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Improving Patient Outcomes with Minimally Invasive Surgery

Each month, MISS eNews brings you the latest on novel minimally invasive techniques and findings from around the world.


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Vol. 8 No. 16



This month’s MISS eNews takes an international perspective, with an interview with MISS faculty member Dr. Matthew Kroh.  Dr. Kroh is Chief of the Digestive Disease Institute at Cleveland Clinic Abu Dhabi, which is one of its five Centers of Excellence. I spoke with Dr. Kroh about his personal and professional experience to date moving from northeast Ohio to Abu Dhabi and taking on a leadership position at this new institution, as well as asked some questions about the new campus itself. Enjoy the interview, as well as the article recommendations following it—all of which are from  staff who serve with Dr. Kroh at Cleveland Clinic Abu Dhabi.
Colleen Hutchinson

Interview with Dr. Matthew Kroh

Dr. Kroh is Institute Chairman, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, and faculty of MISS 2018

Colleen: What are some of the biggest differences in your experience at CCF Ohio versus your current experience internationally?

Dr. Kroh: Interestingly, the day-to-day practice is quite similar. However, the culture and interaction with patients, physician partners, and caregivers throughout the organization is quite different. We have a very diverse Digestive Disease Institute here at Cleveland Clinic Abu Dhabi. Physicians have trained around the world and represent diverse cultures from North America, Europe, and all parts of the Middle East. Similar to Ohio, my physician partners have come to Cleveland Clinic Abu Dhabi to provide world-class healthcare, and to advance education and research—similar to the goals within the United States. Our patient population is quite heterogeneous and hails from around the world. There is a significant portion of patients from the United Arab Emirates, and the greater region, but also from Southeast Asia, Northern Africa, and Southern Europe. This adds significant interest and unique challenges to caring for patients—not only in a clinical sense, but also because it requires a better awareness of individual cultures and expectations.

Colleen: What are the challenges to growing a program there?
Dr. Kroh: We’re in a phase of rapid growth. From a digestive disease standpoint, we’re focusing on new and expanding programs in bariatric surgery, liver and pancreatic disease, including transplantation, and programs in minimally invasive and robotic general and colorectal surgery, including inflammatory bowel diseases. We are looking to assemble a world-class team from diverse training programs to come together to address the needs of our patients. In particular, Cleveland Clinic Abu Dhabi is filling an important role as a tertiary referral center that is a comprehensive academic medical center for the region.

Colleen: Do you find differences in observations of patient characteristics, care/treatment paths, and clinical outcomes there versus in the US?
Dr. Kroh: Yes and no. Even though many of the services that we offer here previously weren’t available, the delivery from a technical standpoint is quite similar. However, patients present with different types and severities of disease than one might expect in the United States. One particularly important example of this is the obesity epidemic. Even though obesity and weight-related diseases are increasing worldwide, the metabolic effects of obesity are especially prevalent in the region. Among our bariatric surgery patients, nearly 40% at the time of operation already have a diagnosis of diabetes. This is in stark contrast to most US programs, and double what many centers often see.

Colleen: How does insurance differ there versus in the US?
Dr. Kroh: Insurance coverage is highly variable and reflects the diversity of the people in the country. It is important to realize that 85% of the population of Abu Dhabi is ex-patriot. The insurance coverage for these patients varies depending on country of origin and individual plans related to employment. Many of the patients from out of country who seek care here rely on government, private, and personal support..

Colleen: What has been the most surprising part of your experience moving from northeast Ohio to Abu Dhabi?
Dr. Kroh: From a professional standpoint, it has been very gratifying to assume a leadership position among an outstanding group of physicians and surgeons. I am consistently impressed by their outstanding care and breadth of experience. From a personal standpoint, it is a unique and tremendous opportunity to experience a new and rich culture, and access to an entirely new part of the world. This has been especially true for our 10-, 12-, and 14-year-old children who are gaining exposure that will broaden their global perspectives.

