Colleen: What is the value of MISS for you as a presenter/attendee and for MIS surgeons?
Dr. Rosser: I think that MISS is an invaluable asset for practicing surgeons. The meeting itself has become a platform that serves as a unique crossroads where academia meets practicality. This is a great resource for not only the everyday general surgeon, but academic surgeons who are also on the cutting edge. As for the speakers, it is not a meeting where the attendees are the only ones learning. The other advantage to MISS is that it allows collegial banter back and forth that exposes the nuances of our craft. This is very unique to this conference, and enables attendees to benefit from listening to the experts exchange positions on innovative and sometimes controversial topics. This is what you get from the “MISS Experience.” I call it “real world laparoscopy.”
Colleen: Can you give us what you think are the big takeaway points from the panel discussion you participated in, Surgeon's Personal Journey with Bariatric Surgery, which focused on surgeons who have had surgery?
Dr. Rosser: This panel was extremely interesting because it was comprised of four surgeons who had bariatric surgery. They shared the internal vantage point of “healers (surgeons) who needed to be healed.” This represented two different but interesting, overlapping perspectives. The big takeaways included the fact that all four shared a long and serpentine journey in their battle with obesity. This expedition featured weight loss and regain, self-blame, and feelings of inferiority. All came to a “tipping point” with the realization that they were embraced by a disease that needed a surgical solution. The panel highlighted their struggle to surrender the position of being a clinician and trusting their physician/surgeon as all patients must do. I introduced a less known issue for bariatric patients and that is the lack of support assets for family and love ones who struggle to be a helping hand while addressing their own stressful challenges. My wife Dana Rosser has led the charge to acknowledge that they cry out for assistance with their circumstances as well. She often says, “Ours is a song that no one hears.” Finally, I cautioned bariatric surgeons that they must steadfastly monitor their biases and let compassion be the banner that is always at the “tip of their healing spear.” Size discrimination is the last bastion of bigotry. It cannot dwell within practice patterns because it distorts your evaluation of those who seek your services and your judgment of their success or failure.
Colleen: You also spoke on the diagnosis and conservative treatment of GERD. Can you tell us what were the main points you wanted to drive home for the audience in that presentation?
Dr. Rosser: The news flash is that GERD is not being effectively treated and diagnosed. Upwards of 41% of patients with GERD are misdiagnosed and have diseases from cancer to irritable bowel syndrome to non-allergic chronic rhinitis. Additionally, patients are being exposed to the ravages of the complications associated with inappropriate use of PPIs. Surgeons should seriously consider that they can do a better job for patients. If the goal of better care is to be reached, surgeons must have a thorough, objectively based evaluation of a patient’s symptoms profile both for formulation of a sound diagnostic approach and effective conservative treatment. The routine use of objective evaluation tools is important both for the initial evaluation and tracking treatment success or failure. Up to 12 different diagnostic tests can be needed for patients depending on their presenting symptoms and review of systems. The three mainstays include transnasal esophagogastroenteroscopy (TNEG), Bravo 24- to 48-hour pH studies, and esophageal manometry. TNEG is a diagnostic procedure that allows the cost-effective screening evaluation of symptoms under local anesthesia. It also assists in the evaluation for yeast pharyngitis, which mimics GERD and is frequently missed by standard endoscopy.
Colleen: What are your thoughts on the new tools and technologies for battling GERD? Do you think they are promising?
Dr. Rosser: Some are very hopeful, and some are not as much. I must admit, I myself really lean more toward fundoplication and hiatal hernia repair. If a patient has a hiatal hernia, it has to be repaired. And fundoplication in expert hands can be a great long-term solution. I like to tailor the operation to the patient. Using manometry, I find that I detect motility disorders and this impacts my choice of procedure. I am performing 50% complete wraps (Nissen) and 50% partial wraps. I’ve done the LINX®, and I have had great success but still have some concerns about the long-term erosion issue. But it has potential. Beyond the LINX®, I’m not so excited about some of the things out there on the market. While initial data are good for some of these procedures and treatments, I am not sold on their long-term durability.
Colleen: Are you looking at the 5G-development timeline and its potential impact on medicine given your interest and work in telemedicine and mobile telemedicine applications?
