March 6 - 9, 2018

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MISS eNEWS

Improving Patient Outcomes with Minimally Invasive Surgery

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

 

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MISS NEWS

Vol. 8 No. 18

 

Introduction

As we come up on the 18th Annual Minimally Invasive Surgery Symposium (MISS), I had the opportunity to speak to Phil Schauer, MD, Executive Director of the Minimally Invasive Surgery Symposium. With critical presentations on Enhanced Recovery After Surgery; education and discussion on new advances in endoscopic therapies, devices, and advanced surgical techniques; and valuable workshops in general and bariatric surgery, this year’s meeting is not one to miss (no pun intended!). Read on for a short take on the content of this meeting from its founder, and don’t miss the critical recommendations on new literature from thought leaders in general surgery. Enjoy!

Colleen Hutchinson

  

 

Colleen: How would you characterize the unique value of attending MISS versus other conferences?
Dr. Schauer: Not only does MISS include the top experts and relevant topics for the practicing surgeon, it also provides a friendly, relaxed environment that encourages dialogue between speakers and an audience of enlightened surgeons. Unique for a medical conference, the speakers and audience learn quite a bit from each other, and that organic critical discussion that unfolds in this setting is one of the key components of MISS that sets it apart and makes it such a valuable meeting for all general surgeons to attend.

Colleen: What are some of the key topics and speakers for 2018 MISS?
Dr. Schauer: Key advances in our core elements of MIS, including foregut, colorectal, hernia, and bariatrics, will be addressed by our outstanding faculty. Enhanced Recovery After Surgery has been so transformative that we decided to add it to our core topics. Speakers will hear a lot about new procedures, controversial topics and tips of the trade that span all these areas within MIS.

Colleen: Can you tell the readers a little about ERAS and the decision to focus a section of the meeting on it?
Dr. Schauer: The opioid crisis, along with pressure to reduce cost and improve patient satisfaction, have really accelerated interest and development of ERAS. This year’s scope includes the international evidence supporting it (from ERAS Society and ASER), lessons learned from its initial implementation in colorectal surgery, use in other specialty areas of surgery, and how to implement an enhanced recovery program in your own center—from the initial steps to full implementation, which includes dealing with everyone from administrators to pharmacists. Attendees will learn about opioid-reducing treatments, strategies such as TAP block and other local anesthetic delivery methods, non-opioid pain medications, perioperative fluid management, and specialized care pathways that reduce readmissions, get our patients out quicker, and lower costs.

Colleen: There are quite a few new techniques and technologies/devices in the metabolic surgery arena. Can you comment on some of those that you see as most promising and groundbreaking (in trial or approved)?
Dr. Schauer: New endoscopic treatments for obesity, including the new balloons, endoscopic suturing procedures, and more will be discussed. The single anastomosis bypass procedures such as the “mini-gastric bypass” are also gaining popularity. In addition to these and other new advances, devices and techniques being presented, our agenda and panel discussions will address their pros and cons and billing issues. Controversies are covered as well, for example the explosion of robotic hernia repair, evidenced-based rationale on procedure selection such as when to perform sleeve gastrectomy versus gastric bypass, quality outcomes with mesh, treatment and endoscopic therapies for esophageal motility disorders and Barrett’s, and surgical management of IBD, diverticulitis, and LGIB. Renowned speakers will present critical new data on outcomes in metabolic surgery, hernia, colon surgery and and other topics.

 

Suggested Readings

 


Foregut

Article: Poor reproducibility of gallbladder ejection fraction by biliary scintigraphy for diagnosis of biliary dyskinesia. Rose J, Fields R, Strasberg S. J Am Coll Surg. 2017 Nov 17.
https://www.ncbi.nlm.nih.gov/pubmed/29157795
Rees Porta: Although 20% of cholecystectomies in the US are for biliary dyskinesia, it remains a poorly understood and understudied disease. This study only looked at 30 patients but shows that HIDA scan reproducibility is a proverbial coin flip (53% of positive studies were normal on repeat testing 25-56 days later). Although most of these patients had their first HIDA performed at another institution and protocol variation certainly is certainly a factor, it does compliment a recent abstract from Salt Lake City also showing 45% discordance with repeat testing. Clearly, more research is needed regarding the validity of HIDA scan, but most importantly to identify factors to help predict who will benefit most from cholecystectomy.

Article: Concurrent bariatric surgery and paraesophageal hernia repair: comparison of sleeve gastrectomy and Roux-en-Y gastric bypass. Shada AL, Stem M, Funk LM, Greenberg JA, Lidor AO. Surg Obes Relat Dis. 2018 Jan;14(1):8-13.
https://www.ncbi.nlm.nih.gov/pubmed/28869165
Dr. Michael Schweitzer: The article looks at the controversy over paraesophageal repair at the time of bariatric surgery by using the NSQIP database from 2011 to 2014 to examine if the morbidity is higher than similar patients who had no PEH repair. 7.8% of patients underwent PEH repair. The study found no significant increase in complications between the two groups. There was, however, an increased risk of morbidity in the patients who had PEH/gastric bypass when compared to PEH/sleeve gastrectomy (6.20% vs 2.69%, p<.001). The authors acknowledge that the CPT code for a PEH repair may have been used for patients with a small hiatal hernia.