Colleen: Is there a difference in adoption to new techniques and procedures there?
Dr. Kroh: The way in which new technologies and therapies are introduced to the region are similar; however, Cleveland Clinic provides access to therapies that previously did not exist. As in the United States, introduction of new and innovative therapies, when backed by appropriate data, is one of the foremost missions of our institution. Digestive diseases are increasingly being treated by minimally invasive surgery and advanced endoscopic procedures. It has been exciting to introduce new therapies here, such as per oral endoscopic myotomy (POEM) for achalasia, per oral pyloromyotomy (POP) for gastroparesis, as well as primary endoluminal therapies for metabolic diseases and management of bariatric surgery complications with endoscopy. Additionally, our programs unique to the region include a comprehensive hepato-pancreatico-biliary center including transplantation, inflammatory bowel disease, a swallowing center, and endocrine surgery expertise. These sorts of cutting-edge treatments previously were not performed at all or not readily available. It is quite gratifying to be able to treat patients effectively and in a less invasive way.


Suggested Readings


Article: Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: A randomized controlled trial. Watson DI, Thompson SK, Devitt PG, Smith L, Woods SD, Aly A, Gan S, Game PA, Jamieson GG. Ann Surg. 2015 Feb;261(2):282-9.
Dr. Ricard Corcelles: Currently, there remains hesitancy about the preferred technique for repair of very large hiatus hernia. Surgeons disagree about whether or not to use mesh, and what type of mesh is best. In order to answer this demand, Watson and colleagues piloted a prospective double-blinded randomized trial (n=126) designed to define the effectiveness of mesh repair for large hiatus hernia. The primary outcome for the study was recurrence of hiatus hernia using barium meal radiology and upper gastrointestinal endoscopy. At one-year follow-up, no significant differences for mesh versus sutured repair were identified. However, absorbable mesh was associated with the highest recurrence rate 31%, versus 23% after suture repair, and 13% after no absorbable mesh. The strengths of this study are the high follow-up rate (at least 90% per treatment arm), it is double blinded, and it is a multicentre trial.


Article: Endoscopic submucosal dissection versus surgical resection for early gastric cancer: a retrospective multicenter study on immediate and long-term outcome over 5 years. Seung Jee Ryu, Byung-Wook Kim, Boo Gyeong Kim, et al. Surg Endosc. 2016 Dec;30(12):5283-5289.
Dr. Ricard Corcelles: Endoscopic submucosal dissection (ESD) has been acknowledged as a treatment option for selected early gastric cancers (EGC). Nevertheless, extended indications for ESD are not broadly accepted (mucosal cancer > 2 cm without ulcer; mucosal cancer with an ulcer < 3 cm; and minimal submucosal invasive cancer). The aim of this study was to evaluate long-term oncologic outcomes after ESD (n=81) versus surgical resection (n=144). After more than 5 years of follow-up, Ruy et al. reported no difference in overall survival rate for EGC lesions that met the expanded criteria. However, these results must be cautiously appraised as per recurrence and disease-free survival rate: five-year cancer recurrence rate of the ESD group was 12.3% versus 2.1% of the surgical group (p<0.01); five-year disease-free survival rate of the surgical group was 97% versus 85% of the ESD group (p<0.01). In summary, the study shows that ESD might be an acceptable option for EGC considering overall survival rates but with higher risk of recurrences.


Article: Laparoscopic extraperitoneal repair versus open inguinal hernia repair:20 year follow-up of a randomized controlled trial. Barbaro A, Kanhere H, Bessell J, et al. Hernia (2017) 21: 723-727.
Dr. Bret Cardwell: Authors reopened a randomized controlled trial that was finished in 1994. They specifically looked at the 20-year hernia recurrence rate. Data was available on 98 or 104 (94%) of the original study participants, a surprisingly high percentage. The value of this is an important and intriguing look at the lifetime durability of TEP vs open mesh inguinal hernia repairs. Yes, this was early in the history of laparoscopic hernia repair. When I ask my patients which is more important to them—low recurrence or low early postoperative pain, the answer is usually, “Doc, I only want to go through this surgery once!” If low recurrence rates our patients’ “gold standard” of inguinal hernia repair, then open repair remains the champion.


