Introduction

This month’s issue features an interview with Dr. Neil Floch, who agreed to discuss with me the topic of social media, which he is presenting on at our upcoming MISS. Dr. Floch is an Associate Clinical Professor of Medicine at the University of Vermont Medical School and Frank Netter School of Medicine at Quinnipiac University, Section Head of General Surgery at Norwalk Hospital, and Director of Bariatric Surgery for Western Connecticut Health Network. He is in private practice at Fairfield County Bariatrics, specializing in laparoscopic revisional bariatric surgery and foregut surgery. Dr. Floch has been at the forefront of social media since it became a topic for surgeons, and he has come to be recognized as an expert on the subject as it relates to doctors and healthcare. I’d like to extend a very warm thank you to Dr. Floch for taking the time to share his insights and experience with us in this interview.  To hear Dr. Floch's complete presentation, I encourage you to join us at MISS!
I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders at the forefront of research and innovation. Thank you to all of this month’s contributors.

–Colleen Hutchinson

Colleen: How can surgeons use social media to build their practice and promote themselves?
Dr. Floch: Surgeons can promote their practice in many ways. Daily posts by themselves or assistants can communicate information about the practice such as seminars and support groups. Applications such as LinkedIn, Doximity, closed Facebook groups and Twitter are great for professional growth of one’s practice but are less in touch with patients.
Patients dwell on Instagram and in closed Facebook groups. Entering the realm of the patient can be difficult. Using patient hashtags such as #vsg or #bariatricsurgery on Instagram and Twitter can start a following by other patients.
Starting a closed Facebook group for your practice or hospital program is a great way to promote the practice to new patients seeking information and will help nurture your current patients.
The first step is to simply join LinkedIn and Doximity. Posting your CV on LinkedIn will establish your global, professional presence. Doximity will allow you to be found by others who want to contact you with a clinical question.

Colleen: Why should surgeons engage in social media?
Dr. Floch: Surgeons need to engage in social media for multiple reasons. Whether they engage in multiple applications or not, people are talking and commenting about them on Facebook groups as well as many of the other applications.
Many applications are very useful. LinkedIn provides a professional presence and places their CV online for all other professionals to see. Doximity provides a local presence in their community of physicians and a way to contact local doctors that may not be working in their institution.
Twitter allows for a broad reach on events that are current and new procedures as well as upcoming meetings. Issues presented on Twitter are most likely to gain the attention of the media, politicians and physicians across the world. There is a large, robust group of physicians on Twitter. Interested Twitter users can subscribe to my “Docs that Tweet” lists at @Neil Floch MD in the list section. Collaboration can be performed directly on Twitter across specialties and geographical locations.

Colleen: Is it a good method of communication with patients?
Dr. Floch: Communicating with patients on social media is somewhat risky and can be done to give general information, but specific medical advice is discouraged. Twitter chats such as #obsm Obesity Social Media are valuable, and @obsmchat is a great Twitter chat that occurs the second Sunday at 9:00pm EST. Adding the hashtag #obsm will enter each tweet into the chat and looking up #obsm in a search will show each tweet in the chat. Collaboration begins on Twitter chats as many individuals from all walks participate.

Colleen: How about as a method of communication with referral physicians?
Dr. Floch: Physician to physician communication on social media is one of the greatest ways to reach individual physicians, physician assistants, and nurse practitioners who can be otherwise difficult to access. Following physicians on Twitter and LinkedIn and Doximity in your community and directly messaging them is possibly the best way of collaborating as long as messages are not time sensitive.

Colleen: Do you have advice on how to increase followers?
Dr. Floch: The best way to increase followers is to follow others. Initially it may seem awkward to follow someone you do not know. The point of social media is to build new bridges and to reach out with a gesture of communication, friendship and possibly collaboration. Many individuals follow everyone. I have found that only 15% of those that you follow will follow you back on Twitter. It is also acceptable to unfollow those people who do not follow you back.
Conversely, others feel that only following the most prestigious individuals is the best technique to become certified. Certification by Twitter is somewhat mysterious and based not on following but more on profession as celebrities, authors, and television personalities are most likely to be certified. Many physicians are certified but usually for their side profession.
Following others on Instagram is similar to Twitter and open to all. Those on Facebook usually like to follow those with whom they have an acquaintance. Many personal pictures reside on Facebook and sharing may open your personal life to the public. Many professionals may choose to keep their Facebook page personal.
Following individuals on Doximity and LinkedIn is encouraged, but endorsements should be sincere and respected.

Colleen: What are your thoughts on the legalities surrounding surgeons sharing case info for advice on social media?
Dr. Floch: It is unsafe to share specific cases on social media unless the patients are depersonalized for age, gender, location, and specifics of their medical condition. Accurate patient cases can be presented with a prior signed consent for usage of their picture or story. I have my patients sign a document before I post a picture.
Commenting or reposting pictures that patients present on social media is different. The onus is now on the patient who willingly volunteered their information.

Colleen: Even within closed groups?
Dr. Floch: There is a level of trust in closed groups. Presenting specific cases can be done but the legality is unclear as to their discoverability. I would argue that a closed Facebook group is a global morbidity and mortality meeting. Others could argue the contrary. Depersonalizing patient information as much as possible is best in these groups if prior signed authorization is not obtained.

Colleen: What does MISS offer that makes it a valuable meeting?
Dr. Floch: MISS has always been on the forefront of laparoscopic surgical information and patient care. The meeting provides information on the most controversial issues and state of the art techniques.

Colleen: We look forward to your presentation next week on using social media to grow your practice as part of the MISS metabolic/bariatric program.

Suggested Readings

Hernia

Article: Long-term efficacy of laparoscopic Nissen versus Toupet fundoplication for the management of types III and IV hiatal hernias. Huerta CT(1), Plymale M(2), Barrett P(2), Davenport DL(3), Roth JS(4)(5). Surg Endosc. 2018 Nov 26. doi: 10.1007/s00464-018-6589-y. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30478698
Dr. Marina Kurian: This article details results of partial versus full fundoplication in larger (type III and IV) paraesophageal hernia (PEH) patients. Although objective testing wasn’t done, symptomatic questionnaires are routinely used to evaluate post fundoplication patients. PPI used post procedure was similar between patients—26% of patients who had Nissen reported current proton-pump inhibitor use versus 31% of Toupet patients. Patient satisfaction was also similar between the Toupet and Nissen groups (67% vs 72%). Median responses across both groups showed a symptom score of 0. Crural repair was done on all patients. The authors concluded that both partial and full fundoplication in type III and IV PEH patients result in similar symptom control. The importance is that in these patients, manometry may not be an accurate reading of what the patient’s esophageal motility is. I would opt for a Toupet if I were worried about dysmotility. Now I can expect an equivalent outcome. A limitation of sorts is that formal pH testing and manometry was not done postoperatively.

Colon

Article: Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Fleshman J, Branda ME, Sargent DJ, et al. Ann Surg. 2018 Aug 3. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30080730
Dr. Bradley Davis: This is the followup to Dr. Fleshman’s 2015 randomized trial evaluating the non-inferiority of laparoscopic surgery when compared to open surgery for the treatment of rectal cancer. This article confirms that laparoscopic surgery can provide excellent long-term outcomes in the hands of expert surgeons. The original study was not powered to answer the question of survival and local recurrence, but this is currently the highest quality data that exists to evaluate this important point. In this article, the median followup was 47.9 months and the disease-free survival
(DFS) in both groups was 79.5% lap and 83.2% open (not significant). Locoregional recurrence (lap 4.6%, open 4.5%) and distant recurrence (lap 14.6%, open 16.7%) were similar between the 2 groups.

Foregut

Article: Barrett’s esophagus before and after Roux-en-Y gastric bypass for severe obesity. Andrew B, Alley JB, Aguilar CE, Fanelli RD. Surg Endosc (2018) 32:930–936
 https://www.ncbi.nlm.nih.gov/pubmed/28779257
Dr. Bill Richards: The authors reviewed 14 patients with biopsy-proven Barrett’s esophagus for at least 1 year after gastric bypass. Gastric bypass-induced significant weight loss (35.1 percentage body weight loss) and complete regression of Barrett’s (endoscopic and histologic) occurred in 6/14 (43%) patients. This small series adds to the body of evidence that suggests that gastric bypass will induce regression of Barrett’s in the morbidly obese individual. Gastric bypass is the preferred bariatric operation for the morbidly obese individual who has Barrett’s esophagus.

