Faculty Bibliography

INTRODUCTION/BACKGROUND:GLP-1 receptor agonists (GLP1-RAs) are increasingly prescribed as an alternative to bariatric surgery for weight loss, and may pose as an alternative to conversion Roux-En-Y Gastric Bypass (cRYGB) in patients with insufficient weight loss or weight recurrence after sleeve gastrectomy [A C, N C, A I. Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: a systematic review and network meta-analysis. International Journal of Surgery; 2022;Jensen et al. in Obes Surg 33:1017-1025, 2023; Jamal et al. in Obes Surg 34:1324-1332, 2024; Lautenbach A, Wernecke M, Stoll FD, Meyhöfer SM, Meyhöfer S, Aberel J. 1422-P: The potential of semaglutide once-weekly in patients without Type 2 Diabetes with weight regain or insufficient weight loss after bariatric surgery. Diabetes 2022; 71(Supplement_1);]. METHODS AND PROCEDURES/METHODS:Adult patients ≥ 18 years old, who previously underwent a sleeve gastrectomy and were subsequently treated with weekly injectable Semaglutide or Tirzepatide, or treated with conversion from sleeve gastrectomy were included for analysis. Patients converted for GERD, GLP1-RA use with BMI ≤ 35, or pre operative GLP1-RA use were excluded. Post operative weights and Hgb A1C were assessed from 3 months to 3 years post intervention (start of GLP1-RA or surgery). T-test, ANOVA, and chi-squared analysis were used to compare groups, while multivariable linear regression analysis was used to evaluate the effect of bariatric surgery on %TBWL at 3 years post intervention when adjusting for baseline characteristics. RESULTS:4901 patients were included for analysis (3004 cRYGB, 1897 GLP1-RA). There was no difference in pre-intervention weight (242.8 ± 44.4 GLP1-RA vs 242.3 ± 57.8 cRYGB, p = .993). cRYGB patients had a higher baseline Hgba1c (6.19 ± 1.4 vs 5.85 ± 1.2, p < 0.001). cRYGB was associated with significantly greater weight loss at all post operative time points up to 3 years post intervention, (26.1 vs 13.7%, p < 0.001). There was no significant difference in Hgba1c control between treatments at all post intervention time points (all p > 0.05). In the multivariate linear regression analysis, when adjusting for sex, baseline BMI, baseline age, and non-white race, cRYGB was associated with an 11% greater %TBWL compared to those who were treated with a GLP1-RA. CONCLUSIONS:For patients who have had insufficient weight loss or weight recurrence following sleeve gastrectomy, conversion to RYGB offers greater, long-term weight loss compared to GLP1-RAs.

INTRODUCTION/BACKGROUND:Robotic sleeve gastrectomy (RSG) is increasingly used in bariatric surgery, but its safety compared to laparoscopic sleeve gastrectomy (LSG) remains debated. METHODS:We retrospectively reviewed electronic medical records of 927 (575 RSG, 352 LSG) patients at a single academic center from June 2021 to August 2023. The baseline and operative characteristics of the study groups were compared using two-sample t tests, Wilcoxon rank-sum tests, chi-square tests, and Fisher's exact tests. Thirty-day complication rates were compared using multiple logistic regression, adjusted for baseline factors, operative characteristics, ASA class, and staple-line reinforcement. Statistical analysis was conducted using SAS 9.4, and p-values < 0.05 were considered significant. Logistic regression was used to evaluate whether complication rates were different between RSG and LSG while adjusting for other factors. RESULTS:(RSG 43, LSG 43.12, p = 0.806), average age 39.8 (RSG 39.3, LSG 40.7, p = 0.084), and 74% were females (RSG 75%, LSG 69.8%, p = 0.032). Baseline characteristics were comparable between the two groups. Median operative time was 73 min for RSG vs 66 min for LSF (p = 0.0002). Thirty-day complication rates were 3.5% in both groups (adjusted OR = 1.00, 95% CI 0.43-2.35, p = 0.998). Quarterly analysis and CUSUM demonstrated no residual learning-curve effect on complications. Power analysis confirmed ≥ 80% power to detect a ≥ 5% absolute difference. Missing-data sensitivity analyses corroborated primary findings. CONCLUSIONS:RSG is as safe as LSG within 30 days, with a modest 7-min operative-time penalty that is unlikely to be clinically meaningful.

BACKGROUND:Globally, many surgeons perform varying revisional procedures to convert either a primary sleeve gastrectomy (SG) or laparoscopic adjustable gastric band (LAGB) for the management of recurrent weight gain. There is no consensus on efficacious revision surgery in terms of long-term weight loss and comorbidity management. Nationally, the most common revision procedure is to a Roux-en-Y gastric bypass (RYGB). Internationally, there are other options in frequent use. This includes the one-anastomosis gastric bypass (OAGB). Both RYGB and OAGB have different potential complications and issues but have been very successful in many patients. OBJECTIVES/OBJECTIVE:To assess OAGB and RYGB as revision surgery, differences in weight loss, and nutritional status at approximately 1 year. SETTING/METHODS:Single university hospital system. METHODS:Patients who underwent OAGB as a revision of SG or LAGB were case matched by age, sex, and primary bariatric procedure to patients who underwent RYGB during January 2019 to October 2022. RESULTS:This study looked at 113 patients with either a primary SG or LAGB. Fifty-eight patients were converted to OAGB, and 55 patients were converted to RYGB. The OAGB cohort had a greater total body weight loss compared with the RYGB. There were no significant differences in postoperative nutritional values between the groups, except for decreased vitamin B12 levels in the RYGB cohort. CONCLUSION/CONCLUSIONS:Patients who underwent conversion from either SG or LAGB to OAGB experienced a greater TBWL at 1-year postoperatively compared with those who underwent conversion to RYGB, without difference in nutritional deficiencies.