Article: Factors associated with hernia recurrence after laparoscopic total extraperitoneal repair for inguinal hernia:a 2-year prospective cohort study. Schjøth-Iversen L, Refsum A, Brudvik K. Hernia (2017) 21: 729-735.
Dr. Bret Cardwell: This is detailed, in-depth, and is a large (1194) cohort of patients. The study results support three preoperative factors for postoperative hernia recurrence after TEP: 1) BMI >30; 2) type of inguinal hernia “medial” (direct); and 3) repair of recurrent hernia. This was a well-done study, and the large size allowed the variables to show a clear result. The problem became that that a clear result was not carried over into the conclusion, as the conclusion stated information that was not studied in the project. Focus on what matters, and if obesity, hernia type, and recurrent hernias are what matter, how do we as surgeons improve our outcomes using that information?


Article: What are the long-term results 8 years after sleeve gastrectomy? Noel P, Nedelcu M, Eddbali I, Manos T, Gagner M. Surg Obes Relat Dis. 2017 Jul;13(7):1110-1115.
Dr. Javed Ahmed Raza: Sleeve gastrectomy has become the most commonly performed bariatric procedure in the world. There is very little data about the long-term effectiveness and complications of sleeve gastrectomy. This article highlights successful weight loss maintenance in 59% of cases at 8 years. 20% of the patients required revisional surgery. In addition, 31% of patients reported gastroesophageal reflux symptoms at 8 years. These are some of the important areas that need to be discussed when counseling patients for sleeve gastrectomy.


Article: Comparison of economic and clinical outcomes between patients undergoing laparoscopic bariatric surgery with powered versus manual endoscopic surgical staplers. Roy S, Yoo A, Yadalam S, Fegelman EJ, Kalsekar I, Johnston SS. J Med Econ. 2017 Apr;20(4):423-433.
Dr. Javed Ahmed Raza: This is a large-scale study of over 30,000 patients undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy comparing the outcomes with the use of either manual or powered staplers. The powered stapler group was associated with lower costs and lower rate of bleeding/transfusion especially in the sleeve gastrectomy group.


Article: Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Kumar N, Thompson CC. Gastrointest Endosc. 2016 Apr;83(4):776-9.
Dr. Matthew Kroh: Bariatric surgery, and in particular, Roux en-Y gastric bypass, is a proven, durable therapy for obesity and weight-related diseases. With the current obesity epidemic, hundreds of thousands of patients worldwide undergo successful surgical procedures that improve their overall health and ultimately mortality. However, there is a subset of patients, probably on the order of 5 to 25%, who will have weight regain and accruement of weight related comorbid diseases. For these patients, options are limited. Endoluminal revision offers compelling advantages in that the procedure is performed transorally, avoiding the operative field, and typically requires a short or no-hospital stay with excellent safety profiles. However, efficacy and durability of these interventions has been limited to date.
Kumar et al present their experience in this study with endoscopic gastrojejunostomy revision after previous Roux en-Y gastric bypass, and subsequent weight regain. The group has previously published their earlier experiences, and this cohort of 150 patients at 3 years represents one of the largest series of patients at the furthest time point from intervention. Inclusion criteria included gastrojejunostomy >15mm, and average weight regain was nearly 50% of excess weight loss after weight nadir. Adverse events were mild and rare. The authors show an 8.7% total body weight loss at 3 months after the procedure. At 36-month follow-up, with 110 of the 150 original patients available for evaluation, the total body weight loss was maintained at 8.6%, with a larger standard deviation. The authors do not report on weight-related comorbid diseases, nor do they describe other interventions that might have been instituted by a multidisciplinary team, including nutritional education, exercise programs, and pharmacotherapy interventions.
Endoscopic revision of bariatric surgical procedures is a compelling intervention with improving outcomes. This study reports on a large group of patients at 3 years, representing longer-term data for these evolving procedures. Further studies, including longer duration of follow-up and further generalizability beyond specialized centers, will likely dictate whether these procedures will be more commonly used to treat patients with weight regain after previous surgery.


