Faculty Bibliography

Aims: Leaks after laparoscopic sleeve gastrectomy (LSG) often present after discharge from the hospital, making it difficult to diagnose leak in the early postoperative period. This study evaluates preoperative, intraoperative, and postoperative factors in their association with leaks after LSG. Methods: A retrospective case-controlled study of 1762 LSG from 2006-2014 was performed. All radiographically confirmed leaks were included. Controls were patients who underwent LSG without leak, selected using a 10:1 (control:study) case-match. Data included patient characteristics, intraoperative factors, and esophagram results. Clinical indicators including SIRS criteria (presence of = 2: temperature<36 degreeC or >38 degreeC, heart rate>90 bpm, respiratory rate>20 breaths/min,WBC>12,000 or <4,000) and self-reported pain score were collected on postoperative day (POD) 2 and at the time of leak, if applicable. Statistics included univariate analyses and multivariate logistic regression. Results: Of the 1762 LSG, 20 (1.1 %) leaks were compared with 200 case-matched controls. Three patients developed leak during their index admission (mean = 1.3 days, range = [1,2]), while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days (median = 15, range = [4,63]) postoperatively. Leaks were similar to controls in baseline characteristics; however, the leak group had fewer black patients (5 % vs. 17 %, p = 0.022). There were no differences in intraoperative characteristics including staple reinforcement, bougie size, leak test, or operativetime between groups. Contrast extravasation on routine postoperative esophagram was seen in only two (10 %) of the twenty patients with enteric leaks; other esophagram findings (e.g. delay, dilatation) did not differ between leaks and controls. Patients with both early and late leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent factors associated with leak included fever (p<0.0001), SIRS criteria (p = 0.0034), and pain score = 9 (p = 0.010). Conclusions: Contrast extravasation on routine postoperative esophagram may detect early leaks after LSG, but the vast majority of leaks have normal results and present days to weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study, and may be used as criteria to selectively obtain postoperative esophagrams after LSG

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: 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

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

BACKGROUND: Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG). METHODS: We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission. RESULTS: Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) >/=3 days (OR 2.54, CI = [1.19, 5.40]), intraoperative drain placement (OR 3.11, CI = [1.58, 6.13]), postoperative complications (OR 8.21, CI = [2.33, 28.97]), and pain at discharge (OR 8.49, CI = [2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR 72.4, CI = [15.8, 330.5]). CONCLUSIONS: The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

BACKGROUND: Adjustable gastric bands have undergone significant design changes since their introduction. Band diameter, balloon volume, and shape have been modified to create high balloon fill volumes but lower and more evenly distributed pressure on the upper stomach. There have been few comparative studies on complication rates with different band types. OBJECTIVES: To compare complication rates among different types of adjustable gastric bands at a single institution. SETTING: University-affiliated hospital, United States. METHODS: We performed a retrospective cohort study of adult patients with a body mass index>/=35.0 kg/m(2) who underwent laparoscopic adjustable gastric banding from January 1, 2001 to December 31, 2007 and were followed for at least 5 years. Primary outcomes of the analysis were complications requiring operative management at our institution within the first 5 years after initial band placement. Reoperative procedures included diagnostic laparoscopy, hiatal hernia repair, band repositioning, replacing the band, removing the band, and converting to another bariatric procedure. RESULTS: For this study, 2711 patients met the inclusion criteria-1827 (67.4%) women and 884 (32.6%) men. Bands initially implanted included first-generation bands, LAP-BAND 9.75 cm (24.0%), 10 cm (33.9%) and Vanguard (24.8%) and second-generation bands, AP standard (9.5%) and AP large (7.9%). Four hundred and eighty-five patients experienced complications requiring reoperation. The 5-year follow-up rate was 63.3%. In the first 5 postoperative years there were significantly fewer complications with second-generation bands (10.0% versus 19.5%, P<.0001). Smaller, older bands had the highest complication rates (LAP-BAND 9.75 cm, 28.2%) and complication rates decreased with each successive model. Rates of band removal were not different between first- and second-generation bands. The rate of multiple complications was low at 1.5%. CONCLUSION: First-generation bands are associated with higher complication rates. Our study found that complication rates decreased with each successive model. We can expect that future design modifications will continue improve the performance with the adjustable gastric band. (Surg Obes Relat Dis 2015;0:000-00.) (c) 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.

BACKGROUND: Short- and mid-term data on Roux-en-Y gastric bypass (RYGB) indicate sustained weight loss and improvement in co-morbidities. Few long-term studies exist, some of which are outdated, based on open procedures or different techniques. OBJECTIVES: To investigate long-term weight loss, co-morbidity remission, nutritional status, and complication rates among patients undergoing RYGB. SETTING: An academic, university hospital in the United States. METHODS: Between October 2000 and January 2004, patients who underwent RYGB>/=10 years before study onset were eligible for chart review, office visits, and telephone interviews. Revisional surgery was an endpoint, ceasing eligibility for study follow-up. Outcomes included weight loss measures and rates of co-morbidity remission, complications, and nutritional deficiencies. RESULTS: RYGB was performed in 328 patients with a mean preoperative body mass index of 47.5 kg/m2. Of 294 eligible patients, 134 (46%) were contacted for follow-up at>/=10 years (10+Year follow-up). Mean percentage excess weight loss (%EWL) was 58.9% at 10+Year. Higher %EWL was achieved by non-super-obese versus super-obese (61.3% versus 52.9%, P = .034). Blood pressure, lipid panel, and hemoglobin A1c improved significantly. At 10 years, remission of co-morbidities was 46% for hypertension and hyperlipidemia and 58% for diabetes mellitus. Thirty patients (9%) had revisional surgery for weight regain. Sixty-four patients (19.5%) had long-term complications requiring surgery. All-cause mortality was 2.7%. Nutritional deficiencies were seen in 87% of patients. CONCLUSIONS: Weight loss after RYGB appears to be significant and sustainable, especially in the non-super-obese. Co-morbidities are improved, with a substantial number in remission a decade later. Nutritional deficiencies are almost universal.

Intro: Laparoscopic adjustable gastric banding is well-known for its safety profile. However, band removal, especially for a device-related complication, may be more complex due to the scar tissue created by the band. The objective of this study is to review perioperative outcomes of patients requiring band removal for device-related complications. Methods: A retrospective review was conducted of all band removals over a 13 year period (2001-2014) for a device-related complication (e.g. slippage, erosion, gastric necrosis). Bands removed for weight loss failure or intolerance were excluded from this review. Perioperative complication, readmission and reoperation/re-intervention was defined according to the Metabolicand Bariatric Surgery Accreditation and Quality Improvement Program standards. Results: A total of 104 patients required band removal for a device-related complication. In the same time frame 7633 bands were implanted. The average age at band removal was 44 years old and the average BMI was 35.6. The most common reason was slip (42%) and erosion (28%). The 30-day complication rate from the removal was 26% (27/104) - most commonly pneumonia and perigastric abscess. The 30-day readmission rate and reoperation/ re-intervention rate were 15% and 10%, respectively. There was one mortality (1%) from septic shock secondary to erosion. There were no statistically significant differences in age (p = 0.452) or BMI (p = 0.523) between those who had a 30-daycomplication and those who did not. Conclusions: Band-related complications are rare. Band removal for device-related complication may be associated with significant morbidity