The utility of endoscopy prior to bariatric surgery: an 11-year retrospective analysis of 885 patients.

INTRODUCTION: Our aim was to evaluate the diagnostic yield of routine preoperative esophagogastroduodenoscopy (p-EGD) in patients undergoing bariatric surgery. Many medical problems that are common in patients with obesity, including gastroesophageal reflux disease (GERD) and hiatal hernias, have important implications for patients undergoing bariatric surgery. While p-EGD is considered standard of care prior to antireflux surgery, the role of p-EGD in bariatric surgery patients remains controversial. METHODS AND PROCEDURES: We performed a retrospective chart review of 885 patients who underwent primary bariatric surgery at a university hospital-based bariatric surgery program between March 2011 and February 2022. Clinical history, demographics, and preoperative EGD reports were reviewed for abnormal findings. RESULTS: Of the 885 patients evaluated in this study, one or more abnormal EGD findings were observed in 83.2% of patients. More than half of our patients (54.7%) presented with history of heartburn, reflux, or GERD. EGD findings demonstrated a hernia in 43.1% of patients [(Type I: 40.6%; Type II: 0.5%; Type III: 2.1%)]. 68.0% of patients were biopsied. Among patients who were biopsied, other findings included gastritis (32.4%), esophagitis (8.0%), eosinophilic esophagitis (4.7%), or duodenitis (2.7%). We found ulcers in 6.7% of patients. Pathology was consistent with H. pylori in 9.8% of biopsies taken and consistent with BE in 2.7%. Following routine p-EGD, 11.2% of patients were placed on PPI and 8.3% were recommended to stop NSAIDs. CONCLUSION: Gastroesophageal reflux disease and associated pathology are common in the bariatric population. Preoperative EGD in patients undergoing bariatric surgery frequently identifies clinically significant UGI pathology. This may have important implications for medical and surgical management. Given the rate of abnormal preoperative endoscopic findings in obese patients, the work-up for bariatric surgery should align with the current recommendations for foregut surgery.

Repairing small type I hiatal hernias at the time of RYGB is not necessary to achieve resolution of reflux symptoms.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) is the gold standard operation for gastroesophageal reflux disease (GERD) in patients with severe obesity, but there is variability in surgeon opinion regarding whether small type I hiatal hernias (HH) require routine repair concurrently with RYGB. We sought to examine whether leaving small type I HHs unrepaired during RYGB affected GERD outcomes. METHODS: Pre-operatively our patients all receive endoscopy, and select patients with reflux symptoms receive esophagram based on attending surgeon practice and preference. We routinely repair paraesophageal hernias (PEH) concurrently with RYGB, but refrain from repairing small type I HH if, intra-operatively, the gastric fat pad and cardia are below the diaphragm with no evidence of retraction into the mediastinum. Records from 268 consecutive patients undergoing primary RYGB between January 2016 and February 2021 who completed pre-operative GERD-HRQL assessments were reviewed for presence of type I HH or PEH. Mann-Whitney U tests examined the pre-operative to post-operative change in GERD-HRQL in patients with type I HH left unrepaired at the time of RYGB (HH group) and patients with no hernia (NH group). RESULTS: Pre-operatively, GERD-HRQL scores were not statistically different between HH group (median = 7, mean = 8.5, n = 100) and NH group (median = 6.5, mean = 7.2, n = 141) (p > 0.05). Post-operatively, there was no increase in GERD-HRQL scores patients whose hernias were left unrepaired. Neither group had clinically pathologic post-operative GERD-HRQL scores, with median 6 months scores of 1 for HH group (n = 68) versus 1.5 for NH group (n = 90) (p > 0.05), and median 12 months scores of 1.5 for HH group (n = 40) versus 1 for NH group (n = 56) (p > 0.05). CONCLUSION: Repair of small type I HH is not necessary to achieve effective, durable resolution of reflux symptoms with RYGB. Omitting repair reduces operative time, cost, and potential risk without adverse impact on post-operative reflux symptoms.

The Role of Resilience in Psychological Health Among Bariatric Surgery Patients.