Article: Teaching peroral endoscopic myotomy (POEM) to surgeons in practice: an "into the fire" pre/post-test curriculum.
Kishiki T, Lapin B, Wang C, Jonson B, Patel L, Zapf M, Gitelis M, Cassera MA3, Swanström LL, Ujiki MB. Surg Endosc. 2017 Sep 15. doi: 10.1007/s00464-017-5823-3. [Epub ahead of print]
Dr. Matthew Kroh: Per oral endscopic myotomy (POEM) for achalasia is increasingly being used to treat all types of achalasia. Groups worldwide are accruing experience and reporting data that show the efficacy, and increasingly, the durability of the procedure. The skill set necessary to treat patients and perform this advanced endoscopic procedure is being gained across a spectrum of practitioners, trained in surgical and gastroenterological paradigms. Little data exists on the optimal training mechanism to further propagate this procedure and other similar advanced techniques, especially in the post-graduate period.
In this report from Kishiki et al, the investigators report a series of courses taught by 11 experienced POEM endoscopists (personal experience >50) from two centers, and the results of a proposed training curriculum to teach POEM. With a program of pre-procedural training, didactic lectures, and hands-on experience with ex vivo and in vivo models, 65 participants were evaluated. Even with pre-test disparities between their “expert” and “novice” groups, the proposed curriculum resulted in similar post-course testing results, indicating that the curriculum and skills testing improved both groups, but in particular the lower skill set group. Data on specific trainee experience in advanced endoscopic procedures would be helpful to better gauge pre-course skill sets, and it would also be interesting to see how many of the participants eventually ended up performing POEM after the training session.
In an era when increasingly complex endoluminal surgical procedures are being performed, training and expertise development remains a challenge. Increasingly, validated and readily available programs will need to be established to allow for these minimally invasive therapies to be widely available to our patients.


Article: Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial. Ponsioen CY, de Groof EJ, Eshuis EJ, LIR!C study group, et al. Lancet Gastroenterol Hepatol. 2017;2(11):785-792.
Dr. Shafik Sidani: Nonstricturing short segment Crohn’s disease of the terminal ileum intractable to conservative management is generally treated by escalation to biologic agents. This study offers laparoscopic ileocecal resection as an alternative to treatment with biologics with comparable patient-reported quality of life outcomes and morbidity in this group of patients. It will be interesting to hear about the cost-effectiveness data comparing the two groups in the future.


Article: One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis. Schultz JK, Wallon C, Blecic L, Forsmo HM, Folkesson J, Buchwald P, Kørner H, Dahl FA, Øresland T, Yaqub S; SCANDIV Study Group. Br J Surg. 2017;104(10):1382-1392.
Dr. Shafik Sidani: Surgical management of Hinchey III diverticulitis has become controversial with the emergence of laparoscopic lavage as an alternative to resection. This study comparing the two approaches reports one-year results showing that severe morbidity and mortality are similar. It highlights the shortcomings of each approach, increased unplanned reinterventions in the lavage group, and an increased stoma rate in the resection group. It cautions about the specific risks associated with lavage.


Vol. 8 No. 15



It is my pleasure this month to feature an interview with Dr. Ted Adams, of Intermountain Healthcare in Salt Lake City, Utah. Dr. Adams is a member of the 2018 Minimally Invasive Surgery Symposium faculty and co-author of the recent critical New England Journal of Medicine article titled “Weight and Metabolic Outcomes 12 Years after Gastric Bypass.” The bariatric article recommendations in this issue of MISS E-News focus on this article. Original in its design, the study compares patients who underwent Roux-en-Y gastric bypass (surgery group) with both patients who sought but did not undergo surgery (mainly because of insurance coverage issues) (nonsurgery group 1) and patients who did not seek surgery. Their findings illustrate the durability of Roux-en-Y gastric bypass surgery, showing long-term weight loss, and lower incidence of diabetes, blood pressure and dyslipidemia at 12 years postoperative versus not having surgery. Read on for some insights from Dr. Adams on these exciting findings, and be sure to join us at the 2018 MISS to hear Dr. Adams speak on his study in person.
Please enjoy the article recommendations from thought leaders in minimally invasive surgery, and we hope you’ve planned your travel to Las Vegas for MISS, March 6-9, 2018.
Colleen Hutchinson


Dr. Schauer: How does this new study highlight access-to-surgery issues, and what are your thoughts on treatment access?
Dr. Adams: This long-term study supports the finding that bariatric surgery is the only treatment for severely obese patients who wish to reduce and maintain weight loss. The findings of this study may provide greater incentive for insurance companies to cover such weight loss procedures.