 


Bariatric

Article: Bariatric surgery in women of childbearing age, timing between operation and birth, and associated perinatal complications. Parent B, Martopullo I, Weiss N, et al. JAMA Surg 2017; 152 (20):128-135.
https://www.ncbi.nlm.nih.gov/pubmed/27760265
Dr. Robert Brolin: This retrospective cohort study is one of a relatively small number of published papers that suggest that having bariatric surgery is associated with an increased risk to offspring of postoperative bariatric surgery patients. The nonoperative control group was anthropomorphically comparable with the postoperative group, except postoperative patients had significantly greater median BMIs and a threefold higher incidence of malnutrition versus nonoperative patients. The specific type of bariatric operation was not noted. In lieu of the differences between operative and nonoperative patients, it is unclear whether operative status was the causal reason for the higher incidence of perinatal complications in this report.

Article: Gastric bypass surgery produces a durable reduction in cardiovascular disease risk factors and reduces the long-term risks of congestive heart failure. Benotti, PN, Wood C, Carey DJ, et al. J Am Heart Assoc. 2017;6 017 May 23;6(5).
https://www.ncbi.nlm.nih.gov/pubmed/28536154
Dr. Ricardo Cohen: Metabolic/bariatric surgery is a powerful tool that produces long-term weight loss and control of several associated conditions. Several other studies have already shown decreased cardiovascular events and mortality after surgery, but have never approached the influence of surgery over incidence and mortality secondary to congestive heart failure. This is a retrospective longitudinal cohort study utilizing a prospective surgical registry with linkage to clinical information. The Roux-en-Y gastric bypass (RYGB) and matched controls (N=1724 in each cohort) were followed for up to 12 years after surgery (overall median of 6.3 years). The primary study endpoints of major cardiovascular events (myocardial infarction, stroke, and congestive heart failure) were evaluated using Cox regression.
This study found that individuals undergoing RYGB surgery are at nearly half the risk of a severe cardiovascular event 8 years after surgery compared with similar patients who did not have surgery. Besides decreasing cardiovascular risk factors and events, this is the first study that shows decreased congestive heart failure after RYGB.
Again, this study by Benotti et al reinforces the role of metabolic/bariatric surgery, namely RYGB over cardiovascular risk factors and events, besides a lower long-term risk of congestive heart failure.

 


Colon

Article: Trainee-associated outcomes in laparoscopic colectomy for cancer: propensity score analysis accounting for operative time, procedure complexity and patient comorbidity. Kasten KR, Celio AC, Trakimas L, Manwaring ML, Spaniolas K. Surg Endosc 2018;32:702-711.
https://www.ncbi.nlm.nih.gov/pubmed/28726138
Dr. Sean Langenfeld: This well-designed NSQIP study used propensity score matching to evaluate laparoscopic colectomies for cancer being performed by attending alone (31%) or with assistance from junior residents (5%), mid-level residents (24%), chief residents (26%), or fellows (14%). They found that cases with chief residents or fellows had significantly higher morbidity, insinuating that higher-level trainees with increased autonomy can negatively impact outcomes. This information should not be used to withhold cases from learners, but instead to heighten awareness to the dangers of hands-on training in complex laparoscopy. The next generation of surgeons needs to master these techniques, so it is the surgeon’s responsibility to maintain safety at all times during that process.

Article: Incisional hernia after midline versus transverse specimen extraction incision: a randomized trial in patients undergoing laparoscopic colectomy. Lee L, Mata J, Droeser RA, et al. Ann Surg 2017; Nov 21.
https://www.ncbi.nlm.nih.gov/pubmed/29166359
Dr. Sean Langenfeld: Site of specimen extraction after laparoscopic colectomy can impact pain, infection rates, cosmesis, and hernia rates, with retrospective studies previously showing benefit to transverse incisions. To my knowledge, this is the first randomized controlled trial with adequate power to truly compare midline to transverse incisions. It involved 165 patients undergoing laparoscopic colectomy with specimen extraction through either a midline periumbilical incision or a transverse incision lateral to the rectus. There was no difference in short-term outcomes (pain, LOS, SSI, and incision length), but transverse incisions had a lower rate of hernia at a mean follow up of 30 months (2% vs 15%, p=0.013).

 


Endoscopy

Article: Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: Mid-term analysis of an emerging procedure. Tyberg A, Nieto J, Salgado S, et al. Clin Endosc. 2017 Mar;50(2):185-190.
https://www.ncbi.nlm.nih.gov/pubmed/27642849
Dr. Douglas Adler: This article describes the use of the EDGE procedure to perform ERCP in patients following Roux-en- Y gastric bypass. It is exciting but experimental. The EDGE procedure allows ERCP to be done after gastric bypass without a trip to the operating room.