OBJECTIVE: Many individuals who undergo bariatric surgery have experienced repeated unsuccessful diet attempts and negative messages from healthcare providers, family, and others about their weight. Research pre- and post-operatively has taken a pathological or risk-based approach, investigating psychiatric problems and disordered eating. In contrast, the current study explores resilience in this population. METHODS: Participants were 148 bariatric surgery patients. Participants completed measures pre-operatively and 1.5-3 years post-operatively, including the Binge Eating Scale, Eating Disorder Examination Questionnaire, Patient Health Questionnaire, Generalized Anxiety Questionnaire, Impact of Weight on Quality of Life, Coping Responses Inventory, and Duke Social Support and Stress Scales. The Connor-Davidson Resilience Scale was measured post-operatively. RESULTS: Correlations demonstrated a significant association between post-operative resilience and lower symptoms of binge eating, disordered eating, depression, anxiety, and impact of weight on quality of life. Resilience was also associated with greater social support and less social stress, and greater use of approach coping strategies. Resilience was significantly associated with improvements in symptoms of binge eating, disordered eating, depression, anxiety, and impact of weight on quality of life from pre- to post-operative assessments. In regression models, associations remained significant after controlling for psychosocial variables at baseline (e.g., binge eating symptoms pre-operatively) and demographic covariates. CONCLUSIONS: Psychological resilience has been under-studied in the literature on obesity and bariatric surgery, with a primary focus on risk factors for poor outcomes. This study was among the first to investigate associations between resilience and post-operative psychological outcomes. Results suggest the field would benefit from consideration of patient resilience in psychological assessments and interventions.

Self-Pay Payer Status Predicts Long-Term Loss to Follow-Up After Bariatric Surgery.

PURPOSE: In spite of widespread recommendations for lifelong patient follow-up with a bariatric provider after bariatric surgery, attrition to follow-up is common. Over the past two decades, many programs have sought to expand access to care for patients lacking insurance coverage for bariatric surgery by offering "self-pay" packages; however, the impact of this financing on long-term follow-up is unclear. We sought to determine whether payer status impacts loss to follow-up within 1 year after bariatric surgery. MATERIALS AND METHODS: Records of 554 consecutive patients undergoing bariatric surgery who were eligible for 1-year post-surgical follow-up between 2014 and 2019 were retrospectively reviewed. Multiple logistic regression examined the relationship between demographics, psychological variables, payer status, and loss to follow-up. RESULTS: Self-pay status more than tripled the odds of loss to follow-up (OR = 3.44, p < 0.01) at 1 year following surgery. Males had more than double the odds of attrition (OR = 2.43, p < 0.01), and members of racial and ethnic minority groups (OR = 2.51, p < 0.05) were more likely to experience loss. CONCLUSIONS: Self-pay patients, males and members of racial and ethnic minority groups, may face additional barriers to long-term access to postoperative bariatric care. Further investigation is greatly needed to develop strategies to overcome barriers to and disparities in long-term post-surgical care for more frequently lost groups.

Prospective Collection of PROMIS Physical Function Measure Demonstrates Significant Improvement After Bariatric Surgery.

BACKGROUND: We evaluated quality of life among bariatric surgery patients using patient-reported outcomes (PROs). We hypothesized that physical function would improve after bariatric surgery. METHODS: We prospectively collected PROs beginning in December 2015. We used the validated Patient-Reported Outcomes Measurement Information System (PROMIS) instruments because of their broad applicability and ability to use computer-adapted technology to survey. Measures are repeated at clinic visits, both pre- and postoperatively. Data were reviewed through February 2018. Data were analyzed comparing pre- and postop physical function PRO (PF PRO) by procedure: laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). Additional variables were included in an adjusted linear mixed-effects regression model in order to isolate the effect of surgery on PF PRO over time. RESULTS: This cohort included 279 bariatric surgery patients. The mean follow-up time was 1.5 years after surgery. The procedure groups were similar in terms of age and race but differed by gender and preoperative BMI. The PF-PRO measure showed significant improvement following surgery for both procedures. CONCLUSION: Patient-reported physical function improved significantly after bariatric surgery. There was no significant difference between procedures.

Randomized sham-controlled trial of the 6-month swallowable gas-filled intragastric balloon system for weight loss.