Dr. Schauer: Let’s discuss durability. What does your study in terms of long-term durability of weight loss illustrate, and how does your study compare to the Swedish Obesity Study (SOS) and the veterans Arterburn study in terms of showing durability of weight loss following surgery?
Dr. Adams: Weight loss durability out to 12 years following RYGB surgery was impressive in this Utah study, with very little change in mean percent weight loss from 6 to 12 years (-28.0% weight loss at 6 years compared to -26.9% at 12 years). Similarly, the SOS study reported a weight loss of -25% at 10 years following RYGB and a large retrospective Veterans study by Arterburn et al. reported a 10-year post-RYGB surgery percent weight loss of -28.6%.

Dr. Schauer: Is the durability of improvement in diabetes remission equally as favorable as with weight loss?
Dr. Adams: Using the same criteria for defining diabetes remission throughout the entire study, the 12-year follow-up for diabetes was 51%, compared to 62% and 75% at years 6 and 2, respectively. This represents a change in percent diabetes remission of 32% from years 2 to 12. In comparison, the change in percent weight loss from 2 to 12 years was 23%. This would suggest weight loss durability (23% change) is slightly better compared to durability of diabetes remission (32% change).

Dr. Schauer: Other than weight loss and diabetes remission, what other cardiovascular benefits did you find most remarkable?
Dr. Adams: Perhaps the most significant additional benefit reported for patients who had RYGB surgery was their very low incidence of diabetes. Only 3% of the RYGB surgery patients developed diabetes over the 12-year follow-up period. Additional benefits for the RYGB patients included improved blood lipids and high blood pressure.

Dr. Schauer: Did you find any complications to surgery that are noteworthy?
Dr. Adams: The participants who had RYGB surgery had a greater number of suicides when compared to the non-surgical participants. This finding has been reported in other bariatric surgery studies. This finding suggests greater attention be given to this uncommon but very serious outcome.

Dr. Schauer: Thank you for taking the time, Ted. We look forward to hearing more on your findings when you present at the 2018 MISS.


Suggested Readings


Article: Risk of death among users of proton pump inhibitors: a longitudinal observational cohort study of United States veterans. Xie Y, Bowe B, Li T, Xian H, Yan Y, Al-Aly Z. BMJ Open. 2017 Jul 4;7(6):e015735.
Dr. Ajita Prabhu: This article is interesting because after proton pump inhibitors (PPI) came along, there was a substantial shift away from anti-reflux surgery in favor of medical therapy. As PPIs have become widely available over the counter, their use has also increased. Most medications, as we know, have some side effect profile, and likely anything we do to change our body's natural physiology comes with some consequence. Because this is an observational study and not a prospective head-to-head comparison, it's difficult to draw any hard conclusions that can inform the use of PPIs. Also, there is some potential that the patients who took PPIs in this study had greater risk of death for other reasons that are unmeasured variables in this case. That said, I think that considering this article in combination some other recent literature about PPIs, these findings probably warrant a closer look at this line of therapy. I don't think that doctors and patients should abandon PPIs at this point based on these findings. Rather, more prospective studies are needed, and also maybe it would be helpful to take a pause before just assuming all meds are ok to take. It's probably a good idea to consider potential consequences of the use of these drugs instead of assuming that they are all harmless just because they are widely available.


Article: Simulation model for laparoscopic foregut surgery: the University of North Carolina Foregut Model. Schlottmann F, Murty NS, Patti MG. J Lap Adv Surg Techniques. July 2017, 27(7): 661-665.
Dr. Akshay Chauha/ Dr. Dmitry Oleynikov: Surgical simulation has undergone an enormous transformation since the early 1990s, evolving from manikins and plastic benchtop kits to 3D printing and patient-specific virtual reality systems. While traditional simulators like cadavers and bench-top models were mostly used to train and assess the skills of novice surgeons, new-age simulators help expert surgeons prepare for unique surgical conditions specific to the patient. These new devices are redefining the role of simulations, expanding their use from training to preoperative planning. However, this new technology comes with a huge cost, which is not affordable by many training programs.
The authors in this paper have made an innovative model to bridge the significant gap that presently exists between box-lap and virtual-reality simulators and live surgery. They have developed a high-fidelity, real tissue simulator that allows training in laparoscopic foregut operations. This allows the surgeon to practice laparoscopic foregut procedures preoperatively in a virtual environment with accurate renditions of the patient’s anatomical variations. This will hopefully decrease the cost of physician training while increasing physician quality in the future.