Bariatric

Article: ASMBS position statement on medium and long term durability of weight loss and diabetic outcomes after conventional stapled bariatric procedures. Azagury D, Papasavas P, Hamdallah I, Gagner M, Kim J. Surg Obes Relat Dis. 2018 Oct;14(10):1425-1441.
https://www.ncbi.nlm.nih.gov/pubmed/30242000
Dr. Shanu Kothari: The clinical issues committee of the ASMBS, led by Dr. Dan Azagury, has recently reviewed the medium- and long-term durability of weight loss and diabetes outcomes after conventional stapled bariatric procedures. Many of us are aware that bariatric/metabolic surgery is the most effective intervention for significant and sustained weight loss and are equally aware of the impact that bariatric/metabolic surgery has on diabetes remission. Critics of these interventions often cite poor long-term followup and weight regain as reasons not to endorse bariatric/metabolic surgery. The goal of the clinical issues committee was to review the medium- and long-term (greater than 5-year) outcomes with regard to stapled bariatric procedures, specifically laparoscopic gastric bypass, sleeve gastrectomy, and biliopancreatic diversion/duodenal switch. This comprehensive review includes more than 138 references and over 15,000 patients.
We are well aware of the challenges in the long-term follow-up compliance within the bariatric population as well as variations in individual technique for these respective surgical procedures. Criticisms aside, this comprehensive review summarizes the long-term follow-up data from the existing literature. Each of these respective surgical procedures had several papers with 10-year followup and some up to 25-year followup following gastric bypass. Based on this review, the authors concluded that bariatric/metabolic surgery results in significant and sustained weight loss in longer-term followup. In addition, with regard to longer followup of prospective randomized trials, diabetes remission is still superior to optimal medical management. This paper should remain as a key reference for anyone who is presenting evidence on this topic or simply wants to maintain talking points regarding the longer-term outcomes following bariatric/metabolic surgery and its outcomes.

Article: Marginal ulcer continues to be a major source of morbidity over time following gastric bypass. Pyke O, Yang J, Cohn T, Yin D, Docimo S, Talamini MA, Bates AT, Pryor A, Spaniolas K. Surg Endosc. 2018 Dec 12. doi: 10.1007/s00464-018-06618-5. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30543040
Dr. Marina Kurian: This article on marginal ulcer post-gastric bypass highlights the long-term riskier patients as well as underlining the need for long-term surveillance of these patients. This article gave an estimate of the cumulative incidence over time from 1 to 8 years for surgical intervention for marginal ulcer. Limitations are that this is an administrative database and may not capture all patients. However, this is a longitudinal database and trends can be appreciated. Perhaps longer prophylactic treatment with PPIs or h2 (histamine) blockers are warranted in the younger age group and those with greater weight loss.

Introduction

This month’s issue features an interview between Dr. Phil Schauer and Dr. Lee Kaplan. Dr. Kaplan is giving the keynote address at this year’s upcoming MISS, titled  “An Individualized Approach to Obesity Treatment.” He is the director of the Obesity, Metabolism and Nutrition Institute, founding director of the Massachusetts General Hospital (MGH) Weight Center, and associate professor of medicine at Harvard Medical School. He currently also serves as President-elect of The Obesity Society. With clinical expertise in the areas of obesity medicine, gastroenterology and liver disease, Dr. Kaplan focuses on obesity causes and complications and development of new, more effective strategies for preventing and treating obesity and related disorders. I’d like to extend a very warm thank you to Dr. Kaplan for taking the time to share his insights and experience with us in this interview.
I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders at the forefront of research and innovation. Thank you to all of this month’s contributors!

–Colleen Hutchinson

Dr. Schauer: Which operation is best for diabetes, GERD, BMI 35-45, BMI 45+, BMI 55+?
Dr. Kaplan: It appears that for patients with severe, treatment-resistant or long-standing type 2 diabetes, gastric bypass is generally a more effective and durable operation than sleeve gastrectomy, and I favor this operation unless it is relatively contraindicated for an individual patient. For patients with less severe diabetes or pre-diabetes, either operation appears effective. By analogy, I generally favor gastric bypass for progressive NAFLD such as NASH or early cirrhosis. For patients with severe or complicated GERD, I also favor gastric bypass, primarily because sleeve gastrectomy appears somewhat more likely to exacerbate the reflux and its complications. Conversely, for patients who are at increased risk of nutrient deficiencies or their sequelae, I generally favor sleeve gastrectomy.
With respect to patients with different degrees of obesity, I favor sleeve gastrectomy in smaller patients, especially those with BMI < 45, and would more seriously consider gastric bypass in patients whose preoperative BMI is significantly higher than 40. However, additional, controlled studies are needed to determine which of the available bariatric/metabolic procedures provides the best long-term benefit for each subgroup of patients.

Dr. Schauer: How are the new ADA guidelines for metabolic surgery being implemented into clinical practice?
Dr. Kaplan: One of the greatest barriers to the optimal use of bariatric and metabolic surgery is the inchoate sense that surgical therapies for obesity and diabetes is unsafe, overzealous, or simply “inappropriate.” These visceral impressions run counter to the evidence accumulated from both randomized controlled trials and long-term observational studies. With greater and more widespread appreciation of obesity as a disease, and with broader provider exposure to the powerful effects of surgery on diabetes and other metabolic diseases, more non-surgical providers will have personal experience with these operations. With this exposure, the current barriers to metabolic surgery are likely to recede, leading to broader clinical implementation of the recent guidelines for surgery to treat type 2 diabetes.

Dr. Schauer: When should surgeons use anti-obesity medications (AOMs) before or after bariatric surgery? (Editor note: the original question used the term “weight loss drugs.”)
Dr. Kaplan: Please note first that I refer to medications to treat obesity as “anti-obesity medications,” not “weight loss drugs.” With obesity broadly recognized as a disease, I think that it is also important to recognize that these medications, like bariatric surgery used for obesity, are a means of treating a disease. The term “weight loss drugs” implies that they only work by causing decreased food intake. By this logic, when the weight loss stops, the drug is no longer working, which is a mistaken notion. Like other therapies for chronic disease, they change physiology in a way that promotes a lower set point (think anti-hypertensives, anti-diabetes medications, and statins for improving hypercholesterolemia). Proof of ongoing activity after the weight loss has stopped is found in the rapid weight regain (or regain of hypertension, diabetes, or hypercholesterolemia) if these metabolic medications are stopped. Bariatric surgery doesn’t stop working just because patients stop losing weight; reversing a gastric bypass even decades later is associated with rapid regain of the lost weight. All effective anti-obesity therapies – lifestyle, drugs, and surgery – act by lowering the body’s defended total fat mass.
The use of anti-obesity medications (AOMs) serves different purposes before and after surgery. Before surgery, AOMs can be important contributors to inducing substantial preoperative weight loss, which can make the surgical procedure easier and safer, particularly in patients with severe obesity. Because of the substantially greater average effectiveness of bariatric surgery (compared with medications), most practitioners stop the AOMs at the time of surgery, a practice that I endorse. Future studies may demonstrate a value of concurrent initiation of medical and surgical therapy, but pending those studies, I routinely stop preoperative AOMs immediately before the surgery.
After bariatric surgery, anti-obesity medications can be an effective means of augmenting the benefits of the surgery. Indeed, anecdotal evidence has recently accumulated that suggests that the effects of surgery and medications can be additive or even synergistic, demonstrating that the operation and the drugs work via distinct, complementary, physiological mechanisms. There are two clinical situations when postoperative AOMs appear to be most helpful. First, in patients who experience less than optimal post-operative weight loss, I generally start one or more AOMs after 2-3 months of a stable post-operative weight (typically 9-15 months after surgery). Second, in patients who experience significant weight regain later after bariatric surgery, medications can often stop or reverse this weight gain. In this situation, I generally favor starting with lifestyle intervention (e.g., healthier diet, physical activity, sleep, circadian patterns, and stress levels) to stabilize the patient’s weight for a couple of months, followed by initiation of one or more AOMs. In both of these scenarios (inadequate weight loss and weight regain, respectively), starting an AOM at a time of weight stability substantially increases our ability to assess whether and how much the medication is helping. If a patient is still losing weight when the drug is started, it is difficult to assess whether an added AOM is effective. If a patient is still regaining weight, modest effects of the AOM may be undetectable, and subsequent cessation of weight regain may or may not be a result of the medication. Since only a small portion of the population will respond to any specific AOM with substantial weight loss, we often have to try several AOMs – alone or in combination – before finding an optimal regimen for an individual patient. Effective regimens will need to be used long-term, so it is essential that we evaluate them under conditions (pretreatment weight stability) that maximize our ability to determine whether or not they work. This is also the way that we optimally assess these medications in patients who have not previously undergone surgery.
Some clinicians have suggested the routine, concomitant use of medications in patients undergoing bariatric surgery. There is little evidence to support this approach, which requires choosing the AOM without assessing its effectiveness in each individual patient. Given the large patient-to-patient variability in response to individual drugs, this approach is likely to be associated with significant long-term use of ineffective medications. In the future, when proven pretreatment predictors of clinical response to individual medications are available, concurrent surgery-drug combinations may be more attractive.