BACKGROUND: Obesity is a significant health problem and additional therapies are needed to improve obesity treatment. OBJECTIVE: Determine the efficacy and safety of a 6-month swallowable gas-filled intragastric balloon system for weight loss. SETTING: Fifteen academic and private practice centers in the United States. METHODS: This was a double-blind, randomized sham-controlled trial of the swallowable gas-filled intragastric balloon system plus lifestyle therapy compared with lifestyle therapy alone for weight loss at 6 months in participants aged 22 to 60 years with body mass index 30 to 40 kg/m2, across 15 sites in the United States. The following endpoints were included: difference in percent total weight loss in treatment group versus control group was >2.1%, and a responder rate of >35% in the treatment group. RESULTS: Three hundred eighty-seven patients swallowed at least 1 capsule. Of participants, 93.3% completed all 24 weeks of blinded study testing. Nonserious adverse events occurred in 91.1% of patients, but only .4% were severe. One bleeding ulcer and 1 balloon deflation occurred. In analysis of patients who completed treatment, the treatment and control groups achieved 7.1 ± 5.0% and 3.6 ± 5.1% total weight loss, respectively, and a mean difference of 3.5% (P = .0085). Total weight loss in treatment and control groups were 7.1 ± 5.3 and 3.6 ± 5.1 kg (P < .0001), and body mass index change in the treatment and control groups were 2.5 ± 1.8 and 1.3 ± 1.8 kg/m2 (P < .0001), respectively. The responder rate in the treatment group was 66.7% (P < .0001). Weight loss maintenance in the treatment group was 88.5% at 48 weeks. CONCLUSIONS: Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.

Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-En-Y Gastric Bypass.

BACKGROUND: While there are various techniques to create the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass (LRYGB), many surgeons prefer using a circular stapler. One drawback of this method, however, is the higher incidence of surgical site infections (SSIs). To investigate the effect of a dual ring wound protector on SSIs during LRYGB. METHODS: In April 2016, our bariatric surgical group implemented an intervention whereby a dual ring wound protector in conjunction with a conical EEA stapler introducer was used when creating the gastrojejunostomy. SSIs from pre- and post-intervention were compared using Fisher's exact test. Only LRYGBs performed with a circular stapler were included in our analysis. Student's t test and χ2 were used to compare pre- and post-intervention groups with respect to demographics and co-morbidities. RESULTS: Between April 2015 and January 31st, 2017, our surgeons performed 158 LRYGBs using a circular stapler for the gastrojejunostomy. There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group. The pre- and post-intervention groups were not statistically different. The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.0371). The use of a dual ring wound protector for LRYGBs with circular stapled gastrojejunostomy was associated with an 86% relative risk reduction in SSIs. CONCLUSION: Using a dual ring wound protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled gastrojejunostomy significantly decreased SSIs.

Pyloroplasty Offers Relief of Postfundoplication Gastroparesis in Patients Who Improved After Botulinum Toxin Injection.

BACKGROUND: Endoscopic intrapyloric Botox (onabotulinumtoxin A; Allergan Pharmaceuticals) injections can improve postfundoplication gastroparesis, but responses are not durable. Surgical pyloroplasty may relieve gastroparetic symptoms, but patient selection criteria are poorly defined. We hypothesize that pyloroplasty provides durable improvement in patients whose symptoms improved after Botox injection. STUDY DESIGN: A retrospective chart review was performed of patients with postfundoplication gastroparesis who improved after Botox injection and then underwent pyloroplasty. Gastric emptying studies (GES), Gastroparesis Cardinal Symptom Index (GCSI) score, symptoms, and outcomes were reviewed. RESULTS: Ten patients received Heineke-Mikulicz pyloroplasty after reporting improvement with Botox injection. The mean operative time was 114 minutes (range 55-234 minutes). Three of 10 patients required conversion to open surgery, and the median length of stay was 3 days. Gastroparesis symptom improvement occurred in 9 of 10 patients. Postoperative GES normalized in 5/5 patients (median 205 decreased to 70 min, P < .05). Median preoperative GCSI was 3.67, improved to 2.22 at 1 month postsurgery (P = .010) and to 2.11 on most recent follow-up (P = .015). Median duration of follow-up was 34 months (range 1-101 months). CONCLUSION: Heineke-Mikulicz pyloroplasty can improve symptoms and gastric emptying times in patients with postfundoplication gastroparesis. Improvement with intrapyloric Botox injection may select candidates for pyloroplasty.

