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. 18
As we come up on the 18th Annual Minimally Invasive Surgery Symposium (MISS), I had the opportunity to speak to Phil Schauer, MD, Executive Director of the Minimally Invasive Surgery Symposium. With critical presentations on Enhanced Recovery After Surgery; education and discussion on new advances in endoscopic therapies, devices, and advanced surgical techniques; and valuable workshops in general and bariatric surgery, this year’s meeting is not one to miss (no pun intended!). Read on for a short take on the content of this meeting from its founder, and don’t miss the critical recommendations on new literature from thought leaders in general surgery. Enjoy!
Colleen: How would you characterize the unique value of attending MISS versus other conferences?
Colleen: What are some of the key topics and speakers for 2018 MISS?
Colleen: Can you tell the readers a little about ERAS and the decision to focus a section of the meeting on it?
Colleen: There are quite a few new techniques and technologies/devices in the metabolic surgery arena. Can you comment on some of those that you see as most promising and groundbreaking (in trial or approved)?
Article: Poor reproducibility of gallbladder ejection fraction by biliary scintigraphy for diagnosis of biliary dyskinesia. Rose J, Fields R, Strasberg S. J Am Coll Surg. 2017 Nov 17.
Article: Concurrent bariatric surgery and paraesophageal hernia repair: comparison of sleeve gastrectomy and Roux-en-Y gastric bypass. Shada AL, Stem M, Funk LM, Greenberg JA, Lidor AO. Surg Obes Relat Dis. 2018 Jan;14(1):8-13.
Article: Bariatric surgery in women of childbearing age, timing between operation and birth, and associated perinatal complications. Parent B, Martopullo I, Weiss N, et al. JAMA Surg 2017; 152 (20):128-135.
Article: Gastric bypass surgery produces a durable reduction in cardiovascular disease risk factors and reduces the long-term risks of congestive heart failure. Benotti, PN, Wood C, Carey DJ, et al. J Am Heart Assoc. 2017;6 017 May 23;6(5).
Article: Trainee-associated outcomes in laparoscopic colectomy for cancer: propensity score analysis accounting for operative time, procedure complexity and patient comorbidity. Kasten KR, Celio AC, Trakimas L, Manwaring ML, Spaniolas K. Surg Endosc 2018;32:702-711.
Article: Incisional hernia after midline versus transverse specimen extraction incision: a randomized trial in patients undergoing laparoscopic colectomy. Lee L, Mata J, Droeser RA, et al. Ann Surg 2017; Nov 21.
Article: Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: Mid-term analysis of an emerging procedure. Tyberg A, Nieto J, Salgado S, et al. Clin Endosc. 2017 Mar;50(2):185-190.
Article: Endoscopic or surgical step-up approach for infected necrotising pancreatitis: A multicentre randomised trial. van Brunschot S, van Grinsven J, van Santvoort HC, Dutch Pancreatitis Study Group, et al. Lancet. 2018 Jan 6;391(10115):51-58.
Article: Carolinas comfort scale as a measure of hernia repair quality of life: a reappraisal utilizing 3788 international patients. Heniford T, Lincourt A, Walters A, et al. Ann Surg. 2018 Jan;267(1):171-176.
Article: Higher recurrence rate after endoscopic totally extraperitoneal (TEP) inguinal hernia repair with ultrapro lightweight mesh: 5-year results of a randomized controlled trial (TULP-trial). Roos M, Bakker WJ, Schouten N, et al. Ann Surg. 2018 Jan 4. [Epub ahead of print]
Vol. 8 No. 17
Happy New Year! This month: Schauer & Schauer! We are excited to introduce Dr. Daniel P. Schauer, who is an associate professor at the University of Cincinnati, where his focus has been on bariatric surgery outcomes research.
Interview with Dr. Daniel Schauer
Dr. Phil Schauer: Your recent study showed that bariatric surgery was associated with a reduced cancer rate after surgery. Do other studies support this finding?