Dr. Schauer: Which medications? What are the key side effects to look out for?
Dr. Kaplan: Since each patient is likely to respond differently to individual or combination AOM treatments, we generally need to assess multiple agents to identify a regimen optimal for each patient. The medications that we use most commonly after bariatric surgery are the same ones that we use in the absence of surgery. They include phentermine, topiramate, liraglutide, bupropion, naltrexone, lorcaserin, metformin, zonisamide, or an SGLT-2 inhibitor, used alone or in 2- or 3-drug combinations.
The side effect profile of each of these agents is distinct, and it is important to understand the risks of each medication and how to minimize those risks. Knowledge of which patients should avoid each of the AOMs is similarly critical. It is often best to refer to a local obesity medicine specialist to manage this aspect of care for each bariatric or metabolic surgical patient.

Dr. Schauer: Which new endoscopic procedures are best?
Dr. Kaplan: None of the currently available endoscopic procedures is ideal. For treating obesity, intragastric balloons have demonstrated modest short-term benefits, but the need to remove the balloon after 4-6 months severely limits the long-term benefits of these devices. The Aspire A-tube has been shown to be the most effective endoscopic weight loss approach, but visceral resistance to this procedure and likely misunderstanding of its mechanism has severely limited its use. Other approaches, including endoscopic gastric plication, and gastric or vagal electrical stimulation, appear less effective long-term. Newer technologies, including the transpyloric shuttle and a magnet-based endoscopic jejunoileal bypass, appear promising, but further study is needed.
For the endoscopic treatment of type 2 diabetes, duodenal mucosal resurfacing (DMR) and endoscopic placement of an endoluminal duodenojejunal liner appear to most effectively reproduce the physiological effects of gastric bypass. Early controlled studies of DMR and the endoluminal liner are promising. In the case of the endoluminal liner, clinical success will likely require developing a device anchoring system that is effective while avoiding the demonstrated risk of life-threatening hepatic abscess.

Suggested Readings

Bariatric

Article: Clinical significance of perioperative hyperglycemia in bariatric surgery: evidence for better perioperative glucose management. Meister KM, Hufford T, Tu C, Khorgami Z, Schauer PR, Brethauer SA, Aminian A. Surg Obes Relat Dis. 2018 Aug 18. pii: S1550-7289(18)30463-5.
https://www.ncbi.nlm.nih.gov/pubmed/30245036/
Dr. Dimitri Pournaras: This retrospective review of all patients undergoing gastric bypass or sleeve gastrectomy in the Cleveland Clinic included almost 2000 patients. A significant proportion of patients experienced perioperative hyperglycaemia and this was associated with infective complications, prolonged length of stay and higher risk of readmission. The importance of glycaemic control in patients with and without diabetes was highlighted. Safe and effective strategies to achieve this remain to be studied.

Article: Severe anemia after Roux-en-Y gastric bypass: a cause for concern. McCracken E, Wood GC, Prichard W, Bristrian B, Still C, Gerhard G, Rolston D, Benotti P. Surg Obes Relat Dis. 2018 Jul;14(7):902-909.
https://www.ncbi.nlm.nih.gov/pubmed/29735346
Dmitry Oleynikov: Metabolic surgery is currently the only long-term and effective solution to the obesity epidemic. The bariatric operations are not without complications, however. Nutritional deficiencies are common after Roux-en-Y gastric bypass, and iron deficiency is the most common nutritional complication of this surgery. Physicians need increased awareness on the importance of extended clinical nutrition follow-up of high-risk groups that include women and older males undergoing Roux-en-Y gastric bypass.

Hernia

Article: Inguinal hernia: four open approaches. Towfigh S. Surg Clin North Am. 2018 Jun;98(3):623-636.
https://www.ncbi.nlm.nih.gov/pubmed/29754626
Dr. Talar Tejirian: Minimally invasive inguinal hernia repair has been increasing in popularity. As residents are performing more laparoscopic and robotic inguinal hernia repairs, there is concern that the art of open inguinal hernia repair will be lost. The importance of understanding the different techniques of open hernia repair cannot be overstated, because even for minimally invasive surgeons, situations will arise where open inguinal hernia is the right choice. Open anterior inguinal hernia repairs are better in certain situations, such as a patient with a recurrence after a posterior or minimally invasive repair or for a patient who cannot undergo general anesthesia. This paper does an excellent job describing in detail four very important approaches for open inguinal hernia repair: Lichtenstein, Bassini, McVay, and Shouldice repairs. In addition to having historical significance, these repairs, when done appropriately, have good outcomes. This paper is a go-to guide to understand open inguinal hernia repair basics, the specifics of these repairs, how they are performed, and the differences between them, as well as situations for their appropriate use. The information is useful for young surgeons still in training and for seasoned surgeons as a refresher or review for techniques they occasionally incorporate into practice.
 
Article: Randomized clinical trial comparing laparoscopic hiatal hernia repair using sutures versus sutures reinforced with non-absorbable mesh. Oor JE, Roks DJ, Koetje JH, et al. Surg Endosc. 2018;32:4579-89.
https://www.ncbi.nlm.nih.gov/pubmed/29766301
Dr. Talar Tatarian and Dr. Aurora Pryor: Hiatal hernia recurrence following laparoscopic primary repair remains an ongoing issue for surgeons. To date, there remains no consensus on the optimal repair technique with regards to the use of mesh. This study is a randomized controlled trial comparing radiographic and symptomatic outcomes following laparoscopic hiatal hernia repair with non-absorbable sutures (n=36) versus sutures reinforced with non-absorbable mesh (n=36). The investigators found no difference in 1-year recurrence after primary repair and repair with non-absorbable mesh, as demonstrated on upper endoscopy (14.4% vs. 17.2%, p=0.746) and barium swallow (11.4% vs. 19.4%, p=0.370). They also demonstrated equivalent symptomatic outcomes in the two cohorts. This study adds to the current body of literature reinforcing that while mesh may be safe, we still need a better solution to prevent hiatal hernia recurrence.

Colon

Article: The American Society of Colon and Rectal Surgeons clinical practice guidelines for the use of bowel preparation in elective colon and rectal surgery. Migaly J, Bafford AC, Francone TD, Gaertner WB, Eskicioglu C, Bordeianou L, Feingold DL, Steele SR. Dis Colon Rectum. 2019 Jan;62(1):3-8. doi:10.1097/DCR.0000000000001238. PubMed PMID: 30531263.
https://www.ncbi.nlm.nih.gov/pubmed/30531263
Dr. Bradley Davis: This clinical practice guideline has just been updated and is the most recent literature review pertaining to the use of mechanical bowel preparation in elective colorectal surgery with the addition of preoperative oral antibiotics. The authors give a strong recommendation for the use of preoperative oral antibiotics and mechanical bowel prep prior to elective colorectal resections. This sees the pendulum swing squarely back from no bowel prep, which had become popular over the past decades and was part of the official ERAS Society recommendations published in 2012. The authors also recommend against the routine practice of giving patients oral antibiotics alone or mechanical bowel prep alone – reinforcing the concept that the two work together as one treatment.