Pregnancy After Bariatric Surgery: National Survey of Obstetrician's Comfort, Knowledge, and Practice Patterns.

OBJECTIVE: The objective of this study is to survey a nationally representative sample of obstetricians regarding comfort, knowledge, and practice patterns of caring for pregnant women after bariatric surgery. MATERIALS AND METHODS: We conducted an online survey of US obstetricians and describe obstetrician's demographics, practice settings, and practice patterns. We assessed respondent's knowledge and recommended practices. We compared provider knowledge by years since completing residency, scope of practice (generalist or specialist), and practice setting (academic setting or other). Statistical significance was set at p < 0.05. RESULTS: A total of 106 completed the survey (response rate of 54%). Respondents had a median age of 47 and median 17 years in practice. Sixty-two percent were generalists. Nearly all of the respondents (94%) had some experience with caring for pregnant women after bariatric surgery and 83% reported feeling "very comfortable" (48%) or "somewhat comfortable" (35%) providing care for this population. Most (74%) were aware of increased risk of small for gestational age after surgery. Only 13% were able to correctly identify all recommended nutritional labs and 20% reported that they "did not know" which labs are recommended. There were no differences in comfort, experience, knowledge, and practice patterns by physician characteristics and practice settings. CONCLUSION: While most obstetricians are aware of perinatal risks after bariatric surgery, a substantial percentage of obstetricians are unaware of recommended practices regarding nutrition and nutritional monitoring. As bariatric surgery becomes increasingly prevalent among reproductive age women, educational interventions to increase obstetricians' knowledge of optimal care of pregnant women after bariatric surgery are urgently needed.

Preventing Returns to the Emergency Department FollowingBariatric Surgery.

BACKGROUND: Unnecessary emergency department (ED) visits following bariatric surgery represent a significant source of inefficient resource utilization. This study aimed to identify potential strategies aimed at preventing unnecessary returns to the ED following bariatric surgery. The study was conducted in University Hospital, USA. METHODS: The electronic medical records of all patients who underwent bariatric surgery at our institution between January 2011 and October 2015 were retrospectively reviewed. Information regarding procedure, gender, age, preoperative BMI, obesity-related comorbid conditions, postoperative length of stay (LOS), and reasons for ED visits within 90 days of surgery were obtained. Six practitioners (four attending surgeons, one resident physician, and one physician assistant) independently reviewed patient chief complaint and clinical findings at the time of ED returns. Reasons for ED return were scored as either preventable or non-preventable. "Preventable" denoted that an ED return could potentially be avoided by means of a system change in our bariatric practice. RESULTS: Our institution performed 361 bariatric procedures during the study period. Of these, 65 patients had 91 ED visits, 23 of which resulted in readmissions, and two of which required operative interventions. The ≤90-day all-cause postoperative ED visit rate was 18% (n = 65). Of the 91 ED visits, 47% were deemed preventable (n = 43). The most common preventable reasons for ED returns were nausea, vomiting, dehydration (NVD) (27.9%), postoperative pain (25.6%), wound evaluations (20.9%), and compliance issues (14%). CONCLUSIONS: Postoperative ED visits following bariatric surgery are prevalent and costly. Many of these visits are potentially preventable. Implementing outpatient strategies to address these causes will likely attenuate inefficient resource utilization.

Safety Analysis of Bariatric Patients Undergoing Outpatient Upper Endoscopy with Non-Anesthesia Administered Propofol Sedation.

BACKGROUND: Non-anesthesia administered propofol (NAAP) has been shown to be a safe and effective method of sedation for patients undergoing gastrointestinal endoscopy. Bariatric surgery patients are potentially at a higher risk for sedation-related complications due to co-morbidities including obstructive sleep apnea. The outcomes of NAAP in bariatric patients have not been previously reported. METHODS: In this retrospective cohort study, severely obese patients undergoing pre-surgical outpatient esophagogastroduodenoscopy (EGD) were compared to non-obese control patients (BMI ≤ 25 kg/m2) undergoing diagnostic EGD at our institution from March 2011-September 2015 using our endoscopy database. Patients' demographics and procedural and recovery data, including any airway interventions, were statistically analyzed. RESULTS: We included 130 consecutive pre-operative bariatric surgical patients with average BMI 45.8 kg/m2 (range 34-80) and 265 control patients with average BMI 21.9 kg/m2 (range 14-25). The severely obese group had a higher prevalence of sleep apnea (62 vs 8%; p < 0.001), experienced more oxygen desaturations (22 vs 7%; p < 0.001), and received more chin lift maneuvers (20 vs 6%; p < 0.001). Advanced airway interventions were rarely required in either group and were not more frequent in the bariatric group. CONCLUSIONS: With appropriate training of endoscopy personnel, NAAP is a safe method of sedation in severely obese patients undergoing outpatient upper endoscopy.

