Faculty Bibliography

BACKGROUND:Gastroparesis is a chronic disorder characterized by delayed gastric emptying without mechanical obstruction, significantly impacting patient quality of life. Management of refractory gastroparesis remains challenging, with both gastric electrical stimulation (GES) and prokinetic medications used as treatment options. This systematic review synthesizes the available evidence on GES clinical outcomes, the role of continued prokinetic therapy after GES, and indirect comparative data relevant to symptom management in adult patients with refractory gastroparesis. METHODS:A comprehensive systematic review was conducted following PRISMA guidelines. Multiple databases were searched for studies published between 2000 and 2011 focusing on GES for gastroparesis. This window was selected to capture the period from initial FDA Humanitarian Device Exemption approval of the Enterra system (2000) through publication of cohorts with mature, multi-year follow-up (up to 10 years), maximizing the durability evidence available for analysis. Inclusion criteria required adult patients with refractory gastroparesis, GES as primary intervention, symptom-related outcomes, and minimum 6-week follow-up. Eight studies met eligibility criteria with follow-up periods ranging from 6 weeks to 10 years. Quality assessment utilized the Newcastle-Ottawa Scale for cohort studies and Cochrane risk-of-bias tools for controlled trials. RESULTS:Gastric electrical stimulation (GES) demonstrated significant symptom improvement in patients with treatment-resistant gastroparesis. Controlled studies showed vomiting frequency reduction of 57% at 6 weeks, improving to 67.8% after one year (p < 0.001). Long-term data revealed ≥ 50% reduction in Total Symptom Scores in 58% of diabetic gastroparesis patients, 53% of post-surgical cases, and 48% of idiopathic gastroparesis patients (p < 0.05) (Fig. 3; Table 2). Combination therapy (GES plus prokinetics) yielded significantly better symptom scores (1.35) compared to GES alone (2.20, p = 0.02). Device-related infection requiring removal occurred in approximately 7% of cases. No direct head-to-head comparisons between GES and prokinetic medications alone were identified. CONCLUSION/CONCLUSIONS:GES provides substantial symptom relief for treatment-resistant gastroparesis, particularly in diabetic gastroparesis. Combination therapy with GES plus prokinetics appears superior to GES monotherapy. However, the absence of direct comparative studies limits definitive conclusions regarding relative effectiveness versus prokinetic medications alone. Future randomized controlled trials are needed to establish optimal treatment protocols and patient selection criteria along with the role of other surgical approaches. Planned next steps include direct comparisons of GES with pyloric-directed interventions - namely gastric per-oral endoscopic myotomy (G-POEM) and surgical pyloroplasty - to clarify the optimal positioning of GES within the contemporary treatment algorithm for refractory gastroparesis.

BACKGROUND:Robotic hiatal hernia repair (RHHR) has emerged as an innovative alternative to conventional laparoscopic techniques, offering potential advantages in visualization, dexterity, and ergonomics. However, predictors of revision surgery following RHHR remain incompletely understood. This systematic review investigates key surgical and patient factors associated with revision within 5 years following RHHR. METHODS:We systematically searched PubMed/MEDLINE, Embase, the Cochrane Library, and Web of Science from inception through July 2025 for studies reporting revision or recurrence after RHHR, following PRISMA 2020 guidance. Eligible studies enrolled adults undergoing primary RHHR (≥ 10 patients) and reported revision or recurrence with at least 12 months of follow-up. Two reviewers independently screened records and extracted data, with disagreements resolved by a third reviewer; methodological quality was appraised using the Newcastle-Ottawa Scale. Because of substantial clinical and methodological heterogeneity (variable hernia size criteria, fundoplication and crural closure techniques, outcome definitions, and follow-up duration), a formal quantitative meta-analysis was judged inappropriate; we therefore performed a structured descriptive synthesis with sample size-weighted pooled estimates where data permitted. RESULTS:), advanced age (> 70 years), and comorbidities (diabetes, chronic steroid use) showed inconsistent associations with revision risk, with only 6 of 14 cohorts performing multivariate analysis to control for confounding variables. CONCLUSION/CONCLUSIONS:Hernia size consistently emerges as the primary determinant of revision following RHHR, with larger hernias demonstrating substantially higher revision rates regardless of surgical approach. Based on available data, the 5-year revision rate for RHHR ranges from 0 to 5.7%, with an estimated weighted average of 3.2%. Technical considerations including mesh reinforcement and reconstruction methods remain incompletely understood due to significant reporting variations across studies. Patient-specific factors require further investigation through adequately powered prospective studies. Future research demands rigorous prospective designs with standardized documentation of surgical techniques, hernia characteristics, and patient profiles to better identify and stratify revision risk factors after RHHR. The development of consensus guidelines for reporting outcomes in hiatal hernia surgery would facilitate meaningful comparison across studies and improve our understanding of optimal surgical approaches.

