 25,569 laparoscopic bariatric surgery cases were performed, including 9749 LSG (PMVT incidence after LSG = .4%). Mean age and body mass index were 40 years (18-65) and 43.4 kg/m2 (35-59.7), respectively. Abdominal pain was the most common (98%) presenting symptom. Of patients, 92% had a hematologic abnormality identified, and of these, FVIII elevation was the most common (76%). The vast majority (90%) was successfully managed with therapeutic anticoagulation alone. A smaller number of patients required small bowel resection (n = 2) and surgical thrombectomy (n = 1). There were no mortalities. CONCLUSIONS: A high index of clinical suspicion and prompt diagnosis/treatment of PMVT usually leads to favorable outcomes. FVIII elevation was the most common (76%) hematologic abnormality identified in this patient cohort. Further studies are needed to determine the prevalence of FVIII elevation in patients seeking bariatric surgery.

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

The management of refractory gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy can be challenging. After conservative measures with medical management, dietary changes, and behavioral modification have failed, revision surgery can be considered. Preoperative evaluation should include radiographic and endoscopic studies to assess for any possible anatomic or functional etiologies. We present a case of a patient with refractory GERD after laparoscopic sleeve gastrectomy who was found to have a large sliding hiatal hernia. She was successfully treated with a hiatal hernia repair and conversion to roux-en-y gastric bypass

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

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: 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