Transepithelial Transport of PAMAM Dendrimers Across Isolated Human Intestinal Tissue.

Poly(amido amine) (PAMAM) dendrimers have shown transepithelial transport across intestinal epithelial barrier in rats and across Caco-2 cell monolayers. Caco-2 models innately lack mucous barriers, and rat isolated intestinal tissue has been shown to overestimate human permeability. This study is the first report of transport of PAMAM dendrimers across isolated human intestinal epithelium. It was observed that FITC labeled G4-NH2 and G3.5-COOH PAMAM dendrimers at 1 mM concentration do not have a statistically higher permeability compared to free FITC controls in isolated human jejunum and colonic tissues. Mannitol permeability was increased at 10 mM concentrations of G3.5-COOH and G4-NH2 dendrimers. Significant histological changes in human colonic and jejunal tissues were observed at G3.5-COOH and G4-NH2 concentrations of 10 mM implying that dose limiting toxicity may occur at similar concentrations in vivo. The permeability through human isolated intestinal tissue in this study was compared to previous rat and Caco-2 permeability data. This study implicates that PAMAM dendrimer oral drug delivery may be feasible, but it may be limited to highly potent drugs.

Acceptability of the decision support for safer surgery tool.

BACKGROUND: We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events. METHODS: The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests. RESULTS: During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably. CONCLUSION: The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings.

A comparison of outcomes between open and laparoscopic surgical repair of recurrent inguinal hernias.

BACKGROUND: Inguinal hernia recurrence after surgical repair is a major concern. The authors report their experience with open and laparoscopic repair of recurrent inguinal hernias. METHODS: After institutional review board approval, a retrospective review was performed with the charts of 197 patients who had undergone surgical repair of recurrent inguinal hernias from January 2000 through August 2009, and the data for 172 patients who met the inclusion criteria were analyzed. Surgical variables and clinical outcomes were compared using Student's t test, the Mann-Whitney U test, chi-square, and Fisher's exact test as appropriate. RESULTS: The review showed that 172 patients had undergone either open mesh repair (n=61) or laparoscopic mesh repair (n=111) for recurrent inguinal hernias. Postoperative complications were experienced by 8 patients in the open group and 17 patients in laparoscopic group (p=0.70). Five patients (8.2%) in the open group and four patients (3.6%) in the laparoscopic group had re-recurrent inguinal hernias (p=0.28). Four patients in the open group (9.5%) and no patients in the laparoscopic group had recurrence during long-term follow-up evaluation (p=0.046). In the laparoscopic group, 76 patients (68.5%) underwent total extraperitoneal (TEP) repair, and 35 patients (31.5%) had transabdominal preperitoneal (TAPP) repair. Postoperative complications were experienced by 13 patients in the TEP group and 4 patients in the TAPP group (p=0.44). Two patients (2.6%) in the TEP group and two patients (5.7%) in the TAPP group had re-recurrent inguinal hernias (p=0.59). CONCLUSIONS: This retrospective review showed no statistical difference in the re-recurrence rate between the two techniques during short-term follow-up evaluation. However, the laparoscopic technique had a significantly lower re-recurrence rate than the open technique during long-term follow-up evaluation. Both procedures were comparable in terms of intra- and postoperative complications. Among laparoscopic techniques, TEP and TAPP repair are acceptable methods for the repair of recurrent inguinal hernia. A multicenter prospective randomized control trial is needed to confirm the findings of this study.

Surgeon perceptions of Natural Orifice Translumenal Endoscopic Surgery (NOTES).