Article: Efficacy and safety of the over-the-scope clip (OTSC) system in the management of leak and fistula after laparoscopic sleeve gastrectomy: A systematic review. Shoar S, Poliakin L, Khorgami Z, et al. Obes Surg. 2017 Sep;27(9):2410-2418. doi: 10.1007/s11695-017-2651-4.
Dr. Douglas Adler: The authors provide a good meta-analysis on adverse events after bariatric surgery and how to fix them. Bariatric fistulas are really common and vexing—the paper looks at endoscopic means to fix them and how well they work.


Article: Endoscopic submucosal dissection and EMR for large colorectal polyps: "The perfect is the enemy of good." Heitman SJ, Bourke MJ. Gastrointest Endosc. 2017 Jul;86(1):87-89.
Dr. Emre Gorgun: I like this article from Michael Bourke in which he envisions that essentially all benign and low-risk malignant lesions in the colorectum will be one day recognized, accurately characterized, and ultimately cured without surgery. He acknowledges that endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are remarkable innovations and represent a leap forward toward realizing


Article: Does preoperative bowel preparation reduce surgical site infections during elective ventral hernia repair? Krpata DM, Haskins IN, Phillips S, Prabhu AS, Rosenblatt S, Poulose BK, Rosen MJ. J Am Coll Surg. 2017 Feb;224(2):204-211.
Dr. Michael Rosen: Dr. Krpata et al from the Americas Hernia Society Quality Collaborative (AHSQC) recently examined the potential benefits and pitfalls in utilizing a routine mechanical bowel preparation for patients undergoing elective ventral hernia repairs. This practice is often touted as making it easier to handle the bowel and reducing potential intraoperative or postoperative complications. However, to date, no other group has evaluated the utilization of bowel preparation in elective ventral hernia. It is an important point, as many patients do not like to take a bowel preparation prior to hernia surgery, and it has been postulated to increase ileus and is certainly associated with perioperative dehydration in many patients. Utilizing the AHSQC database, the authors evaluated 3,709 patients that underwent hernia repair and compared those that received a mechanical bowel preparation with a group that did not utilize logistic regression modeling. Their findings were very interesting as they noted that patients that had a clean ventral hernia repair (CDC class I) were significantly more likely to experience a surgical site infection, surgical site occurrence, and surgical site occurrence requiring procedural intervention if they had a preoperative mechanical bowel prep. Even when evaluating the patients with contaminated hernias, a bowel preparation was still more likely to result in surgical site occurrences requiring procedural intervention when compared to those that did not receive a prep. Given this information from a large database with well-matched groups, it seems reasonable to eliminate mechanical bowel preparation from the preoperative optimization of patients undergoing ventral hernia repairs.


Article: Drain placement does not increase infectious complications after retromuscular ventral hernia repair with synthetic mesh: an AHSQC analysis. Krpata DM, Prabhu AS, Carbonell AM, Haskins IN, Phillips S, Poulose BK, Rosen MJ. J Gastrointest Surg. 2017 Oct 5. doi: 10.1007/s11605-017-3601-0. [Epub ahead of print]
Dr. Michael Rosen: This article tries to answer the age-old question of whether putting drains next to the mesh after an open ventral hernia repair is a good idea or a bad idea. Using the AHSQC database, the authors compared the results of 300 patients that underwent open retromuscular repairs with synthetic mesh, of which 200 had drains and 100 did not. Using a propensity-matched analysis, these authors found that retromuscular drain placement was not associated with any higher rates of surgical site infection, mesh infection, or other negative result. They did note, however, that drains tended to result in lower rates of seroma.


