Endoluminal Vacuum Therapy as a Salvage Procedure for Difficult Anastomotic Leak Post Roux-en-Y Gastric Bypass.

We present a case of a woman in her 60s, with a history of a gastric sleeve resection, over 50% excess body weight loss, and subsequent severe gastroesophageal reflux disease refractory to maximal medical therapy, who underwent a conversion of a sleeve gastrectomy to a Roux-en-Y gastric bypass with hiatal hernia repair. On postoperative day five, she was evaluated at our emergency department for vomiting and inability to tolerate oral intake. Imaging revealed a large retrocardiac hiatal hernia and extraluminal contrast extravasation. She was taken to the operating room after resuscitation, where the gastric pouch and roux limb were found to have significant edema with recurrence of the hernia. This was able to be reduced and a frank perforation was found at the posterior aspect of the anastomosis. A covered metal stent was placed by the gastroenterologist and drains were left in place.  In the ICU, nasojejunal feeds were stopped given suspicion of backflow with persistent leak. A decision was made to remove the stent and place an endoluminal vacuum (endoscopic vacuum-assisted wound closure [EVAC]). After three subsequent vacuum-sponge changes, the perforation was found to have healed. Patient was tolerating a diet on discharge. This case is an example of a complication where a multidisciplinary approach to a difficult leak resulted in recovery with the use of EVAC. We believe this is a valuable tool to have in our armamentarium for difficult-to-manage leaks.

The Importance of the Institution of a Robotic Curriculum on Resident Training and Performance.

In 2018, general surgery topped the number of robotic cases. Over 90% of residents participate, but only 65% of programs have a formal curriculum, and less than half track progress. Many are insufficient at training due to an observational role. This paper reviews Marshall University General Surgery Residency program's robotic curriculum, which started in 2018. The curriculum consists of a weekend course and simulations, enabling residents obtain certification. Residents participated in Intuitive's Resident Robotic Olympics with first place in 2019 and second and third place in 2020. For the 2021 year, the robotic curriculum was revised into phases based on year. Deadlines and forms help improve and track progress. It is important to develop a curriculum with a protocol for training, monitoring, and credentialing to ensure proficiency. Marshall University General Surgery robotic curriculum has been successful at improving robotic skill, enabling residents to obtain a robotic surgery certification upon graduation.