BACKGROUND:Sleeve gastrectomy has become a gold standard in addressing medically refractory obesity. Robotic platforms are becoming more utilized, however, data on its cost-effectiveness compared to laparoscopy remain controversial (1-3). At NYU Langone Health, many of the bariatric surgeons adopted robotic surgery as part of their practices starting in 2021. We present a retrospective cost analysis of laparoscopic sleeve gastrectomy (LSG) vs. robotic sleeve gastrectomy (RSG) at New York University (NYU) Langone Health campuses. METHODS:All adult patients ages 18-65 who underwent LSG or RSG from 202 to 2023 at NYU Langone Health campuses (Manhattan, Long Island, and Brooklyn) were evaluated via electronic medical records and MBSAQIP 30-day follow-up data. Patients with prior bariatric surgery were excluded. Complication-related ICD-10/CPT codes are collected and readmission costs will be estimated from ICD codes using the lower limit of CMS transparent NYU standard charges (3). Direct charge data for surgery and length of stay cost data were also obtained. Statistical T-test and chi-squared analysis were used to compare groups. RESULTS:Direct operating cost data at NYU Health Campuses demonstrated RSG was associated with 4% higher total charges, due to higher OR charges, robotic-specific supplies, and more post-op ED visits. CONCLUSIONS:RSG was associated with higher overall hospital charges compared to LSG, though there are multiple contributing factors. More research is needed to identify cost saving measures. This study is retrospective in nature, and does not include indirect costs nor reimbursement. Direct operating costs, per contractual agreement with suppliers, are only given as percentages. Data are limited to 30-day follow-up.

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.

BACKGROUND:Post-herniorrhaphy pain is common with an estimated 8-10% incidence of mesh-related complications, requiring mesh explantation in up to 6% of cases, most commonly after inguinal hernia repairs. Reoperation for mesh explantation poses a surgical challenge due to adhesions, scarring and mesh incorporation to the surrounding tissues. Robotic technology provides a versatile platform for enhanced exposure to tackle these complex cases. We aim to share our experience with a novel robotic approach to address these complex cases. METHODS:A descriptive, retrospective analysis of patients undergoing a robotic mesh explantation (RoME) for mesh-related chronic pain, or recurrent ventral hernia by two surgeons between the period of March 2016 and January of 2020. The patients were evaluated for resolution of mesh related abdominal pain as well as early post-operative complications. RoME was performed with concomitant hernia repair in cases of recurrences. RESULTS:Twenty-nine patients underwent a robotic mesh explantation (RoME) for mesh-related chronic pain, or recurrent ventral hernia between March 2016 and January of 2020. Nineteen patients (65.5%) had a prior inguinal hernia repair and 10 patients (34.5%) had a prior ventral hernia repair. Indications for mesh removal included chronic pain with or without hernia recurrence. Seventeen patients (58.6%) reported improvement or resolution of pain postoperatively (63% with a prior inguinal hernia repair and 50% of patients with a prior ventral hernia repair). Five patients (17.2%) required mesh reinforcement after explantation. Nineteen patients (65.5%) underwent mesh explantation with primary fascial closure or no mesh reinforcement. The mean follow-up was 36.4 days. The most common postoperative complication was seroma formation (6.8%), with one reported recurrence (3.4%). CONCLUSION/CONCLUSIONS:Robotic mesh explantation in challenging cases due to the effect of chronic scarring, adhesions and mesh incorporation to the surrounding tissues is safe and provides an advantageous platform for concomitant hernia repair in these complex cases.

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:During the past decade, laparoscopic adjustable gastric banding (LAGB) was one of the most popular surgical procedures in treating morbid obesity. Long-term effects, specifically on esophageal motility, of LAGB have not been well described in the literature despite the high prevalence of reoperations and post-operative dysphagia. We aimed to characterize esophageal dysmotility after long-term follow-up using data of high-resolution esophageal manometry (HRM) performed in patients who presented for LAGB removal. The research was conducted in Academic Hospital Center in the USA. METHODS:Research was conducted with approval from the institution's Institutional Review Board. We included 25 consecutive patients who were requesting removal of the band or revisional bariatric surgery. All patients underwent HRM between 2011 and 2015. RESULTS:A Fisher's exact test two-sided p value 0.41 shows no statistically significant difference in proportions of normal motility or impaired motility between asymptomatic and symptomatic patients. CONCLUSIONS:Patients with a history of LABG can have esophageal dysmotility whether they are symptomatic or asymptomatic. Based on existing literature, we recommend pre-operative manometry in these patients requesting revisional surgery.

STUDY OBJECTIVE/OBJECTIVE:To evaluate the comorbidities and surgical factors involved in the genesis of intraoperative pressure ulcers. DESIGN/METHODS:Retrospective chart review. SETTING/METHODS:Anesthesiology department of a university medical center. MEASUREMENTS/METHODS:The charts of 222 patients with varying illness, who underwent an operation of at least two hours' duration, were analyzed retrospectively. Data on surgery type, case length, comorbidities, intraoperative surgical position, and area of ulceration were recorded. MAIN RESULTS/RESULTS:Risk factors for intraoperative pressure ulcer development include surgical times of 4 hours or longer; comorbidities affecting tissue perfusion (namely, diabetes, hypertension, and nonspecific cardiac issues); supine placement during surgery; and abdominal, noncardiac thoracic, and orthopedic operations. Regions of the body most at risk for ulceration include the coccygeal/sacral region, the buttocks, genitalia, and heels. CONCLUSIONS:Pressure ulcers are a costly, debilitating, and avoidable complication of surgery.