Foregut

Article: Per-oral pyloromyotomy (POP) for medically refractory gastroparesis. Rodriguez JR, Strong AT, Haskins IN, Landreneau JP, Allemang MT, El-Hayek K, Villamere J, Tu C, Cline MS, Kroh M, Ponsky JL. Ann Surg. 2018;268(3):421-30. https://www.ncbi.nlm.nih.gov/pubmed/30004920
Dr. Talar Tatarian and Dr. Aurora Pryor: Per-oral pyloromyotomy (POP) is a newer procedure used for the treatment of medically-refractory gastroparesis, introduced as an endoscopic alternative to laparoscopic pyloromyotomy. This paper reports on the short-term outcomes of the first 100 cases of POP at a single high-volume center. At 90 days post-procedure, there was a significant improvement in mean overall Gastroparesis Symptom Index (GCSI) (3.820.86 vs. 2.521.2, p<0.001). Additionally, 78% of patients with a postoperative gastric emptying study demonstrated improvement in 4-hour emptying, with a mean improvement of 23.6% (p<0.001). The authors report an overall complication rate of 10%. Further follow-up is needed to assess long-term efficacy, but POP appears to be a promising procedural option for the treatment of gastroparesis.

Article: Laparoscopic magnetic sphincter augmentation versus double-dose proton pump inhibitors for management of moderate-to-severe regurgitation in GERD: a randomized controlled trial. Bell R, Lipham J, Louie B, et al. Gastrointest Endosc 2019;89:14-22.e1.
https://www.ncbi.nlm.nih.gov/pubmed/30031018
Dr. Bill Richards: This was a well-designed, randomized, multicenter clinical trial testing the efficacy of magnetic sphincter augmentation (MSA) versus increasing the dose of PPI for patients with regurgitation symptoms. MSA significantly improved symptoms, decreased esophageal acid exposure, decreased all reflux events, and increased satisfaction (81% v. 2%). MSA resulted in transient dysphagia in 28% of patients, but at 6 months only 4% reported long-term dysphagia. This trial supports MSA surgery rather than increasing doses of PPI for the treatment of GERD symptoms refractory to single dose PPI.

Introduction

As we come up on the 19th Annual Minimally Invasive Surgery Symposium (MISS), Phil Schauer, MD, Executive Director of the Minimally Invasive Surgery Symposium, and I decided to do something a little different for this issue. We enlisted Dana Telem, MD, a new speaker at MISS this year, to interview incoming ASMBS President Eric DeMaria, MD, on current issues in the field of bariatrics. Dr. DeMaria is Professor and Chief, Division of General/Bariatric Surgery in the Department of Surgery, Brody School of Medicine at East Carolina University in Greenville, NC. We are thrilled to have him opine on the following questions posed by another thought leader in the field. Thanks to both Drs. DeMaria and Telem for their efforts, and good luck to Dr. DeMaria in this year of his presidency. In line with our bariatric interview focus this month, we are featuring all bariatric suggested readings in this issue.
Happy Holidays, everyone!

–Colleen Hutchinson

Dr. Telem: How would you describe MISS and its impact on you and others?
Dr. DeMaria: I have to say MISS is a fantastic meeting. I was fortunate to be invited as a speaker from the very beginning and now it has grown so dramatically in scope while retaining its intensive focus on cutting edge topics in bariatric and metabolic surgery. I so appreciate Phil Schauer’s vision in developing this meeting and its critical contribution to our specialty over these many years. But at the same time, the meeting has retained its friendly and collegial culture allowing all of us to get together and interact, not just professionally but on a personal level, too. I can’t say enough good things about MISS.

Dr. Telem: What are the biggest barriers facing bariatric surgeons today?
Dr. DeMaria: The biggest barriers we face in bariatric surgery have to do with access to care for our patients suffering from this devastating disease. But I would not say access in the traditional sense, because now we have states in which insurance coverage is quite good overall, yet still very few people end up having surgery. Data suggest that surgical treatment remains at or near the 1% level for patients who could benefit greatly from surgical treatment. We do face one significant insurance-related access issue—the growing use of increasing time periods of insurance-mandated non-surgical weight loss efforts. This has been proven repeatedly to provide no measurable value to our patients’ outcomes, yet we see many insurance companies increasing their use of this delay tactic. Unfortunately, we have all seen patients hurt by this type of arbitrary delay in treatment.

Dr. Telem: How do we go about increasing utilization of bariatric surgery as surgeons?
Dr. DeMaria: Our access to care priorities must continue to focus on the goal of a universal health benefit for bariatric surgery, but also must involve educating on all fronts to reduce the ignorance that leads to under-utilization of bariatric surgery. We need to keep working hard to educate our medical colleagues about the incredibly strong evidence of the effectiveness and safety of metabolic/bariatric surgery. So many healthcare providers still seem to believe that the disease of obesity—with its strong underlying genetic causes—can be treated effectively by “putting down the fork and pushing away from the table.” Such outdated and, frankly, ignorant pronouncements hurt our credibility as a specialty that appropriately treats our patients for the metabolic disease of obesity while reinforcing the culture of non-treatment and anti-obesity prejudice that persists in most of our medical communities.
I have often wondered why our medical colleagues, particularly our primary care providers, are apparently not held to the same standard as surgeons in being required to provide detailed informed consent discussions about their recommended treatment interventions, including discussing alternatives to the recommended treatment course. I think if our medical colleagues were held to the same standards in this regard, we would see a tremendous increase in surgical referrals for metabolic procedures as the patients would finally be “allowed” to see that surgery carries the highest level of success for treatment of obesity and its related disorders.

Dr. Telem: As President, what are the goals/mission of your presidency, and what do you see as the field’s biggest challenge(s) currently?
Dr. DeMaria: Our biggest challenge remains the low ‘penetration’ of surgical treatment in the population of patients who are eligible based on criteria for severe obesity. It is difficult for us to argue that surgery has an important role to play in combating the obesity epidemic when we treat such a small percentage of patients annually. We must address the issue of fear of surgery and help people understand that surgery has evolved and is no longer to be feared given modern minimally invasive techniques. Instead, we should help patients understand that the more rational fears are derived from an understanding of the severe consequences of obesity and serious obesity-related diseases, including diabetes, heart disease, cancer and even premature death.
The goal of my presidential year is to recognize the incredibly talented, committed, and devoted members of the ASMBS who work tirelessly to help our patients in their struggle for better health and quality of life via successful metabolic bariatric surgery. I am seeking to achieve a renewed spirit of enthusiasm and re-engagement within our organization in order to re-focus that energy externally on the challenges we all face. My goal is to bring new ideas and strategies forward for discussion and deployment. The ultimate goal is wider application of metabolic bariatric surgery as we seek to help more patients suffering from the disease of obesity.

Suggested Readings in Bariatrics

Article: Does robotic Roux-en-Y gastric bypass provide outcome advantages over standard laparoscopic approaches?
Rogula T, Koprivanac M, Janik MR, Petrosky JA, Nowacki AS, Dombrowska A, Kroh M, Brethauer S, Aminian A, Schauer P. Obes Surg. 2018 Sep;28(9):2589-2596.
https://www.ncbi.nlm.nih.gov/pubmed/29637410
Dr. Jaime Ponce: This is a single center comparison between robotic and laparoscopic approach for Roux-en-Y gastric bypass. The study didn’t show any differences in safety when robotic approach was compared to laparoscopic linear-stapled or hand-sewn gastrojejunostomy techniques. The robotic surgery increased operative time. One variable that was not evaluated unfortunately was the estimated cost difference. Further randomized controlled studies are needed to further evaluate the benefits of these approaches, including potentially the specific-surgeon need of either approach to achieve better results.

Article: ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Pratt JSA, Browne A, Browne NT, et al. Surg Obes Relat Dis. 2018 Jul;14(7):882-901.
https://www.ncbi.nlm.nih.gov/pubmed/30077361
Dr. Eric Ahnfeldt: Childhood obesity is becoming more prevalent, and often my patients are parents of obese children. Even though I am not a pediatric surgeon or perform bariatric surgery on children, this article is a massive resource for all bariatric surgeons who are asked questions by patients about treatment options for their obese children. It covers 13 obesity disease-related comorbidities and outcomes, and addresses the decision-making process when approaching the question of childhood obesity treatments. The panel of experts that contributed was impressive and well represented by the major children’s programs across the country.