Dr. Rosser: Yes. In 1992, when I first started in telemedicine, everything was about bandwidth or lack thereof. All the early exploration with telemedicine in surgery involved working around the expense and limitation of bandwidth. I have been through bandwidth expansion, starting with dial-up POTS lines, then ISDN and satellite communications, 3G and 4G. Now entering the 5G age, I feel its ultimate impact will be determined by security and not bandwidth availability. I am fearful that this global challenge could provide a similar bottleneck to adoption posed by bandwidth limitation 20 years ago. Finally, it must be remembered you can have all the bandwidth in the world but it is your process and protocols that are at the heart of advancing care and providing great outcomes.
Colleen: As an inventor of educational tools for surgeons, what do you think is needed for the coming robot platforms and challenge to teach the resident of today open, laparoscopic, and multiple platform robotics?
Dr. Rosser: I hope you do not think less of me for shying away from this major controversy. I will only say this about the dilemma illuminated by your question. I want to preface my comments by saying that I think robotics will pay an important role in the future of surgery. Currently, we are on a journey to discover the procedures where it has the most impact. However, just like in aviation, the foundation of the competency of a surgeon cannot rely solely on technology. Look at the recent crashes related to the automated piloting system with certain high-tech Boeing aircraft. The effective application of technological platforms must be leveraged upon a foundation of individual skill, expertise, and competency. In the audience there were upwards of 30 surgeons that had graduated from my Top Gun Laparoscopic Skills and Suturing program and they all agreed with this comment, “Skill determines if you are one of the greatest surgeons of all time and not a legend in your own mind.”
Article: Comparison of laparoscopic 270° posterior partial fundoplication vs total fundoplication for the treatment of gastroesophageal reflux disease: a randomized clinical trial. Hakanson BS, Lundell L, Bylund A, Thorell A. JAMA Surg. 2019 Mar 6. [Epub ahead of print]
Rees Porta: The authors randomized 456 patients to laparoscopic Toupee fundoplication (posterior 270° wrap with gastropexy) vs Nissen fundoplication (360°). No bougie was utilized and all patients were operated on by one of the two study surgeons. Patients and followup providers were blinded to the surgery that had been performed. Endoscopy, pH monitoring, manometry, and QoL surveys were used both pre- and post-operatively with followup to 5 years. Interestingly, their study shows no statistically significant superiority with the Nissen regarding acid suppression or GERD symptom control over the partial fundoplication. The Toupee demonstrated statistically significant less dysphasia at 6 weeks for liquids and at 1 and 2 years for solids. This well designed study avoided many of the limitations seen in previous publications and challenges the longstanding notion that the Nissen is the gold standard for anti-reflux surgery.
Article: Early referral for esophageal pH monitoring is more cost-effective than prolonged empiric trials of proton-pump inhibitors for suspected gastroesophageal reflux disease. Kleiman, David, Fahey, Thomas et al. J Gastrointest Surg. 2014 Jan;18(1):26-33
Dr. Rosser: This article stresses the academic rationale for an objective based evaluation of patients with suspected GERD that have undergone a limited PPI challenge. It is aimed at establishing an accurate diagnosis. Forty-one percent of patients diagnosed as having GERD have other illnesses.
Article: Systematic endoscopy 5 years after sleeve gastrectomy results in a high rate of Barrett’s esophagus: results of a multicenter study. Sebastianelli L, Benois M, Vanbiervliet G, et al. Obes Surg. 2019 Jan 21. [Epub ahead of print]
Dr. Ricardo Cohen: Sleeve gastrectomy (SG) is the most performed operation in the US and some parts of the world. Regardless that it delivers (absolute) less weight loss long-term and it is a less effective metabolic operation, it carries the incidence of de novo gastroesophageal reflux from 15 to 30%. On top of all that is the incidence of Barrett’s esophagus (BE) of around 18% in 5 years followup. The authors found an association of weight loss failure and BE and recommend systematic endoscopy in all SG after 5 years postoperative. It is known that the vast majority of bariatric surgery centers worldwide has a low follow-up rate. Thus, endoscopic surveillance may be the right recommendation. However, its penetrance in the real world seems to be very low. This paper is a call to remind all healthcare professionals involved in the care of bariatric patients that the indiscriminate indication of SG has serious long-term drawbacks.