BACKGROUND:Despite widespread use of Roux-en-Y gastric bypass (RYGB), there are no standardized limb lengths in the United States. METHODS:A multi-center retrospective cohort study was conducted from 2020 to 2023. Eligible patients who had undergone RYGB were divided into subgroups based on BP limb lengths: short (50-75 cm), intermediate (80-125 cm), and long (150-175 cm). Primary outcomes were total weight loss (TWL) and % TWL at 1 and 2 years. Secondary outcomes were post-operative BMI and % BMI change at 1 and 2 years, micronutrient deficiencies, hypothyroidism, acute kidney injury (AKI) requiring treatment, and remission in associated medical problems. Subgroups were compared using multivariate analysis. RESULTS:Two hundred twenty-eight patients received a long BP limb, 194 patients received an intermediate BP limb, while 152 patients received a short BP limb. Primary outcomes TWL and % TWL were significantly different between the groups at 1 year: TWL and % TWL were greater in patients with long BP limbs. The difference between the long and short BP limb groups increased at the 2-year mark. Patients who had long BP limbs had higher rates of DM remission (12.3% vs 11.9% 6.6%), HTN (8.8% vs 5.7% vs 7.9%), GERD symptoms (14.5% vs 9.8% vs 5.3%), and OSA (8.8% vs 7.7% vs 5.3%). Vitamin A deficiency rates were higher in the long BP limb group. CONCLUSIONS:The results suggest that longer BP limb lengths are conducive to TWL and overall treatment of obesity-related problems without severe rates of complications. Additional longer longitudinal studies are needed to assess the impact of long BP limbs on nutrition and weight loss in the long term.

Internal herniation through the foramen of Winslow (FoW) is a rare, life-threatening diagnosis. We present a case of intestinal obstruction due to herniation of the ileum, cecum, appendix, and ascending colon through the FoW. We reduced the herniation using a small colotomy and preserved the entirety of the bowel. We closed the FoW and colotomy and secured the bowel to the lateral abdominal wall by suture cecopexy. Due to the rarity of this pathology, the literature remains unclear about the benefits of prophylactic measures, hence, we recommend continued reporting of cases and research on prophylactic measures. Further, our own treatment strategy outlined in this report may provide further insight into the misdiagnosis and management of FoW hernias.

BACKGROUND:RYGB consists of the Roux limb (RL), the biliopancreatic limb (BPL), and the common channel (CC). There is no consensus on the optimal limb lengths. METHODS:Using a mouse model of RYGB, 30 diet-induced obese mice were divided into two groups with varying BPL and CC lengths: a standard BPL with a long CC (RYGB S) and a long BPL with a short CC (RYGB L). Additionally, 9 age-matched, lean control mice (LC) were also included in this study. RESULTS:RYGB S had limb lengths of RL = 17%, BPL = 24%, and CC = 59%. RYGB L had limb lengths of RL = 17%, BPL = 32%, and CC = 51%. RYGB S and RYGB L had 67% and 40% survival, respectively. Mortality in RYGB L included more instances where the cause of death was not apparent. RYGB L demonstrated greater weight loss, lower energy expenditure, and lower heart mass as compared to RYGB S. Both RYGB groups had lower epidydimal fat mass, spleen mass, and bone mineral density compared to LC. RYGB L had a lower heart mass than RYGB S and LC. While the relative abundance of Eubacterium was lower in RYGB L than in RYGB S, no other gut microbiota differences were observed. CONCLUSIONS:A longer BPL with a shorter CC induces greater weight loss but may lead to adverse effects, including lower heart mass, reduced bone density, and deaths with unclear causes.

PURPOSE/OBJECTIVE:Roux-en-Y gastric bypass (RYGB) leads to the improvement of many obesity-associated conditions. The degree to which post-operative macronutrient composition contributes to metabolic improvement after RYGB is understudied. METHODS:A mouse model of RYGB was used to examine the effects of diet on the post-operative outcomes of RYGB. Obese mice underwent either Sham or RYGB surgery and were administered either chow or HFD and then monitored for an additional 8 weeks. RESULTS:After RYGB, reductions to body weight, fat mass, and lean mass were similar regardless of diet. RYGB and HFD were independently detrimental to bone mineral density and plasma vitamin D levels. Independent of surgery, HFD accelerated hematopoietic stem and progenitor cell proliferation and differentiation and exhibited greater myeloid lineage commitment. Independent of diet, systemic iron deficiency was present after RYGB. In both Sham and RYGB groups, HFD increased energy expenditure. RYGB increased fecal energy loss, and HFD after RYGB increased fecal lipid content. RYGB lowered fasting glucose and liver glycogen levels but HFD had an opposing effect. Indices of insulin sensitivity improved independent of diet. HFD impaired improvements to dyslipidemia, NAFLD, and fibrosis. CONCLUSION/CONCLUSIONS:Post-operative diet plays a significant role in determining the degree to which RYGB reverses obesity-induced metabolic abnormalities such as hyperglycemia, dyslipidemia, and NAFLD. Diet composition may be targeted in order to assist in the treatment of post-RYGB bone mineral density loss and vitamin D deficiency as well as to reverse myeloid lineage commitment. HFD after RYGB continues to pose a significant multidimensional health risk.