Article: Weight and metabolic outcomes 12 years after gastric bypass.
Adams TD, Davidson LE, Litwin SE, Kim J, Kolotkin RL, Nanjee MN, Gutierrez JM, Frogley SJ, Ibele AR, Brinton EA, Hopkins PN, McKinlay R, Simper SC, Hunt SC. N Engl J Med. 2017 Sep 21;377(12):1143-1155.
Dr. Ricardo Cohen: Twelve years after gastric bypass weight loss surgery, the benefits persist in most patients, leading to long-term weight loss, less diabetes, lower blood pressure and fewer cholesterol problems, according to a study of the technique that has had the longest follow-up so far. Researchers compared patients who underwent Roux-en-Y gastric bypass with patients who sought but did not undergo surgery (mainly because of insurance coverage issues) and patients who did not seek surgery.
While 26% of patients in the control groups had type 2 diabetes at the 12-year mark, the rate was a mere 3% with surgery. Remission was more likely when a patient with diabetes was not taking insulin and had a shorter history of the disease, probably because those patients still had enough healthy pancreas cells left to produce insulin. Cardiovascular risk markers, such as cholesterol, collectively improved more with the surgery. The reduction in high blood pressure was significantly greater compared to one of the control groups but not the other. The only drawback of the study was a slightly higher suicide rate within the surgical arm, but causes have yet to be studied. Bariatric surgery is a very efficient and durable option for obesity and its comorbid conditions.


Dr. Jaime Ponce: The relevance of this study is that the gastric bypass, a very effective surgical tool for patients suffering from severe obesity, has been compared to two non-surgical groups that otherwise might qualify for surgery but either didn’t have insurance coverage or were not considering it. The study is over 12 years, a long period of time. This comparative study is unique and very original in its design.
Findings clearly showed that surgery offers better weight loss, better diabetes remission, and lower incidence of hypertension and dyslipidemia at 12 years versus not having surgery.
What we can learn from this paper is that we have a very effective treatment tool for severely obese patients with associated medical problems. Bariatric surgery is safe and in long follow-up shows major weight loss benefits as well as improvement of major obesity-related health problems (diabetes, hypertension, dyslipidemia). Also, it is important to see that patients that are not having “access” to bariatric surgery, either because they don’t have specific insurance coverage or are not been educated, will suffer the consequences of remaining severely obese and deterioration of health and quality of life. Overall in the U.S., less than 1% of the eligible candidates for surgery are having bariatric surgery.(1) We must change the thinking about obesity and begin to remove the policy, social, medical, discriminatory, economic and perceptual barriers that deny people appropriate treatment and support before more people get sick or die. This study supports that treatment for obesity should be an essential health benefit that is provided by all health plans. [(1) Ponce J, DeMaria E, Nguyen NT, Hutter M, Sudan R, Morton JM.  Estimation of American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016;12:1637–1639.]


Article: Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. Berríos-Torres SI, Umscheid CA, Bratzler DW. JAMA Surg. 2017 Aug 1;152(8):784-791.
Dr. Emre Gorgun: This is an important publication in JAMA as the number of surgical procedures performed in the United States continues to rise, and morbidities likewise. This guideline includes multiple evidence-based recommendations for the prevention of surgical site infections (SSI) and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.


Article: Uptake of transanal total mesorectal excision in North America: initial assessment of a structured training program and the experience of delegate surgeons. Atallah SB, DuBose AC, Burke JP, et al. Dis Colon Rectum 2017;60:1023-1031.
Dr. Sean Langenfeld: Transanal total mesorectal excision (taTME) is an innovative approach to minimally invasive rectal cancer surgery, and has gained significant momentum both in practice as well as on the podium. As with all “hot” techniques, there are justified concerns that taTME will become widely disseminated despite a lack of data on long-term outcomes as well as a potential lack of surgeon expertise. Those performing TME from the bottom up will see the anatomy from a brand new perspective, and thus they will encounter new pitfalls, the most dreaded of which is urethral injury in male patients. This study evaluates a well-structured training program, and the authors are to be commended on their leadership and their ability to adapt their program over time. Of note, surgeons in this course are almost all experts in laparoscopic rectal cancer surgery, and yet the workshop involved rectal injury in 4.5% of cadavers and inadvertent prostate mobilization in 20%. A follow-up survey of workshop participants showed that 35% of surgeons reported needing 6 or more cases after the workshop to feel comfortable, while 45% were still uncomfortable with taTME. Additionally, 25% of respondents reported a urethral injury despite completion of the course, so it appears their lack of comfort is justified. To me, it is clear that taTME has an important role in rectal cancer surgery, especially in the narrow male pelvis, but it requires formal training and proper patient selection to avoid serious injury during the surgeon’s ascent of the learning curve.


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