Effectiveness of bedside staplers in bariatric robotic procedures.

BACKGROUND: Few studies have evaluated the use of laparoscopic staplers in robotic procedures (bedside stapling, BS). This study aims to evaluate the effectiveness of BS compared with robotic staplers (RS) in bariatric robotic procedures. METHODS: Patients who underwent robotic sleeve gastrectomy or gastric bypass elective procedures between 1/1/2021 and 12/31/2021 were extracted from PINC AI™ Healthcare Data. The following clinical outcomes were compared: blood transfusion, bleeding, anastomotic leak, intensive care unit (ICU) visit, and 30-day readmission, operating room (OR) time, inpatient costs, and length of stay. We evaluated baseline balance in BS and RS and bivariate association between covariates and outcomes using Chi-square or Fisher exact test and t-test or ANOVA. Multivariable general linear mixed models (GLMMs) with respective gamma or binomial distribution and log-link function were used to obtain adjusted outcomes variations between BS and RS. RESULTS: Total of 7268 discharges were included with 1603 (22.1%) BS and 5665 (77.9%) RS cases. RS cases consisted of a higher number of patients who were Hispanic (17.0% vs. 9.4%), had Medicaid (26.9% vs. 19.4%) and underwent sleeve gastrectomy (68.4% vs. 53.5%). Higher proportions of RS cases were done by providers in Northeast region (35.5% vs. 24.3%), smaller size (< 500 beds; 71.1% vs. 52.3%), and teaching hospitals (59.4% vs. 39%). The adjusted outcomes variations demonstrated that patients that had RS were significantly more likely to have blood transfusions, ICU stays, increased ORT (19 min) and costs ($1273). Sensitivity analysis showed similar results, except no significant differences in blood transfusion rates in both groups. CONCLUSIONS: Bedside staplers significantly reduce healthcare resource utilization with equivalent effectiveness and fewer ICU stays compared to robotic staplers.

Evaluating metabolic and bariatric surgery fellows' attitudes toward their training.

BACKGROUND: The American Society of Metabolic and Bariatric Surgeons (ASMBS) Leadership Academy is conducted at the ASMBS Weekend to prepare surgeons for practice, while in their fellowship. OBJECTIVES: The aim of this analysis is to gather the views of current fellows in training on issues regarding practice patterns and career development. SETTING: Survey at ASMBS Fellows Leadership Academy. METHODS: An online survey was conducted at the last 2 ASMBS Leadership Academy Meetings at the ASMBS Weekend. There were 14 questions. There were 61 respondents. Twenty-three respondents had incomplete surveys and were not included in the final analysis. There were 24 fellows surveyed at the Leadership Academy in November 2022, in San Antonio, TX and 37 in January 2022, in Las Vegas, NV. RESULTS: Fifty-eight percent of attendees were interviewing for employment after their fellowship with 3.64% already employed. Eighteen percent had employment secured upon completion of their fellowship. Of the academic fellows, 29.1% believe that private practice will no longer exist in 2030 and 10.9% of attendees believe that we will have Medicare for all by 2030. Fellows in academic programs ranked their fellowship as either "best decision of my life" or "great" (96.4%) and 3.6% ranked it as "useless (not good/not bad)." Ninety-three percent of attendees said they would do a bariatric fellowship again. Of those that said they would not, all were from a robotic fellowship program. Of those that would do a bariatric fellowship again, 80% stated they would do so at the same institution. CONCLUSIONS: The fellows that attended the ASMBS Leadership Academy overall were very pleased with their fellowship experience, and most would choose to do a MIS/bariatric fellowship again.

Classification of Slippage Following Laparoscopic BariClip Gastroplasty.