Article: Re-sleeve gastrectomy 4 years later: is it still an effective revisional option? De Angelis F, Avallone M, Albanese A, et al. Obes Surg. 2018 Nov;28(11):3714-3716.
https://www.ncbi.nlm.nih.gov/pubmed/30182333
Dr. Ricardo Cohen: Sleeve gastrectomy carries from 20 to 30% revision rates, mainly for gastroesophageal reflux disease (GERD) and weight recidivism. For GERD, many propose re-sleeve gastrectomy based on the assumption that a not properly shaped sleeve may have promoted "de novo GERD.”
The authors of this paper report their bad experience on such an approach after over 50 months of follow-up. They conclude that re-sleeving is not the option for treating GERD. The best suitable treatment is conversion to Roux-en-Y gastric bypass.

Article: Microvascular outcomes in patients with diabetes after bariatric surgery versus usual care. O'Brien R, Johnson E, Haneuse S, et al. Ann Intern Med. 2018 Sep 4;169(5):300-310.
https://www.ncbi.nlm.nih.gov/pubmed/30083761
Dr. Robert Lim: This article examines some of the medical outcomes of bariatric surgery and focuses on the end-stage of diabetic complications. Heretofore, it did not appear that curing diabetes with bariatric surgery prevented the microvascular complications of diabetes, namely neuropathy, retinopathy, and nephropathy, from occurring. While this is only a database study, there were over 4,000 patients in the study group compared to over 11,000 patients in the control group. This study did show that microvascular effects were significantly less in the surgical group and the effect was more pronounced over time. This is an important study that shows that not only is diabetes cured, but its complications are better prevented with surgery. This study lends more proof that bariatric surgery is the best way to treat type II diabetes mellitus.

Article: Clinical significance of perioperative hyperglycemia in bariatric surgery: evidence for better perioperative glucose management. Meister KM, Hufford T, Tu C, Khorgami Z, Schauer PR, Brethauer SA, Aminian A. Surg Obes Relat Dis. 2018 Aug 18. pii: S1550-7289(18)30463-5.
https://www.ncbi.nlm.nih.gov/pubmed/30245036/
Dr. Dimitri Pournaras: This retrospective review of all patients undergoing gastric bypass or sleeve gastrectomy in the Cleveland Clinic included almost 2000 patients. A significant proportion of patients experienced perioperative hyperglycaemia and this was associated with infective complications, prolonged length of stay and higher risk of readmission. The importance of glycemic control in patients with and without diabetes was highlighted. Safe and effective strategies to achieve this remain to be studied.

Article: Comparative effectiveness of bariatric procedures among adolescents: the PCORnet bariatric study. Inge TH, Coley RY, Bazzano LA, et al; PCORnet Bariatric Study Collaborative. Surg Obes Relat Dis. 2018 Apr 17. pii: S1550-7289(18)30175-8.
https://www.ncbi.nlm.nih.gov/pubmed/29793877
Dr. Dimitri Pournaras: This is an important study authored by Dr. Inge and colleagues. A cohort of 544 adolescents undergoing bariatric surgery in up to 56 participating healthcare systems over the course of a decade were studied. Effective and durable weight loss was achieved over 3 to 5 years. Sleeve gastrectomy and gastric bypass were superior compared to gastric banding in terms of weight loss.

Introduction

As we come up on the 19th Annual Minimally Invasive Surgery Symposium (MISS), I had the opportunity to speak to Philip Schauer, MD, Executive Director of the Minimally Invasive Surgery Symposium. We cover a variety of topics, including new technologies in metabolic surgery, what to expect at MISS 2019, whether too many sleeves are being performed, metabolic surgery for NASH, and what the new devices and techniques are in MIS.

I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders at the forefront of research and innovation. New contributor Yuri Novitsky draws attention to early outcomes using the enhanced-view totally extraperitoneal approach in robotic-assisted repair of ventral and incisional hernias. Other topics covered in suggested readings include Robert Lim sharing thoughts on the association of bariatric surgery with changes in interpersonal relationship status, Sean Langenfeld on the timely topic of sponsoring surgeons and potential influence of the da Vinci robot, and Steve Wexner on recent assessment of trends in readmission for diverticulitis.
Enjoy!

–Colleen Hutchinson

An Interview with Philip Schauer, MD
Colleen: What are some of the key topics and speakers for 2019 MISS?
Dr. Schauer:  We have a couple great keynote bariatric speakers covering timely topics this year— Lee Kaplan, presenting on the individualized approach to obesity treatment and also GLP-1 as a treatment option; Eric DeMaria, our newly appointed ASMBS President, presenting on liability prevention strategies; and Aurora Pryor, incoming SAGES President, who will talk about reflux after sleeve.
The interest in enhanced recovery after surgery (ERAS) is exploding. We added ERAS in 2018 as a new component to MISS because of the demand, and in 2019 we have expanded that ERAS component with some of the top ERAS experts from anesthesia, pharmacology, and surgery. New topics include opioid reduction strategies, “prehabilitation,” preemptive medications, and regional blocks.  A new session on ERAS outcomes assessment was added because not all ERAS techniques work, and some may cause harm. Come find out what really works! 

Colleen: You’ve added Aurora Pryor as co-chair of the Foregut MISS program. She brings quite a bit to the table. Can you comment on this addition to your faculty?
Dr. Schauer: Dr. Pryor is President-Elect of SAGES and brings tremendous experience and innovation to MISS given her expertise in foregut and bariatric surgery. She has revamped the MISS Foregut program and brought in some top experts to discuss magnetic sphincter augmentation, new GERD assessment and treatment strategies, tips on surgical technique for PEH repair and reoperative foregut surgery, surgery for gastroparesis, and lots of technique advice. The audience will leave with many practical suggestions in foregut surgery that they can implement immediately. 

Colleen: What are some of the new devices and treatments to be discussed at MISS?
Dr. Schauer: As mentioned, a lot of new ERAS strategies and techniques such as TAP blocks will be discussed at this year’s MISS. Magnetic sphincter augmentation for GERD is new and controversial; it will get much airtime. Robotic surgery continues to gain momentum; the audience will learn more about where robotics makes sense now. The hernia program is full of tips and tricks for abdominal wall reconstruction, mesh selection, loss of domain, and parastomal hernia repair. For the colon portion, you’ll hear about advantages of intracorporeal anastomosis, mesh for ostomy formation, new approaches for complicated diverticulitis, appendiceal mass, and enteric-fistual management.

Colleen: What are some of the techniques and technologies in metabolic surgery that you find most promising and groundbreaking (in trial or approved)?
Dr. Schauer: The duodenal liner, or Endobarrier, may be making a comeback, so find out why at MISS. Gastric balloon enthusiasm has dimmed but there may be a role for balloons in bariatric practice. Endoscopic gastroplasty is gaining momentum—but is it ready? Is it time to add medications to enhance outcomes of surgery? More surgeons are combining weight loss medications with surgery. Some say sleeve + GLP1 = gastric bypass. You’ll hear about these topics and more at MISS.

Colleen: Some say the next big thing is metabolic surgery for NASH. What’s your take on this?
Dr. Schauer: I agree! Last year at MISS we presented a sound rationale for metabolic surgery to specifically treat NASH. The evidence is mounting that NASH may resolve or certainly improve, which is critical given that NASH is a deadly disease resulting in cirrhosis or severe cardiovascular disease in a majority of patients. Medical treatment is largely ineffective; therefore, surgery for NASH may soon become a treatment of choice.

Colleen: What can general surgeons do to develop or improve procedure reimbursement strategies?
Dr. Schauer: At MISS, speakers will discuss sound procedure coding strategies especially for revisional surgery and new procedures. Suggestions on how to increase appropriate referrals for anti-reflux surgery, metabolic surgery, and all MIS procedures will be provided throughout the meeting.

Colleen: Are we performing too many sleeves?
Dr. Schauer: Maybe yes! Sleeve gastrectomy is a great operation with low morbidity, but is not always the best choice for the patient, especially those with GERD, diabetes, or high BMI. At MISS you’ll hear surgeons weigh in on the sleeve epidemic!