INTRODUCTION: If proven feasible and safe, Natural Orifice Translumenal Endoscopic Surgery (NOTES) would still need acceptance by surgeons if it were to become a mainstream approach. METHODS: Three hundred fifty-seven surgeons responded to a preliminary survey describing NOTES and were asked to rate the importance of various surgical considerations and (assuming availability and safety) if they would choose to undergo and/or perform cholecystectomies by NOTES or laparoscopy and why. RESULTS: The risk of having a complication was considered most important. NOTES was theorized to be riskier and to require greater skill than laparoscopy but to potentially cause less pain and convalescence. Nearly three-fourths (72%) of surgeons expressed interest in NOTES training which correlated with younger age, SAGES membership, minimally invasive surgery specialization, and flexible endoscopic volume. Forty-four percent would like to introduce NOTES cholecystectomy into their practices. Among those not preferring NOTES, 88% would adopt NOTES if data showed improved outcomes over laparoscopy. Finally, only 24% would choose to undergo cholecystectomy themselves by NOTES, believing it to be too new and riskier than laparoscopy. DISCUSSION: The risk of having a complication is the greatest concern among surgeons, and safety will affect NOTES acceptance. CONCLUSION: The results of this survey seem to justify more focused future investigations.

Patient attitudes and expectations regarding natural orifice translumenal endoscopic surgery.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has theoretical patient advantages. Because public attitude toward NOTES will influence its adoption, this study aimed to assess patients' opinions regarding the NOTES procedure. METHODS: For this study, 192 patients were surveyed. Both NOTES and laparoscopic surgery (LS) are described together with an example case. Presurgical patients rated the importance of various aspects of surgical procedures and their preference for cholecystectomy via NOTES or LS. RESULTS: Complication risks, recovery time, and postoperative pain were considered more important than cosmesis, cost, length of hospital stay, or anesthesia type (p < 0.001). In the self-reports, 56% of the respondents preferred NOTES for their cholecystectomy and 44% chose LS. The patients perceived NOTES as having less pain, cost, risk of complications, and recovery time but requiring more surgical skill than open surgery or LS (p < 0.04). College-educated patients were more likely to choose NOTES, whereas patients 70 years of age or older and those who had undergone previous flexible endoscopy were less likely to select NOTES (p < 0.04). Although 80% of the patients choosing NOTES still preferred it even if it carried a slightly greater risk than LS, their willingness to choose NOTES decreased as complications, cost, and hospital distance increased and as surgeon experience decreased (p < 0.001). This study had a limitation in that the survey population was from surgery clinics. CONCLUSION: A majority of the patients surveyed (56%) would choose NOTES for their cholecystectomy. The deciding characteristics of the patients were more education, youth, and no previous flexible endoscopy. Procedure-related risks, pain, and recovery time were more important than cosmesis, cost, length of hospital stay, and anesthesia type in the choice of a surgical approach. Patients were less willing to accept NOTES as risks and costs increased and as surgeon experience and availability decreased.

NOTES: cadaveric rendezvous hybrid small bowel resection.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques [1-4]. Before NOTES gains widespread popularity, it must be proven to be a safe and efficacious technique [5]. There are several proposed benefits to the NOTES approach, including potentially decreased abdominal pain, wound infections, and hernia formation. METHODS: Currently, most investigational NOTES procedures are performed using a single transgastric, transcolonic, or transvaginal access point to the abdomen. In order to provide greater range of motion and freedom of movement, a rendezvous procedure using simultaneous transgastric and transcolonic approaches was used to perform a small bowel resection. This video demonstrates a successful NOTES hybrid small bowel resection with the use of two laparoscopic ports in a cadaveric model. A powered stapling device attached to a flexible shaft is introduced transcolonically and facilitates division and re-anastamosis of the small bowel. A dual-channel operating endoscope introduced transgastrically allows for precise dissection and creation of enterotomies necessary for the small bowel resection. CONCLUSIONS: While technically challenging, NOTES hybrid small bowel resection can be accomplished with specially designed instrumentation utilizing the rendezvous technique. There are several technical limitations preventing this procedure from being completed in a pure NOTES fashion. A safe method of creating blind enterotomies will be needed to eliminate laparoscopic visualization of the enterotomy sites. Adequate endoscopic exposure and retraction of tissue is still difficult and currently requires percutaneous adjuncts. New closure devices will be needed for safe and reliable NOTES enterotomy closure. With the development of such instruments, this, as well as other NOTES procedures, will become more technically feasible.