Dr. Dan Schauer: Several other studies have found similar results with respect to the reduction in cancer risk for overall cancers and obesity-associated cancers. Having multiple studies in differing populations with varying data sources that all show a similar reduction in cancer risk helps to strengthen our findings. Our study had more power and more robust matching than some of the previous studies, so we were able to look at many of the specific cancer types.
Dr. Phil Schauer: Which patients received the greatest benefit from cancer reduction?
Dr. Dan Schauer: We found that women benefited the most from cancer reduction. This was likely because only women are at risk of postmenopausal breast and endometrial cancers which are two of the most common obesity associated cancers and two of the cancers that are most sensitive to hormonal changes. We did not show a benefit in men but this lack of evidence does not necessarily mean they do not benefit. We may need a study with more men and longer-term follow-up to see an effect.
Dr. Phil Schauer: Which cancers are most affected?
Dr. Dan Schauer: We found the greatest reduction in postmenopausal breast, endometrial, colon, and pancreatic cancers, as well as esophageal adenocarcinoma. These are all cancers that are strongly associated with obesity.
Dr. Phil Schauer: How does this benefit from bariatric surgery compare to other benefits such as diabetes remission?
Dr. Dan Schauer: While cancer occurs much less frequently than diabetes in patients with severe obesity, it is a real concern and will continue to be a long-term problem with the current trends in obesity prevalence. It is likely that some of the mechanisms are similar between diabetes remission and cancer reduction although further research needs to look into this.
Dr. Phil Schauer: Can you tell us about your follow-up study looking at whether the decrease in cancer risk is associated with weight loss?
Dr. Dan Schauer: In our follow-up study we wanted to determine if the reduction in cancer risk is solely related to weight loss or if there are other mechanisms associated with bariatric surgery that are independent of weight loss as is seen frequently with diabetes. We found that weight loss accounted for the reductions in cancer risk.
Dr. Phil Schauer: Are you surprised by any of your findings on this subject matter?
Dr. Dan Schauer: We were surprised at the magnitude of risk reduction that we found especially when it came to the individual cancers.
Dr. Phil Schauer: From your perspective, what are the implications of these findings as it pertains to both our population’s long-term health and also our healthcare system’s ability to account for these links?
Dr. Dan Schauer: From my perspective, these findings reinforce the importance of treating obesity as a disease. Many of the long-term complications of obesity, such as cancer, can be prevented with effective weight loss treatment using bariatric surgery. The evidence is overwhelming that surgical treatment of severe obesity is effective and can have a large impact on the health of this population.
Dr. Phil Schauer: What is still on the horizon regarding cancer and weight/obesity?
Dr. Dan Schauer: There remain a lot of unanswered questions regarding weight loss and cancer risk. It remains unclear if there is a benefit in men and if the various bariatric surgery procedures have differing effects.
Dr. Phil Schauer: Thank you Dan! We look forward to hearing more on your findings at the upcoming MISS in Las Vegas.
Article: Moderating the enthusiasm of sleeve gastrectomy: up to fifty percent of reflux symptoms after ten years in a consecutive series of one hundred laparoscopic sleeve gastrectomies. Mandeville Y, Van Looveren R, Vancoillie PJ, et al. Obes Surg. 2017 Jul;27(7):1797-1803.
Dr. Ricardo Cohen: The number of sleeve gastrectomies (SG) being performed continues to grow in numbers internationally, except in Brazil, which has the second largest volume of bariatric surgery worldwide following that of the US. The growth is surprising, as SG carries the same number of complications and mortality when compared to the Roux-en-Y gastric bypass (RYGB). Additionally, in retrospective, prospective, and even randomized controlled trials, SG delivers a less ideal weight loss and metabolic control when compared to RYGB. That said, it gets worse when gastroesophageal reflux (GERD) after SG is detailed. Among other papers published in the last few years, Mandeville et all describe, after 10 years of followup, significant increase in reflux symptoms and use of PPIs after SG. Seventeen percent suffered from reflux disease preoperatively, versus 50% at the end of the postoperative follow-up. The chance of developing de novo reflux after SG was 47.8%. Reflux disease was present in 7 of the 26 patients who underwent a secondary RYGB. In 4 of these 7 patients, reflux disease disappeared completely after the secondary RYGB.