Colleen: Tell us a little bit about your new textbook that was just released.
Dr. Schauer: We all learned in medical school “premum no cere” – At first do no harm! This new textbook, Prevention and Management of Complications in Bariatric Surgery, (Oxford) co-edited by Tomasz Rogula and Tammy Fouse, covers all complications of bariatric surgery A to Z, and also emphasizes prevention strategies. Many of our MISS faculty contributed chapters to this text. Within the metabolic and bariatric programs of MISS, these renowned experts will discuss some of the key complications that keep us all awake at night. MISS + New Textbook = Reduced complications!

Suggested Readings

Bariatric

Article: Comparative effectiveness and safety of bariatric procedures in Medicare-eligible patients: a systematic review. Panagiotou OA, Markozannes G, Adam GP, Kowalski R, Gazula A, Di M, Bond DS, Ryder BA, Trikalinos TA. JAMA Surg. 2018 Sep 5:e183326. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30193303
Dr. Ricardo Cohen: There are very few studies on sick older adults as in the Medicare population. The authors present a systematic review of 16 studies in Medicare-eligible patients. Although the studies were heterogeneous, and therefore of low to moderate strength, they concluded that bariatric surgery is safe and effective in that population. The operations resulted in sustained weight loss and remission of comorbidities. Older adults gain the same benefits after bariatric surgery as their younger counterparts. Currently, for unclear reasons, surgery is not widely adopted among older patients. After a thorough preoperative evaluation, indications for bariatric surgery should be broadened in this age range, making all the well-known benefits of bariatric interventions available to Medicare beneficiaries.

Article: Association of bariatric surgery with changes in interpersonal relationship status: results from 2 Swedish cohort studies. Bruze G, Holmin TE, Peltonen M, et al. JAMA Surg. 2018 Jul 1;153(7):654-661.
https://www.ncbi.nlm.nih.gov/pubmed/29590289
Dr. Robert Lim: Since treating obesity is about treating the whole patient and not just weight and BMI, I always enjoy articles that either discuss different aspects of bariatric outcomes or are written by non-surgeons. This study examines the relationship patterns of patients undergoing bariatric surgery versus other obese patients and bariatric patients versus the general population in Sweden. The results are another aspect of the Swedish Obesity Study, and the subjects were examined over a 10-year period. The study probably confirmed our suspicions that divorce was more likely after bariatric surgery and, interestingly, the more weight patients lost, the more likely they were to get divorced. Conversely, single bariatric patients were also more likely to get married after surgery compared to other obese patients and compared to the general population.  Again, the more weight one lost, the more likely this was to happen. Clearly, there is a relationship with weight and relationship status, which again points to how much obesity affects the entire person. Patients should be aware that the surgery might not be the only life-changing event they encounter in their journey of obesity control.

Endoscopy

Article: Early operative outcomes of endoscopic (eTEP access) robotic-assisted retromuscular abdominal wall hernia repair. Belyansky I, Zahiri HR, Sanford Z, Weltz AS, Park A. Hernia (2018) 22:837-847.
https://www.ncbi.nlm.nih.gov/pubmed/29974283
Dr. Yuri Novitsky: This article focuses on a fairly new technique for hernia surgery, called enhanced-view totally extraperitoneal (eTEP) hernia repair. This technique, which allows for complex ventral hernia repairs completed outside of the peritoneal cavity (“extraperitoneal”), was first described in 2012 by Dr. Daes for the repair of inguinal hernias. We have now applied this technique to more complicated ventral hernias, using it to complete both retro-muscular and transversus abdominus releases (TARs) repairs without entering the peritoneal cavity. This article reviewed a total of 37 patients who underwent robotic-assisted eTEPs with two surgeons at a highly specialized hernia center. Perioperative and wound-related complications were recorded, as well as outpatient followup, which ranged from 24 to 109 days. This paper found that the eTEP technique resulted in low intraoperative blood loss, few postoperative complications, and a short length of hospital stay (average LOS was 0.7 days). The most common postoperative complication was seroma (5.4%), while there were no recorded hematomas, SSI, skin necrosis, or wound dehiscence. In addition, surgical technique is described, including patient positioning and recommendations on port placement for robotic repairs. There are limitations of this article, specifically the small cohort of patients, the short followup, and that these are the results of two highly specialized hernia surgeons. However, it is an important article on a new technique that has the potential to further move complex abdominal wall reconstruction in the minimally invasive direction.
 
Article: The safe use of surgical energy devices by surgeons may be overestimated. Ha A, Richards C, Criman E, Piaggione J, Yheulon C, Lim R.  Surg Endosc. 2018 Sep;32(9):3861-3867.
https://www.ncbi.nlm.nih.gov/pubmed/29497829
Dmitry Oleynikov: The use of surgical energy is a part of every surgeon’s daily life. This study emphasizes the need for a structured curriculum for safe use of surgical energy for all surgeons. One such program is the Fundamental Use of Surgical Energy (FUSE) program by SAGES.

Hernia

Article: Evaluation of antibiotic pressurized pulse lavage for contaminated retromuscular abdominal wall reconstruction. Majumder A, Miller HJ, Patel P, Wu YV, Elliott HL, Novitsky YW. Surg Clin North Am. 2018 Jun;98(3):623-636.
https://www.ncbi.nlm.nih.gov/pubmed/27800587
Dr. Tejirian: This study describes the use of pressurized pulse lavage with antibiotic solution for clean-contaminated and contaminated abdominal wall reconstruction operations. The lavage was done in the retrorectus space and cultures of the space were taken before and after the lavage. The mesh was placed after the lavage and wound infections were analyzed. They grouped the mesh into synthetic vs. biologic. Even though most (60%) of the patients had negative cultures before the lavage, the focus was on the 40% with positive pre-lavage cultures. Of the 40%, a majority (81%) converted to negative cultures after the lavage. Not surprisingly, those with positive post-lavage cultures had the highest chance of infection. Since antibiotic pressurized lavage has minimal risk but has the potential to lower chances of infection, it should be considered in clean-contaminated and contaminated cases. Interestingly, patients who had biologic mesh had a higher chance of infection compared to synthetic mesh. However, the authors did not specify which patients had medium weight vs. heavyweight mesh in the synthetic mesh group. It would have been interesting to know if the weight of the mesh influenced chances of infection. The authors report that they will address the limitations of this study by performing a prospective randomized trial comparing antibiotic and non-antibiotic solution for the pressurized pulse lavage. More data on this technique supporting its use can potentially help improve outcomes for these complicated cases.

Colon

Article: Criss CN, Gadepalli SK. Sponsoring surgeons: an investigation on the influence of the da Vinci robot. Am J Surg 2018;216(1):84-87.
https://www.ncbi.nlm.nih.gov/pubmed/28859920
Dr. Sean Langenfeld: This study used the CMS website to identify the “top 20” surgeons based on their amount of funding from Intuitive Surgical, and then evaluated their contribution to the robotic surgery literature for 2015. They found 73% of studies’ conclusions to be positive, 24% to be equivocal, and 3% to be negative toward the robot. Regardless of how one feels about this hot topic, we must all appreciate the potential for conflict of interest, and we can certainly anticipate similar studies in the future.

Article: Liposomal bupivacaine transversus abdominis plane block versus epidural analgesia in a colon and rectal surgery enhanced recovery pathway: a randomized clinical trial. Felling DR, Jackson MW, Cleary RK, et al. Dis Colon Rectum. 2018 Oct;61(10):1196-1204.
Rees Porta: Three colorectal surgeons randomized 200 postoperative patients to receive either fentanyl epidural or liposomal bupivacaine TAP block after a variety of surgeries (open, laparoscopic, and robotic colectomy or proctectomy). Both methods were equally as effective for pain management, but the TAP block was associated with less cost and less opioid use. This same group had previously demonstrated that epidural analgesia was superior to continuous peritoneal bupivacaine infusion. With the national opioid crisis, liposomal bupivacaine TAP block may be the best method to help minimize narcotic use, and I have found it to be safe, simple, and effective in my practice as well.

