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The first modified Delphi consensus statement on sleeve gastrectomy

Mahawar, Kamal K; Omar, Islam; Singhal, Rishi; Aggarwal, Sandeep; Allouch, Mustafa Ismail; Alsabah, Salman K; Angrisani, Luigi; Badiuddin, Faruq Mohamed; Balibrea, Jose María; Bashir, Ahmad; Behrens, Estuardo; Bhatia, Kiron; Biertho, Laurent; Biter, L Ulas; Dargent, Jerome; De Luca, Maurizio; DeMaria, Eric; Elfawal, Mohamed Hayssam; Fried, Martin; Gawdat, Khaled A; Graham, Yitka; Herrera, Miguel F; Himpens, Jacques M; Hussain, Farah A; Kasama, Kazunori; Kerrigan, David; Kow, Lilian; Kristinsson, Jon; Kurian, Marina; Liem, Ronald; Lutfi, Rami Edward; Menon, Vinod; Miller, Karl; Noel, Patrick; Ospanov, Oral; Ozmen, Mahir M; Peterli, Ralph; Ponce, Jaime; Prager, Gerhard; Prasad, Arun; Raj, P Praveen; Rodriguez, Nelson R; Rosenthal, Raul; Sakran, Nasser; Santos, Jorge Nunes; Shabbir, Asim; Shikora, Scott A; Small, Peter K; Taylor, Craig J; Wang, Cunchuan; Weiner, Rudolf Alfred; Wylezol, Mariusz; Yang, Wah; Aminian, Ali
INTRODUCTION/BACKGROUND:Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG. METHODS:We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus. RESULTS:The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE. CONCLUSION/CONCLUSIONS:A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.
PMID: 33433676
ISSN: 1432-2218
CID: 4776812

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times

Pouwels, Sjaak; Omar, Islam; Aggarwal, Sandeep; Aminian, Ali; Angrisani, Luigi; Balibrea, Jose María; Bhandari, Mohit; Biter, L Ulas; Blackstone, Robin P; Carbajo, Miguel A; Copaescu, Catalin A; Dargent, Jerome; Elfawal, Mohamed Hayssam; Fobi, Mathias A; Greve, Jan-Willem; Hazebroek, Eric J; Herrera, Miguel F; Himpens, Jacques M; Hussain, Farah A; Kassir, Radwan; Kerrigan, David; Khaitan, Manish; Kow, Lilian; Kristinsson, Jon; Kurian, Marina; Lutfi, Rami Edward; Moore, Rachel L; Noel, Patrick; Ozmen, Mahir M; Ponce, Jaime; Prager, Gerhard; Purkayastha, Sanjay; Rafols, Juan Pujol; Ramos, Almino C; Ribeiro, Rui J S; Sakran, Nasser; Salminen, Paulina; Shabbir, Asim; Shikora, Scott A; Singhal, Rishi; Small, Peter K; Taylor, Craig J; Torres, Antonio J; Vaz, Carlos; Yashkov, Yury; Mahawar, Kamal
The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.
PMID: 32740826
ISSN: 1708-0428
CID: 4559932

SAGES masters program: determining the seminal articles for each pathway [Editorial]

Stefanidis, Dimitrios; Schultz, Linda; Bostian, Shauna; Sylla, Patricia; Pauli, Eric M; Oleynikov, Dmitry; Kurian, Marina; Khaitan, Leena; Cripps, Michael W; Bachman, Sharon; Alseidi, Adnan; Brunt, L Michael; Asbun, Horacio; Jones, Daniel B
BACKGROUND:The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has recently developed and announced its Masters Program that aims to address existing needs of practicing surgeons for lifelong learning and consists of eight clinical pathways each containing three anchoring procedures. The objective of this study was to select the seminal articles for each anchoring procedure of these pathways using a systematic methodology. METHODS:A systematic literature search of Web of Science was conducted for the most cited articles for each of the anchoring procedures of the SAGES Masters pathways. The most relevant identified articles were then reviewed by expert members of the relevant SAGES pathway committees and task forces and the seminal articles chosen for each anchoring procedure using expert consensus. RESULTS:578 highly cited articles were identified by the original search of the literature and the seminal articles were selected for each anchoring procedure after expert review and consensus. Articles address procedural outcomes, disease pathophysiology, and surgical technique and are presented in this paper. CONCLUSIONS:We have identified seminal articles for each anchoring procedure of the SAGES Masters program pathways using a systematic methodology. These articles provide surgeon participants of this program with a great resource to improve their procedure-specific knowledge and may further benefit the larger surgical community by focusing its attention to must-read impactful work that may inform best practices.
PMID: 32052149
ISSN: 1432-2218
CID: 4304522