Although in their experience, the authors describe a reasonably good weight loss, new onset of GERD was seen in over 40% of the SG population.
This paper is a warning sign for the liberal use of SG. The potential complications, such as Barrett’s esophagus and its relation to cancer, and the complications reported lately on the chronic use of PPIs should really curb enthusiasm for SG.
Article: Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS). Aryaie AH, Singer JL, Fayezizadeh M, Lash J, Marks JM. Surg Endosc. 2017 Feb;31(2):612-617.
Dr. Cory Richardson: Staple line and anastomotic leaks continue to represent some of the most difficult foregut complications to manage. Recent advances in endoscopic management have allowed many patients to avoid reoperation and its associated morbidity and mortality. The authors present their experience with self-expandable metal stents (SEMS) over a 5-year period managing patients with leaks after a variety of surgeries, including esophagectomy, esophageal diverticulectomy, gastric sleeve, gastric bypass, partial gastrectomy, and total gastrectomy. Outstanding efficacy was noted, with clinical resolution of leaks seen in 90% of patients. A 60% complication rate, ranging from mucosal friability to stent migration to aorto-enteric fistula, was observed, stressing the need for careful selection and close followup of all SEMS patients.
Article: Feasibility of a complete pancreatobiliary linear endoscopic ultrasound examination from the stomach. Dhir V, Adler DG, Pausawasdi N3, Maydeo A, Ho KY. Endoscopy. 2017 Sep 21. doi: 10.1055/s-0043-118592.
Dr. Douglas Adler: This paper describes a heretofore previously thought to be impossible way to endoscopic ultrasound (EUS) the entire pancreas from just within the stomach. Truly groundbreaking.
Article: Use of fully covered self-expanding metal stents for benign biliary etiologies: a large multi-center experience. Haseeb A, Siddiqui A, Taylor LJ, et al. Minerva Gastroenterol Dietol. 2017 Sep 5. doi: 10.23736/S1121-421X.17.02428-X.
Dr. Douglas Adler: This article describes a multicenter study on fully covered biliary stents for benign diseases—off-label but very interesting.
Article: Online surgeon ratings and outcomes in hernia surgery: An Americas Hernia Society Quality Collaborative analysis. Haskins IN, Krpata DM, Rosen MJ, Perez AJ, Tastaldi L, Butler RS, Rosenblatt S, Prabhu AS. J Am Coll Surg. 2017 Aug 31. pii: S1072-7515(17)31769-6.
Dr. Michael Rosen: With the growing pressure to measure patient experience and utilize it as a measure of physician quality for value-based payments, there is a critical need to have transparent understanding of what will comprise the process. These authors evaluated the results of several online patient-reported websites to surgeon-reported quality outcomes for ventral hernia repairs. Interestingly, the authors did note that online physician websites do tend to correlate with each other in their measures of patient satisfaction with individual surgeons. However, they did also note that there was no correlation with the patient reported satisfaction with the surgeon and the surgeon’s outcomes or quality. This article should help to counsel patients that utilizing rating websites to identify “high-quality” surgeons can be misleading. It is also important for physicians and surgical organizations to design risk-adjusted, reasonable means for the consumers of healthcare (patients) to make informed decisions about surgical quality.
Article: Lichtenstein versus total extraperitoneal patch plasty versus transabdominal patch plasty technique for primary unilateral inguinal hernia repair: a registry-based, propensity score-matched comparison of 57,906 patients. Köckerling F, Bittner R, Kofler M, Mayer F, Adolf D, Kuthe A, Weyhe D. Ann Surg. 2017 Sep 26. [Epub ahead of print]
Dr. Ajita Prabhu: This is an important article, because it is the largest series to date comparing the 3 most common approaches to inguinal hernia repair. In the past we had accepted that if a surgeon selected a procedure and became skilled at it, that that would be sufficient. Here, with larger data, we are able to see that there may be specific advantages conferred by minimally invasive approaches over open for inguinal hernia repair. As always, we have to be a bit cautious in drawing very broad conclusions from registry-based data, however I think this makes a good argument that surgeons in training should at the very least learn one minimally invasive approach to inguinal hernia repair so that they are able to choose their approach from a position of having options rather than simply performing open surgery because it is how they learned to do the operation. The adoption of MIS approaches for inguinal hernia repair has remained lower than one would expect or hope for, and perhaps this will give some incentive for surgeons to consider learning minimally invasive approaches.