INTRODUCTION: Laparoscopic BariClip gastroplasty (LBCG) is a new reversible gastric sleeve-like procedure without gastrectomy proposed to minimize the risk of severe complications. Still one of the possible complications described with LBCG is slippage. The purpose of the current manuscript is to analyze different cases of slippage and propose a classification of this complication. METHODS: A number of 381 patients who underwent LBCG in 8 different centers were analyzed concerning the risk of slippage. All cases with documented slippage were carefully reviewed in terms of patients' symptomatology (presence of satiety, vomiting), history of weight loss, radiological data, and management of their slippage. A new classification was proposed depending on the anatomy, the symptomatology, and the time of occurrence. RESULTS: We have identified a total of 17 cases (4.46%) of slippage following LBCG. In 11 patients, the slippage was symptomatic with repetitive vomiting and nausea, and in the remaining 6 patients, the slippage was identified by radiological studies for insufficient weight loss, weight regain, or routine radiological follow-up. Depending on the interval time, the slippage was classified as either immediate (in first 7 days) in 6 cases, early (in less than 90 days) in 4 cases, and late (after 3 months) in 7 cases. Evaluation of the radiological studies in these cases identified the following: anterosuperior displacement (type A) in 9 cases, posteroinferior displacement (type B) in 6 cases (one case after 3 months), and lateral displacement (type C) in the remaining 2 cases. The management of the slippage consisted of BariClip removal in 7 cases, repositioning in 5 cases, and conservative treatment in the remaining 5 cases. All patients with conservative treatment were recorded at the beginning of the experience. CONCLUSIONS: Slippage is a possible complication after LBCG. This classification of the different types of slippage can benefit the surgeon in the management and treatment of this complication of LBCG.

Evolving Technique of Laparoscopic Vertical Gastric Clip Placement.

INTRODUCTION: Laparoscopic BariClip gastroplasty (LBCG) will address a similar tubular restriction than the one achieved with the laparoscopic sleeve gastrectomy (LSG) at the level of the gastric fundus, while maintaining the advantage of simplicity and anatomic preservation. The purpose of the current study was to analyze the risk of slippage and to present the evolving technique by adding gastro-gastric plication of the gastric wall covering the BariClip at those areas where the gastric wall "slips" between the limbs of the clip. METHODS: All patients undergoing LBCG with the evolving technique of gastric plication around the device associated with antral gastroplasty from January 2021 to May 2022 were included in the study group (group A). A control group (group B) was designed with patients who underwent previous LBCG technique between May 2017 and June 2019. This is a case-controlled group with patients matched by gender and BMI. We have analyzed the postoperative complications and more notably the slippage. RESULTS: One hundred seventy-six patients (44 male and 132 female) with a mean age of 33 years (± 11) underwent evolving technique of LBCG. A control group of 67 patients who underwent previous technique of LBCG was included. All procedures were completed by laparoscopy with no intraoperative complication. For the study group, we have recorded a number of 5 slippages (2.8%). The diagnosis occurred during the first 6 months after the operation. The management consisted of repositioning-3 cases-and BariClip removal-2 cases. For the control group, we have recorded a number of 3 slippages (4.3%). All three patients underwent BariClip removal, with no repositioning. CONCLUSIONS: We reported a new technique of placement of the BariClip with additional gastric plication anterior, posterior, and volume reduction in the antrum to potentially reduce the rate of slippage and improve weight loss outcomes.

Bariatric surgery in patients with previous COVID-19 infection.