Surgical management of gastroesophageal reflux disease in the obese patient

Nau, P; Jackson, H T; Aryaie, A; Ibele, A; Shouhed, D; Lo Menzo, E; Kurian, M; Khaitan, L
BACKGROUND:Gastroesophageal reflux disease (GERD) affects two thirds of the American population. Obesity is also a disease that affects two thirds of the population. The pathophysiology of reflux disease is reasonably understood, however, the degree to which obesity affects this disease remains poorly defined. Therefore the approach to GERD in the obese patient requires special attention and its own algorithm. METHODS:A literature search was conducted to consolidate the current available literature on GERD and its management in the obese. In addition, the authors reviewed the literature and present expert opinion on controversial topics. RESULTS:It is well established that GERD is increased in obesity and the pathophysiology is reviewed. Management options for GERD are discussed, with a focus on the obese population. Management strategies including fundoplication and gastric bypass are discussed. In addition, bariatric surgery in the setting of GERD is also reviewed. CONCLUSIONS:Currently this is an extremely controversial topic and this white paper presents a strong review of the literature to help guide the management of this challenging disease in this population. Expert recommendations are given throughout the paper based upon the current available data.
PMID: 31720811
ISSN: 1432-2218
CID: 4186892

Gastrojejunostomy stricture after Roux-en-Y gastric bypass, a 17 year experience [Meeting Abstract]

Nowak, B; Fielding, G; Kurian, M; Schwack, B; Bedrosian, A; Ren-Fielding, C
Introduction: The gastrojejunostomy (GJ) during Roux-en-Y gastric bypass (RYGB) can be performed by stapled or hand-sewn techniques, and is at risk for anastomotic stricture, reported in the literature at rates from 0 to 33%. This study reviews a single center's experience with anastomotic stricture and intervention required. Methods and Procedures: A retrospective chart review was performed of 904 patients who underwent RYGB as primary or revisional surgery at a single institution from October 2000 through September 2017. There were 182 patients excluded for follow up duration of less than 1 year, 5 for an esophagojejunostomy rather than GJ, and 1 for gastroparesis as the surgical indication rather than morbid obesity. This left 716 patients to be included in the study. Demographic and operative data were collected including technique for GJ, postoperative follow up, and complications, with a focus on GJ stricture and subsequent interventions.
Result(s): Gastrojejunostomy (GJ) was performed with a 25 CEEA stapler in 674 (94.1%) patients, with a linear stapler in 25 (3.5%), was hand-sewn in 7 (1.3%), and the technique was unknown in the remaining 8 (1.1%). Roux-en-Y gastric bypass was performed as a primary surgery in 522 (72.9%) patients and as a revisional surgery in 194 (27.1%). Stricture of the GJ was diagnosed in 29 (4.1%) patients. The average time to diagnosis of early strictures occurring prior to 3 months was 40.3 days, and for late strictures was 871 days. By technique, stricture was diagnosed in 26 (3.9%) patients in the 25CEEAgroup, 1 (4%) in the linear stapler group, and 2 (22.2%) in the hand-sewn anastomosis group. In primaryRYGBpatients stricture was diagnosed in 20 (3.8%) patients, and in revisionalRYGB in 9 (4.6%) patients (p = 0.626). Esophagogastroduodenoscopy (EGD) with dilation was performed at least once (1-9 times) in 26 patients, 2 with concomitant stenting, 2 required operative intervention, and 1 patient awaits operative intervention. Both patients who required surgery also had marginal ulcers, and possible gastro-gastric fistula at time of surgery.
Conclusion(s): The results of this study show that the 25 CEEA circular stapler is a reasonable technique for performance of the GJ anastomosis in RYGB, with a stricture rate of 3.9%. There is also a slightly increased stricture rate in revisional surgical patients, though not statistically significant
ISSN: 1432-2218
CID: 3811422