Foregut

Article: Factors associated with repeated health resource utilization in patients with diverticulitis. Mathews SN, Lamm R, Yang J, Kang L, Telem D, Pryor AD, Talamini M, Genua J. J Gastrointest Surg. 2017 Jan;21(1):112-120.
https://www.ncbi.nlm.nih.gov/pubmed/27613732
Dr. Steven Wexner: In order to assess trends in readmission for diverticulitis, Cleveland Clinic Florida alumni Dr. Jill Genua used the New York Statewide Planning and Research Cooperative System database. The authors identified 265,724 patients with diverticulitis between 1995 and 2014. They specifically sought to query patients who had undergone at least two hospital admissions, and were able to identify 42,850 patients from the overall group who had been hospitalized at least twice. The authors identified risk factors for two or more readmissions to include younger age, white race, obesity, hypertension, pulmonary disease, hypothyroidism, rheumatoid arthritis, and depression. Interestingly, the 52% of patients readmitted multiple times ultimately had surgery. However, throughout the study period, the percentage of elective cases increased while the percentage of emergent cases decreased. Further analysis of data such as these might help guide us in not only the medical but also potentially the economic management of diverticulitis.

Article: Incidence of cholecystectomy after bariatric surgery. Altieri MS, Yang J, Nie L, Docimo S, Talamini M, Pryor AD. Surg Obes Relat Dis. 2018 Jul;14(7):992-996. Epub 2018 Mar 30.
https://www.ncbi.nlm.nih.gov/pubmed/29724681
Dr. Eric Ahnfeldt: This article by Drs. Alteri and Pryor on the incidence of cholecystectomy after bariatric surgery. I found this helpful in being able to counsel my patients as to the real percentage of risk of needing a cholecystectomy after bariatric surgery. It broke down the incidence by procedure (RYGB, LAGB, SG). It also identified common bile duct injury incidence. As cholelithiasis is a common phenomenon among post-bariatric surgery patients, this article really helped provide data behind my counseling of patients as to the risk of needing a surgery for this problem postoperatively.

Introduction

This month’s issue features an interview with Dr. Aurora Pryor, who is Professor of Surgery in Stony Brook, New York and the new Co-Director of the 2019 MISS Foregut Program in Las Vegas. Dr. Pryor is also currently President-Elect of SAGES. In addition to serving in these critical leadership roles, this past year Dr. Pryor hosted the second Women’s Leadership in Surgery conference, which I was honored to speak at and thoroughly enjoyed. The agenda comprised topics that were of great benefit to both new and seasoned female surgeons. In this interview, Dr. Pryor takes time to share insights on her meeting, the leadership roles she fulfills, and what’s new in foregut surgery.

Click here for my video interview with Dr. Robin Blackstone, a leader in the bariatric field, for her thoughts on being a female surgeon and how bariatric surgery has evolved during the course of her career.

I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders at the forefront of research and innovation. Contributors include a new face—Dr. Talar Tejirian, a hernia specialist from Los Angeles, California.

Enjoy!

–Colleen Hutchinson

An Interview with Aurora Pryor: Taking the Academic Surgery World by Storm!
(Dr. Pryor is a speaker for Medtronic, Merck, Ethicon, Gore and Stryker, and has received research support from Obalon and Baronova.)

As the new MISS Foregut Co-Director, what are your plans for MISS 2019?
Dr. Pryor: The Minimally Invasive Surgery Symposium (MISS) always encompasses the most up to date and relevant information in surgery. This year’s MISS Foregut Program faculty will discuss new technologies and new approaches to the full spectrum of benign foregut disease, plus delve into the diagnosis and management of complex foregut problems. With major advances in the endolumenal management of reflux disease and motility disorders, there is an expanded array of technologies on the horizon. We will have a session focusing particularly on these technologies and how to incorporate them into a foregut practice.

Please tell us about your Women’s Leadership in Surgery conference—its origins and how attending can benefit female surgeons.
Dr. Pryor: I trained at a time when there were not as many women in surgery. I was the first woman to have a child during the Duke residency and was often asked how I made things work. Early on in my faculty career, I met with partners from industry and learned that work life balance issues and struggles with navigating a surgical career were widespread. We were able to hold a conference for women surgeons at Duke in 2009 to address these issues. With the help of industry partners, Caitlin Halbert and I held a NYC conference, with Dana Telem as Co-Chair. I held the conference this year in Philly, with Caitlin Halbert as Co-Chair, and we look forward to hosting it again next fall.

Can you talk about your current role as SAGES President-Elect, including what your goals and key priorities will be serving in the position of President next year?
Dr. Pryor: I am honored to have the opportunity to serve as the SAGES President. One year is a very short time, so much of what I will focus on is moving forward with the current key initiatives of the society. One project that I am particularly excited about is our new effort in video-based assessment of practicing surgeons. This will expand on our Mastery program with assessments in each of our anchoring procedures in Foregut, Bariatrics, Hernia, Colorectal and more. This initiative, being led by Matt Ritter and Liane Feldman, will allow practicing surgeons a comprehensive tool to measure their operative performance. We are also working hard to increase diversity in our leadership and I will continue to focus on this area. I will continue supporting the success of our innovative and enthusiastic members across all the SAGES missions.

What can general surgeons expect regarding new technology advances in foregut surgery?
Dr. Pryor: There have been major advances in the endolumenal management of reflux disease and motility disorders, and an expanded array of technologies is on the way. The 2019 MISS Foregut Program will include a session focused on these technologies and how to incorporate them into your foregut practice.

What are the biggest challenges facing female surgeons today?
Dr. Pryor: I think the biggest challenges facing female surgeons today are the same challenges facing our male colleagues – we are asked to do more, in less time, for less money. All of us are faced with the potential of burnout that can impact our careers as well as our personal lives. Initiatives to address wellness and job satisfaction are essential, but awareness in general is a great place to start.

Dr. Pryor, thank you for taking the time to speak with me, for being an excellent role model for female surgeons everywhere, and for serving as the Foregut Co-Director of the 2019 MISS in Las Vegas!

Suggested Readings

Bariatric

Article: Long-term follow-up after sleeve gastrectomy versus Roux-en-Y gastric bypass versus one-anastomosis gastric bypass: a prospective randomized comparative study of weight loss and remission of comorbidities. Ruiz-Tovar J, Carbajo MA, Jimenez JM, Castro MJ, Gonzalez G, Ortiz-de-Solorzano J, Zubiaga L. Surg Endosc. 2018 Jun 25. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/29943058
Dr. Luke Funk: Single anastomosis gastric bypass is a relatively new procedure that has increased in popularity over the past decade. Medium and long-term outcomes from this procedure are not well described in the literature. This study randomized patients in Spain to 1 of 3 arms: sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB) and single anastomosis gastric bypass. The authors report that single anastomosis gastric bypass patients had greater weight loss and comorbidity resolution 5 years after surgery compared to sleeve and RYGB. These findings suggest that single anastomosis gastric bypass is an effective and durable weight loss option for patients with severe obesity.

Article: Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy: an analysis of MBSAQIP data, 2015–2016 PUF. Demeusy A, Sill A, Averbach A. Surg Obes Relat Dis. 2018 Jul 5.
https://www.ncbi.nlm.nih.gov/pubmed/30098885
Dr. Ponce: In this updated review of the MBSAQIP Participant Use File 2015-2016 data of a total of close to 200,000 laparoscopic sleeve gastrectomies (LSG), staple line reinforcement (SLR) was used in 77% of cases. Bleeding and reoperation rates were statistically lower in the SLR group and no differences in leak rate, which is different than an earlier MBSAQIP review of data 2012-2014 (Ann Surg. 2016 Sep;264(3):464-73), which showed more leak rates in the SLR group. As I have stated before (Ann Surg. 2018 Mar;267(3):e52), I think leaks in LSG happen mainly from technical issues, and as surgeons are getting better and passing the learning curve, the leaks are actually less. The use of SLR is not an associated factor for leaks.

Endoscopy

Article: Three-way comparative study of endoscopic ultrasound-guided transmural gallbladder drainage using lumen-apposing metal stents versus endoscopic transpapillary drainage versus percutaneous cholecystostomy for gallbladder drainage in high-risk surgical patients with acute cholecystitis: clinical outcomes and success in an International, Multicenter Study. Siddiqui A, Kunda R, Tyberg A, Arain MA, Noor A, Mumtaz T, Iqbal U, Loren DE, Kowalski TE, Adler DG, Saumoy M, Gaidhane M, Mallery S, Christiansen EM4, Nieto J6, Kahaleh M. Surg Endosc. 2018 Sep 12. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30209610
Dr. Douglas Adler: Gallbladder drainage in nonsurgical candidates is typically accomplished by percutaneous drainage, which is deeply unpopular with patients. This study compared percutaneous drainage with two types of endoscopic drainage (transampullary and transmural). The paper shows very encouraging results with the newer method (transmural drainage) despite the increased invasiveness of the procedure when compared to transampullary drainage.