BACKGROUND: The process of reintroducing bariatric surgery to our communities in a COVID-19 environment was particular to each country. Furthermore, no clear recommendation was made for patients with a previous COVID-19 infection and a favorable outcome who were seeking bariatric surgery. OBJECTIVES: To analyze the risks of specific complications for patients with previous COVID-19 infection who were admitted for bariatric surgery. SETTING: Eight high-volume private centers from 5 countries. METHODS: All patients with morbid obesity and previous COVID-19 infection admitted for bariatric surgery were included in the current study. Patients were enrolled from 8 centers and 5 countries, and their electronic health data were reviewed retrospectively. The primary outcome was to identify early (<30 d) specific complications related to COVID-19 infection following bariatric surgery, and the secondary outcome was to analyze additional factors from work-ups that could prevent complications. RESULTS: Thirty-five patients with a mean age of 40 years (range, 21-68 yr) and a mean body mass index of 44.3 kg/m2 (±7.4 kg/m2) with previous COVID-19 infection underwent different bariatric procedures: 23 cases of sleeve (65.7 %), 7 cases of bypass, and 5 other cases. The symptomatology of the previous COVID-19 infection varied: 15 patients had no symptoms, 12 had fever and respiratory signs, 5 had only fever, 2 had digestive symptoms, and 1 had isolated respiratory signs. Only 5 patients (14.2 %) were hospitalized for COVID-19 infection, for a mean period of 8.8 days (range, 6-15 d). One patient was admitted to an intensive care unit and needed invasive mechanical ventilation. The mean interval time from COVID-19 infection to bariatric surgery was 11.3 weeks (3-34 wk). The mean hospital stay was 1.7 days (±1 d), and all patients were clinically evaluated 1 month following the bariatric procedure. There were 2 readmissions and 1 case of complication: that case was of a gastric leak treated with laparoscopic drainage and a repeated pigtail drain, with a favorable outcome. No cases of other specific complications or mortality were recorded. CONCLUSION: Minor and moderate COVID-19 infections, especially the forms not complicated with invasive mechanical ventilation, should not preclude the indication for bariatric surgery. In our experience, a prior COVID-19 infection does not induce additional specific complications following bariatric surgery.

The first modified Delphi consensus statement on sleeve gastrectomy.

INTRODUCTION: 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: 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.

Impact of fellowship training on surgical outcomes after appendectomies: a retrospective cohort study.

BACKGROUND: Outcome studies have failed to show significant improvement related to formal fellowship training in different surgical specialties. We aimed to look whether laparoscopic fellowship-trained (FT) surgeons had better outcomes. METHODS: This is an IRB approved retrospective review from a single institution (inner city hospital) on adults undergoing appendectomy from 2008 to 2017. Demographics and 30-day complications were analyzed with univariate and multivariate logistic regression analyses. RESULTS: Total of 558 appendectomies were reviewed. 151 (27.36%) appendectomies were performed by FT surgeons (MIS/CRS), 401 (72.64%) performed by GS. No difference in age, ASA, BMI, race, gender, insurance status, smoking, diabetes mellitus (DM), or hypertension was found. Also, similar rates of non-iatrogenic perforated appendicitis were seen (16.37% GS vs 20% FT, p = 0.318). For major complications, no difference was found between GS and FT (p = 0.63). However, appendectomies performed by GS showed higher rates of post-op ileus (3.99% vs 0.66%, p = 0.04), higher conversion to open (7.55% vs 2.67%, p = 0.039), higher rates of choosing an open approach (17.46% vs 0.66%, p = < 0.001), and longer length of stay (LOS) (median 1.9 vs 1.8 days p = 0.048). Of the 16 patients with ileus from the GS group three were open, two converted to open, and eleven laparoscopic with mean OR time of 70 min and LOS of 13.3 days. The only laparoscopic case from the FT group with ileus had a mean operative time of 56 min and LOS of 15 days. On multivariate regression analysis, only DM was found as risk factor for major complications (OR 3.01, 95% CI 1.307-6.92, p = 0.01), while laparoscopic approach was seen as protective factor against major complications (OR 0.53, 95% CI 0.29-0.97, p = 0.04). CONCLUSION: Laparoscopic fellowship training had a positive outcome on post-op ileus and LOS after appendectomy. This seems to be related to the higher prevalence of choosing laparoscopic technique and lower rate of conversion to open.

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

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.

Obesity and Ventral Hernia Repair: Is There Success in Staging?

Introduction: Obesity predisposes patients to the development of abdominal wall hernias. Ventral hernia incidence, size, and recurrence rate are all increased in this population. As such, the surgeon is likely to encounter patients presenting for metabolic and bariatric surgery with existing ventral hernias. Controversy persists regarding the algorithm for treatment in this situation. Do we wait to repair, or is the weight inconsequential? Materials and Methods: We critically reviewed the available literature accessed through PubMed on the repair of ventral hernias in the obese population. Specifically, we focused on the outcomes after staged repair versus concurrent repair at the time of bariatric surgery. We aim at providing an overview of the conclusions from past and present publications with commentary by the authors. Results: A review of the literature finds conflicting opinions regarding the safety and success of concurrent ventral hernia repair at the time of bariatric surgery. Obese patients frequently have complex hernias and are predisposed to poor wound healing and increased recurrence. Although some small studies find success with concurrent repair, large registry analyses as well as expert consensus statements advocate for staged repair. Conclusion: For the obese patient with large ventral hernia, the authors recommend a staged approach, beginning with bariatric surgery and deferring the hernia repair until significant weight loss is obtained. The exception exists, and each patient must be evaluated critically regarding hernia size, contents, and risk of obstruction if left untreated.