Article: New paradigm of live surgical education: synchronized deferred live surgery. Knol J, Bonjer J, Houben B, Wexner SD, Hompes R, Atallah S, Heald RJ, Sietses C, Chadi SA. J Am Coll Surg. 2018 Oct;227(4):467-473.
Dr. Steven Wexner: Surgery can be taught in many ways: from reading books, perusing photographs and illustrations in journals and textbooks, viewing highly edited truncated videos, or watching live surgery. While live surgery offers numerous significant advantages watching a surgeon work through a problem, discussing the nuances of the surgery with the operating surgeon, and seeing every detail of the operation, it does also have potential theoretical disadvantages. In many instances, the live surgery is performed by a surgeon who arrives in another country in another time zone and has never met or evaluated the patient. The surgeon who is performing the procedure is relying upon the judgment of his or her local hosts to have selected an appropriate case, though the hosts may never have performed the particular surgery being demonstrated. Furthermore, the surgeon may potentially be distracted during the operation by questions from the audience, and the surgeon may also be fatigued due to travel. Even if the surgeon brings his or her own team and equipment, the environment is different and that team must interface with local hosts who may not be fluent in the native language of the visiting surgical team. In an effort to improve upon this paradigm, Joep Knol, the innovator and founder of ilapp (http://ilappsurgery.com), designed dLiveMed (https://www.dlivemed.com), which is a method of synchronized deferred live surgery. He assembled a team including myself to evaluate and describe this technology. One of the main benefits of dLiveMed is the ability to have numerous angles.
In our recent publication in the Journal of the American College of Surgeons, we describe a transanal total mesorectal excision (taTME) procedure recorded with seven cameras, including the 360-degree view of the operating room setup, the “top down” view of the patient, the view of the assisting nursing table and instrumentation, the transabdominal external view, a transabdominal laparoscopic view, a transanal external view, and a transanal endolaparoscopic view. The ability for the surgeon or even the moderator to direct seven cameras while operating live would be at best incredibly challenging and at worst could potentially compromise the integrity and safety of the operation. The potential utility of dLiveMed was highlighted in a wonderful editorial by Julie Ann Freischlag in which she stated: “I think the biggest advantage in using synchronized deferred live surgery is that it takes away almost all of the risk to the patient.” I thank Joep for including me in this remarkable paradigm shifting effort and thank Julie Ann for her tremendously valuable insights. Readers interested in learning more can scan Figure 1 within our article to see the video and picture technology.
Article: Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the Australasian laparoscopic cancer of the rectum randomized clinical trial. Stevenson ARL, Solomon MJ, Brown CSB, et al. Ann Surg 2019;269:596–602.
Dr. Sean Langenfeld: This is the 2-year follow up from the ALaCaRT trial, and is accompanied by the 2-year follow up from the ACOSOG Z6051 trial in the same volume (previously presented to the MISS audience). There is no difference in overall survival, disease-free survival, or locoregional recurrence at 2 years when comparing open to laparoscopic approaches. However, this must be interpreted with caution since neither study was powered or designed for these long-term results. One might assume that an important meta-analysis is coming soon that will shed more light on the issue.
Article: The Dutch bariatric weight loss chart: A multicenter tool to assess weight outcome up to 7 years after sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. van de Laar, Nienhuijs, et.al. Surg Obes Relat Dis. 2018 Nov 24. [Epub ahead of print]
Rees Porta: WHO growth charts are used worldwide by billions of parents and pediatricians. Accurate weight loss charts after bariatric surgery would be immensely helpful for the patient and the surgeon. Dr. van de Laar and colleagues highlight the difficulties with creating these charts (such as length of follow-up and the inherent bias, lack of a standardized measurement of weight loss, and the need for a large multicenter study to ensure proper patient volume) and do an excellent job mitigating these obstacles. Their curves for LSG and RYGB extend out to 7 years and use %AWL, which they describe as the best metric to combat the differences seen with wide preoperative BMI variance. Hopefully we can use the large MBSAQIP database to develop our own graphs. In addition to helping with preoperative expectation management and postoperative monitoring, they could be a valuable tool for further research into identifying risk factors for poor responders (which were identified as male gender, T2DM, and age in this study).