Effects of a single subanaesthetic dose of ketamine on pain and mood after laparoscopic bariatric surgery: A randomised double-blind placebo controlled study

Wang, Jing; Echevarria, Ghislaine; Doan, Lisa; Ekasumara, Nydia; Calvino, Steven; Chae, Floria; Martinez, Erik; Robinson, Eric; Cuff, Germaine; Franco, Lola; Muntyan, Igor; Kurian, Marina; Schwack, Bradley F; Bedrosian, Andrea S; Fielding, George A; Ren-Fielding, Christine J
BACKGROUND:When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE:We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN/METHODS:We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4 mg kg) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING/METHODS:Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS/METHODS:A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION/METHODS:Patients in the ketamine group received a single dose of ketamine infusion (0.4 mg kg) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES/METHODS:The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS:There were no significant differences in visual analogue pain scores between groups (group-by-time interaction P = 0.966; marginal group effect P = 0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean difference = -2.2 (95% bootstrap CI -2.9 to 1.6), Bonferroni adjusted P < 0.001], compared with placebo group in which the scores decreased only by POD 7. Scores on the total scale of SF-MPQ for the ketamine group were smaller compared with the placebo group (P = 0.034). CONCLUSION/CONCLUSIONS:Although there was no significant difference between ketamine and placebo for the primary outcome measure, patients who received ketamine experienced statistically and clinically significant improvement in their comprehensive evaluation of pain, particularly the affective component of pain, on POD 2. However, future studies are needed to confirm the enduring effects of ketamine on the affective response to postoperative pain. CLINICAL TRIAL REGISTRATION/BACKGROUND:NCT02452060.
PMID: 30095550
ISSN: 1365-2346
CID: 3226762


Nowak, B.; Ren-Fielding, C.; Fielding, G.; Kurian, M.; Schwack, B.
ISSN: 0960-8923
CID: 4071502


Nowak, B.; Fielding, G.; Kurian, M.; Ren-Fielding, C.
ISSN: 0960-8923
CID: 4071492

SAGES review of endoscopic and minimally invasive bariatric interventions: a review of endoscopic and non-surgical bariatric interventions

Kurian, Marina; Kroh, Matthew; Chand, Bipan; Mikami, Dean; Reavis, Kevin; Khaitan, Leena
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.
PMID: 29845397
ISSN: 1432-2218
CID: 3136912

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass

Liu, Shinban; Ren-Fielding, Christine J; Schwack, Bradley; Kurian, Marina; Fielding, George A
BACKGROUND:Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure. OBJECTIVE:To investigate long-term results of salvage gastric banding. SETTING/METHODS:University Hospital, New York, United States. METHODS:Data were prospectively collected with retrospective review. Baseline characteristics were evaluated and weights at multiple time intervals (before RYGB, before LAGB, each year of follow-up). Additional data included approach (open or laparoscopic), operative time, hospital length of stay, and postoperative complications. RESULTS:with 22.5% total weight loss and 65.9% excess weight loss. The long-term reoperation rate for complications related to LAGB was 24%, and 8% of patients ultimately had their gastric bands removed. CONCLUSION/CONCLUSIONS:The results of our study have shown that LAGB had good long-term data as a revisionary procedure for weight loss failure after RYGB.
PMID: 30154032
ISSN: 1878-7533
CID: 3480472