Faculty Bibliography

BACKGROUND:Metabolic and bariatric surgery (MBS), despite being the only effective durable treatment for obesity, remains underused as approximately 1% of all patients who qualify undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate treatment. OBJECTIVE:The objective of this study was to provide the best estimated number of metabolic and bariatric procedures performed in the United States in 2020. SETTING/METHODS:United States. METHODS:We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and state databases were used to estimate activity at nonaccredited centers. Data from 2020 were compared mainly with data from the previous 2 years. RESULTS:Compared with 2019, the total number of MBS performed in 2020 decreased from approximately 256,000 to 199,000. Sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable, and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Single-anastomosis duodeno-ileostomy was listed for the first time in 2020. Intragastric balloons placement declined from the previous year. CONCLUSION/CONCLUSIONS:There was a 22.5% decrease in MBS volume from 2019 to 2020, which coincided with the COVID-19 pandemic. Sleeve gastrectomy continues to be the dominant procedure, and for the first time, single-anastomosis duodeno-ileostomy is reported in the MBSAQIP database.

BACKGROUND:Sporadic women involvement in surgery has been recorded since ancient times. Nevertheless, the presence of women in surgical disciplines has been marginal until the last 2 decades, with several barriers still existing worldwide. The aim of the study was to explore the history of women in surgery, with a main focus in North America from until the foundation women surgical societies. METHODS:Database search of studies about the history of women in surgery. RESULTS:The 19th century registered an increased presence of women in medicine; during the 20th century, pioneer women surgeons opened the way to a more consistent involvement of women in surgical specialties. In the last 20 years, increased awareness of barriers limiting women progression in surgical career led to the development of women's surgical societies, with the aim to share common experiences and find solutions to common issues. CONCLUSION/CONCLUSIONS:The history of women in surgery has been paved with challenges: during the last centuries, several barriers limited the inclusion of women in surgical fields, from training to leadership positions. Nevertheless, some pioneers actually broke the rules imposed by a male-dominated field and opened the way to a more diverse and equal future for women surgeons. Nowadays, the existence of women's surgical societies in different countries and their interconnection represents a way to support women surgeons at different stages of their career.

Introduction: Obesity is an increasingly prevalent public health problem which is often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has limited long-term efficacy in patients with morbid obesity and does not address additional weight-related comorbidities. The Roux-en-Y gastric bypass (RYGB) has been proven to be a superior option for effective and durable resolution of GERD in this patient population. Surgeons have reported that access to RYGB as surgical treatment for GERD is often limited by inadequate insurance benefits, but the magnitude and scope of this problem is unknown.
Method(s): A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to the SAGES Foregut Taskforce as well as the SAGES Bariatrics and Foregut Facebook groups.
Result(s): 187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35 kg/m2 and 30 kg/m2 respectively as a cutoff for the RYGB. 89% viewed the RYGB as the procedure of choice when addressing GERD in a prior bariatric surgery patient. 69% reported using the surgery to address recurrent reflux secondary to a failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time the procedure was offered for GERD, and 8% reported they were never able to get approval for the procedure for GERD indications.
Conclusion(s): GERD and obesity are concomitant disease that are best addressed with RYGB. Insurance coverage is often limited by arbitrary and/or discriminatory policies which run contrary to evidence-based medicine. Patient advocacy is critical to improve access to appropriate medical care for GERD in patients with obesity

BACKGROUND:One of the eight clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program is bariatric surgery which includes three anchoring procedures. For each anchoring procedure sentinel articles have been identified to enhance participant surgeon lifelong learning. Roux-en-Y gastric bypass (RYGB) is one of the 3 anchoring procedures for the Bariatric Pathway. In this article we present the top 10 seminal articles regarding the RYGB which surgeons should be familiar with. METHODS:The literature was systematically searched to identify the most cited papers on RYGB. The SAGES Metabolic and Bariatric Surgery committee reviewed the most cited article list and using expert consensus selected the seminal articles that every bariatric surgeon should read. These articles were reviewed in detail by committee members and are presented here. RESULTS:The top 10 most cited sentinel papers on RYGB focus on operative safety, outcomes, surgical technique, and physiologic changes after the procedure. A summary of each paper is presented here, including expert appraisal and commentary. CONCLUSION/CONCLUSIONS:The seminal articles presented here have supported the widespread acceptance and use of the RYGB by bolstering the understanding of its mechanism of action and by demonstrating its safety and excellent patient outcomes. All bariatric surgeons should be familiar with these 10 landmark articles.

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.

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.

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.

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.

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