A Review of the Role of Robotics in Bariatric Surgery: Finding Our Future?

Introduction: Obesity rates continue to rise in America and around the World. Numerous studies show the benefit of bariatric surgery on all-cause mortality in obese patients. Given its substantial role in the future of patient care, we continue to search for the most beneficial ways to optimize patient outcomes and procedural costs in bariatric surgery. Much like laparoscopy was found to greatly improve the morbidity of weight loss surgery, we seek to evaluate the role of robotic surgery in bariatric procedures. Methods: We critically reviewed the available literature accessed through PubMed on the use of robotics in bariatric surgery. We aim to provide an overview of the conclusions from the most recent publications with commentary by the authors. Results: Although the outliers exist, it would appear that the majority of cases point to robotic surgery increasing operating room time and cost without providing significant generalizable improvements in patient outcomes. Promise exists in the use for special groups such as super obese patients or revisional bariatric procedures, however current studies in this subset are equally variable in their outcomes. Conclusion: Despite the current assumptions, we believe there is a future in bariatric surgery for robotics. This may inevitably be seen in the more demanding and difficult cases or in the advancement of the available technology. Likely, as robotics continues to mature, applied artificial intelligence will provide enhanced cues during surgery that augment the surgeon's judgment and skill and result in unanimously improved patient outcomes.

The Interest of Enhanced Recovery After Surgery in a New Bariatric Center.

Background: With the creation of a new bariatric center in Abu Dhabi, United Arab Emirates (UAE) and the organization of this bariatric department according to the international guidelines, a new activity of bariatric surgery started in January 2015. The surgeon had 20 years of experience in this field and he had performed over 5000 major laparoscopic bariatric procedures before starting this new bariatric program. The concept of enhanced recovery after bariatric surgery (ERABS) was applied from the beginning of the program. We decided to analyze the first 2 years of ERAS activity after having split them in two different periods: the 1st year of activity included restrictive procedures and the 2nd year associated malabsorptive surgeries. Materials and Methods: The results of the use of a fast-track program could be measured by different parameters like operative time, length of hospital stay, rate of complications, and rate of readmission and reoperation. Results: Between January and December 2015, 116 patients underwent a bariatric procedure. The mean age was 34.6 years (16-61) and average body mass index (BMI) was 41.7 kg/sqm (32-72.2). Sixty percent of patients were women and 37% of patients had at least one comorbidity (diabetes type 2, high blood pressure, hyperlipidemia, or sleep apnea). Ninety-four percent of the procedures were laparoscopic sleeve gastrectomy (LSG), 2.6% were laparoscopic Roux-en-Y gastric bypass, and 3.4% band removal. The mean operative time was 20 minutes for an LSG (14-45 minutes) and the average hospital stay was 1.2 days (standard deviation [SD]: 0.9-3.3). The rate of complications was 1.7% with 1 postoperative hematoma drained by CT scan on day 14 after the surgery and 1 relative stenosis endoscopically dilated on postoperative day 45. No reoperation was done. No leak was observed. At 1 year, the mean excess weight loss (EWL) was 64% (47-124) in 89 patients with a 76% rate of follow-up. For the 2nd year of activity in 2016, 142 patients went in the program. The mean age was 32.7 years (17-64) and average BMI was 42.3 kg/sqm (31-68). Seventy-two percent were women and 41% of the patients had one comorbidity or more. The majority of surgeries performed were LSG for 83.1% of the patients. RYGB was realized in 4.2% of cases, resleeve gastrectomy in 4.2%, and band removal in 1.4%. Some malabsorptive surgeries were performed as well, such as one anastomosis gastric bypass for 3 patients (4.2%), and single anastomosis duodeno-ilelal in 2 cases (2.8%). The average hospital stay was 1.5 days (SD: 0.9-3.5). No complication was observed. No reoperation was done. Two patients (1.4%) came back to the hospital on postoperative day 2 and 8 after a LSG for one or several episodes of vomiting without further complication. At 1 year, the mean EWL was 68% (49-154) in 98 patients with a 69% rate of follow-up. Conclusions: This new program of bariatric surgery in two steps using fast-track protocols, respecting international guidelines and with an experienced surgeon showed on its 1st year of implementation a 1.7% rate of readmission on 116 patients without reoperation or major complication and a hospital stay of 1.2 days. For the 2nd year of implementation with the inclusion of malabsorptive procedures only 2 patients (1.4%) were readmitted for a short episode of vomiting and the hospital stay was 1.5 days.