Article: Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Hubner M, Blanc C, Roulin D, Winiker M, Gander S, Demartines N. Ann Surg 2015;261(4):648-653.
Dr. Sean Langenfeld: This study is now 2 years old, but carries an important message as enhanced recovery pathways (ERP) become more prevalent in colorectal surgery. Early ERPs showed benefit to thoracic epidural analgesia (TEA) for open colorectal surgery, but this has not been shown for laparoscopic surgery, perhaps because of improvements in multi-modal analgesia as well as decreased overall pain due to smaller incisions. This well-designed randomized controlled trial looked specifically at laparoscopic colorectal surgery in the setting of a mature ERP. The authors found that when compared to a patient-controlled opioid-based analgesia (PCA), epidural analgesia was associated with a higher rate of complications and no difference in postoperative pain scores. In general, TEA is not beneficial for laparoscopic colorectal surgery in the setting of an ERP, and may even be detrimental to patient recovery.
Article: Gastrointestinal symptoms and food intolerance 2 years after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Boerlage TC, van de Laar M, Westerlaken S, Gerdes A, Brandjes D. Br J Surg. 2017 Mar;104(4):393-400. Epub 2016 Dec 19.
Dr. Flavia Soto/Dr. Megan Flores: Bariatric surgery is the most effective treatment for morbid obesity in the long term, of which laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the surgeries preferred.
LRYGB patients can commonly experience food intolerance post-surgery. This study was designed to investigate gastrointestinal complaints and food intolerance more than 2 years after LRYGB, and to compare these with complaints and food intolerance in a pre-bariatric surgery group.
In this cross-sectional study, patients who underwent primary LRYGB had more complaints postoperatively in comparison to patients at a baseline preoperatively. Most interestingly, the patients who reported symptoms of food intolerances were centered on common food sources that trigger dumping syndrome (fried foods, carbonated beverages, sugar-filled cakes, and pastries). Results suggested that flatulence and borborygmus were the most notable gastrointestinal complaints. Addressing dietary restrictions of foods that trigger dumping syndrome and possible food intolerance with patients is vital, and should be included in comprehensive pre/postoperative education counseling of bariatric patients.
In addition, the article explains that postoperative gastrointestinal symptoms may be simply related to food choices and food intolerance. This may guide clinicians to make quick and effective assessments for complaints of gastrointestinal symptoms postoperatively and minimize time and cost to rule out severe complications.
Article: Reoperation and Medicare expenditures after laparoscopic gastric band surgery. Ibrahim AM, Thumma JR, Dimick JB. JAMA Surg. 2017 Sep 1;152(9):835-842.
Dr. Dana Telem: This article highlights the downstream impact of new technology introduction and highlights the importance of post-market approval device monitoring. Nearly a quarter of Medicare patients who underwent gastric band surgery required a device-related reoperation. Additionally, half of payments associated with the band were related to the reoperation. Given the initial popularity of the band, I believe this article serves as a cautionary tale.
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.
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.
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.
Dr. Schauer: How does this new study highlight access-to-surgery issues, and what are your thoughts on treatment access?
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. Schauer: Is the durability of improvement in diabetes remission equally as favorable as with weight loss?
Dr. Schauer: Other than weight loss and diabetes remission, what other cardiovascular benefits did you find most remarkable?
Dr. Schauer: Did you find any complications to surgery that are noteworthy?
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.
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.
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.
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.
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.
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.
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]
Article: Weight and metabolic outcomes 12 years after gastric bypass.
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.
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.
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.