Article: Phase I study of EUS-guided photodynamic therapy for locally advanced pancreatic cancer. DeWitt JM, Sandrasegaran K, O'Neil B, House MG, Zyromski NJ, Sehdev A, Perkins SM, Flynn J, McCranor L, Shahda S. Gastrointest Endosc. 2018 Sep 14. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30222972
Dr. Douglas Adler: Photodynamic therapy for pancreatic cancer delivered via EUS is the focus in this single center, prospective, dose escalation Phase I study. It is a novel and interesting study offering proof of concept.

Hernia

Article: Impact of inadvertent enterotomy on short-term outcomes after ventral hernia repair: An AHSQC analysis. Krpata DM, Prabhu AS, Tastaldi L, Huang LC, Rosen MJ, Poulose BK. Surgery. 2018 May 26. pii: S0039-6060(18)30149-1. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/29843910
Dr. Luke Funk: Inadvertent enterotomies during ventral hernia repair introduce uncertainty regarding the optimal operative approach, use of mesh and position of mesh (e.g. underlay vs. sublay). This study used data from the Americas Hernia Society Quality Collaborative (AHSQC), which includes outcomes from thousands of patients and hundreds of surgeons at non-academic and academic institutions throughout the US. The authors found that inadvertent enterotomies were uncommon (<2%) and were associated with an increased risk of reoperations, readmissions, fistulas, and death. The authors recommended that surgeons use caution regarding the type and location of mesh if they make an inadvertent enterotomy and choose to proceed with a definitive hernia repair that involves mesh.

Article: Ventral hernia management: expert consensus guided by systematic review. Liang MK1, Holihan JL, Itani K, Alawadi ZM, Gonzalez JR, Askenasy EP, Ballecer C, Chong HS, Goldblatt MI, Greenberg JA, Harvin JA, Keith JN, Martindale RG, Orenstein S, Richmond B, Roth JS, Szotek P, Towfigh S, Tsuda S, Vaziri K, Berger DH. Ann Surg. 2017 Jan;265(1):80-89.
https://www.ncbi.nlm.nih.gov/pubmed/28009730
Dr. Tejirian: The article is a great combination of a systematic review and a consensus of a panel of experts. This go-to guide highlights the most relevant topics pertaining to ventral hernias and evidence-based best practices. In addition to the evidence, each topic is associated with expert consensus and a recommendation for future research to help improve knowledge on that topic. The information contained is helpful for all surgeons who repair ventral hernias including both general and plastic surgeons. The section on modifiable risk factors includes information on smoking, obesity, malnutrition and diabetes. It acts as a guide for patient selection and preoperative optimization. Surgical topics about mesh reinforcement, mesh type, mesh location, component separation, primary fascial closure, emergency repair, and incisional hernia prevention are all discussed. This is balanced with a section on nonoperative management of ventral hernias. No matter what percentage of your practice is ventral hernia repair, you will find the concise information contained in this article useful and a worthwhile read.

Colon

Article: Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Fleshman J, Branda ME, Sargent DJ, et al. Ann Surg 2018;Aug 3 [epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30080730
Dr. Sean Langenfeld: This followup to the ACOSOG Z6051 randomized trial focuses on the secondary endpoints of 2-year disease-free survival (DFS) and local recurrence (LR). Laparoscopic resection is found to have similar DFS and LR when compared to open surgery, suggesting that laparoscopic surgery for rectal cancer is safe in experienced hands.

Article: Have Recent Modifications of Operating Room Attire Policies Decreased Surgical Site Infections? An American College of Surgeons NSQIP Review of 6,517 Patients. Farach SM, Kelly KN, Farkas RL, Ruan DT, Matroniano A, Linehan DC, Moalem J. J Am Coll Surg. 2018 May;226(5):804-813.
https://www.ncbi.nlm.nih.gov/pubmed/29408507
Dr. Steven Wexner: Surgical site infection is a major cause of morbidity and cost. Environmental factors that have been thought to potentially impact surgical site infections include personnel attire. In 2015, the Association for Perioperative Registered Nurses (AORN) published recommendations on operating room attire. Some of the areas addressed by their guidelines included minimization of exposed areas of hair and skin. In the absence of scientific evidence, these recommendations were not universally adopted. In order to answer the question of if surgical attire, including implementation of the AORN recommendations, influenced surgical site infection, Farach et al utilized the American College of Surgeons National Surgical Quality Improvement Program database. Data on 6,517 patients operated on between 2014 and 2016 were analyzed. Despite the fact that patients in the post-AORN recommendation implementation group were statistically significantly older and had statistically significantly higher rates of hypertension, hemodialysis dependent, steroid use, and systemic inflammatory response syndrome and were more likely to be ASA class IV, no differences were noted in the rates of SSI before and after implementation. The most significant predictors of SSI were, as potentially suspected, preoperative infection, operative time, and dirty, contaminated, or open wounds. The authors concluded that “implementation of stringent operating room attire policies do not reduce SSI rates.” Moreover, they noted that a hypothetical analysis indicated that almost 500,000 patients would be required to demonstrate a 10% SSI reduction in patients with either a clean or clean contaminated wound. On the basis of this excellent study, for which the senior investigator was my friend Jacob Moalem, implementation of the AORN guidelines do not seem to offer any benefit to SSI reduction.

Foregut

Article: Higher surgical morbidity for ulcerative colitis patients in the era of biologics. Abelson JS, Michelassi F, Mao J, Sedrakyan A, Yeo H.
Ann Surg. 2018 Aug;268(2):311-317.
https://www.ncbi.nlm.nih.gov/pubmed/28448381
Dr. Steven Wexner: Since their introduction in 2005, anti-TNF agents have become widely used in the treatment of patients with mucosal ulcerative colitis. Since 2008, a variety of studies have demonstrated significantly increased postoperative complications in patients receiving anti-TNF therapy prior to surgery (Mor et al; Gu et al; Selvaggi et al). However, a few have failed to identify the increased morbidity associated with anti-TNF agents (Yang et al; Ferrante et al; Gainsbury et al; Coquet-Reinier et al). Abelson et al utilized the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) database and identified 3,803 patients who underwent surgery for ulcerative colitis between 1995 and 2005 and another 3,267 patients between 2006 and 2013. The authors sought to evaluate in-hospital death as well as major in hospital postoperative complications. Other secondary variables included length of stay, discharge to skilled nursing facility or rehabilitation charges, 30-day readmissions, and subsequent surgeries. There were some differences between groups relative to age, ethnicity, and comorbidity. Authors confirmed a higher rate of in-hospital death of 8.1% during the anti-TNF era as compared to 5.5% prior to that time. Similarly, there were significant increases in major events from 5.3% to 7.4%, post-procedural complications from 9.9% to 12.3%, and discharge to settings other than home from 46% to 73%. The authors also noted higher median charges of $66,861 as compared to $46,593 after the introduction of anti-TNFs. The authors adjusted for comorbidity as well as for surgical timing (emergent or urgent, hospital volume, gender, and insurance status).
Following these adjustments they still found that in anti-TNF era, patients were more likely to experience major adverse events, post procedural complications, to require transfusion, and to require discharge to a skilled nursing or rehabilitation facility. Very importantly, there was a significant increase in the percentage of patients who underwent a minimum of three procedures for mucosal ulcerative colitis, from 9% to 14%. The authors concluded that patients having surgery during the anti-TNF era have significantly worse outcomes during hospitalization as well as at both 90- and 365-day follow-up. They acknowledged the shortcomings of the SPARCS database and cited issues such as coding errors; however, they also state that given the large sample size and highly statistically significant differences between the two groups, they do not feel that such coding errors “were a significant issue.” I am impressed by this work produced by Dr. Yeo and her coworkers and trust that this information will be used during the informed consent process with our preoperative patients with mucosal ulcerative colitis. These data also serve as further evidence that it may be best, when medically possible, to delay surgery in patients with mucosal ulcerative colitis receiving anti-TNF agents until the drugs have fully washed out of circulation.