HIV Infection Is Not a Contraindication to Laparoscopic Sleeve Gastrectomy for Morbid Obesity.

BACKGROUND: The efficacy of antiretroviral therapy has made HIV a chronic condition. The prevalence of obesity in HIV positive patients has subsequently risen and is present in 6-34% of men and 21-30% of women (Keithley et al. J Assoc Nurses AIDS Care 20(4):260-74, 2009). Sleeve gastrectomy is a safe and effective procedure for weight loss in the general population, but having HIV may bring hesitation to performing bariatric surgery for some practitioners. OBJECTIVES: The aim of this study is to evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) in patients with HIV. METHODS: A retrospective analysis of prospectively collected data of patients with HIV who underwent LSG at a community hospital by a single surgeon was performed. Nine patients with HIV underwent LSG. Primary outcomes include weight loss at 6 and 12 months and postoperative CD4 count and viral load. Secondary outcomes include alteration to antiretroviral therapy (ART). RESULTS: Our patients had a mean BMI of 46 (range 35-66) and were all well controlled on ART preoperatively. Mean weight loss at 12 months was 40 kg (range 21-55), with mean excess body weight loss 69% (range 42-112). There were no significant changes in CD4 counts, and all patients continued to have undetectable viral loads at 1 year postoperatively. One patient had a change in ART, which was unrelated to bariatric surgery. There were no complications in our patient group. CONCLUSION: This is the largest series to date evaluating sleeve gastrectomy in HIV-positive patients and further supports the safety and efficacy of sleeve gastrectomy in this patient population.

Is a "retained fundus" seen on postoperative upper gastrointestinal series after laparoscopic sleeve gastrectomy predictive of inferior weight loss?

BACKGROUND: Postoperative upper gastrointestinal series (UGI) has never been shown to be effective in ruling out leaks or obstruction after gastric bypass or sleeve gastrectomy. In sleeve gastrectomies, UGI will define the shape of the sleeve and rule out a retained fundus that was not optimally excised during surgery. OBJECTIVES: We aimed to investigate the impact of a "retained fundus" on weight loss to determine whether UGIs can be used to gauge success of the operation and predict outcome. SETTING: Urban community teaching hospital, United States. METHODS: Retrospective study analyzing routine UGIs performed on 203 consecutive patients. Exclusion criteria included low quality UGI (absence of a still image of complete fill with contrast), revisions from gastric band to sleeve, absence of weight-loss data, postoperative leak, and postoperative stenosis. RESULTS: A total of 149 patients were included. Mean excess weight loss at one year for groups 1 through 4 was 67.3%, 72.7%, 67.8%, and 65.9%, respectively. There was no significant statistical difference in excess weight loss between the optimal group and the group of both mild and severe retained fundus (P = .22). The weight loss remained equivalent even when comparing the optimal sleeves with only those with severe retained fundus (P = .19). There was a statistically significant difference in quality of sleeve gastrectomies on UGI with surgical experience showing less retained fundus on the UGIs (P = .006) in the latter half of the series. CONCLUSION: Retained fundus does not seem to cause inferior weight loss in the early postoperative period. Thus, UGI cannot predict weight loss outcomes in the short term.