Article: Endoscopic or surgical step-up approach for infected necrotising pancreatitis: A multicentre randomised trial. van Brunschot S, van Grinsven J, van Santvoort HC, Dutch Pancreatitis Study Group, et al. Lancet. 2018 Jan 6;391(10115):51-58.
https://www.ncbi.nlm.nih.gov/pubmed/29108721
Dr. Douglas Adler: Infected pancreatic necrosis remains a dreaded consequence of acute pancreatitis. Patients typically need drainage of infected fluid and debridement of solid necrotic debris. Historically, surgery has been a first line therapy, but recent years have seen the rise of endoscopic techniques to treat this problem non-surgically. This randomized, multicenter trial showed that surgery and endoscopy were equally effective, but that endoscopic treatment resulted in shorter hospital stays, fewer fistulas, and decreased costs. Endoscopy now appears to be the first line therapy for these patients.

 


Hernia

Article: Carolinas comfort scale as a measure of hernia repair quality of life: a reappraisal utilizing 3788 international patients. Heniford T, Lincourt A, Walters A, et al. Ann Surg. 2018 Jan;267(1):171-176.
https://www.ncbi.nlm.nih.gov/pubmed/27655239
Dr. Shirin Towfigh: The surgeons affiliated with the Carolinas Medical Center have done a nice job of reassessing their Carolinas Comfort Scale (CCS). This paper is timely, as many hernia-related prospective randomized controlled trials and some outcomes databases are using the CCS as part of their data collection. It is comforting to see that their original CCS remains valid in this modern reassessment. Unfortunately, women remain under-represented in the registry that they use for questionnaire validation.

Article: Higher recurrence rate after endoscopic totally extraperitoneal (TEP) inguinal hernia repair with ultrapro lightweight mesh: 5-year results of a randomized controlled trial (TULP-trial). Roos M, Bakker WJ, Schouten N, et al. Ann Surg. 2018 Jan 4. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/29303810
Dr. Michael Rosen: Surgeons are often faced with the decision of what type of mesh to utilize for their inguinal hernia repairs. While there are many options based on anatomic design, self-fixation, etc, the basic question of how heavy of a mesh does one need remains unanswered. As is often the case, the power of marketing and small animal models often drives this discussion. Until recently, it was promoted that "heavyweight" mesh caused increase foreign body reaction, and likely higher rates of chronic pain in the groin. This randomized controlled trial of almost 1,000 inguinal hernias challenges that paradigm. These authors found that after 5 years, a lighter weight mesh had higher chronic pain and recurrence rates than a heavyweight mesh placed during laparoscopic TEP inguinal hernia repair. This article should help surgeons guide their mesh choice during laparoscopic inguinal hernia repairs and should be replicated in the ventral hernia arena.

 

MISS NEWS

Vol. 8 No. 17

 

Introduction

Happy New Year! This month: Schauer & Schauer! We are excited to introduce Dr. Daniel P. Schauer, who is an associate professor at the University of Cincinnati, where his focus has been on bariatric surgery outcomes research.
Given the fact that MISS Director Dr. Phil Schauer rarely meets anyone who shares his last name, he was excited to meet Daniel Schauer, especially given the career and research overlap between them.
In this issue of MISS E-News, Phil Schauer interviews his new adopted cousin for a special Schauer & Schauer interview that focuses on Daniel Schauer’s critical new research findings on bariatric surgery and cancer. Read on for insights on that recent research and also for our current Suggested Readings and commentary from leaders in minimally invasive surgery.
We hope you’ve registered and made your reservations for the 18th Annual MISS that is from March 6-9, 2018, at the Encore at Wynn Las Vegas. Make sure to register by Feb. 5 for discount rates and we look forward to seeing you there!

Colleen Hutchinson

  

 
Interview with Dr. Daniel Schauer

Dr. Phil Schauer: Your recent study showed that bariatric surgery was associated with a reduced cancer rate after surgery. Do other studies support this finding?
Dr. Dan Schauer: Several other studies have found similar results with respect to the reduction in cancer risk for overall cancers and obesity-associated cancers. Having multiple studies in differing populations with varying data sources that all show a similar reduction in cancer risk helps to strengthen our findings. Our study had more power and more robust matching than some of the previous studies, so we were able to look at many of the specific cancer types.
 
Dr. Phil Schauer: Which patients received the greatest benefit from cancer reduction?
Dr. Dan Schauer: We found that women benefited the most from cancer reduction. This was likely because only women are at risk of postmenopausal breast and endometrial cancers which are two of the most common obesity associated cancers and two of the cancers that are most sensitive to hormonal changes. We did not show a benefit in men but this lack of evidence does not necessarily mean they do not benefit. We may need a study with more men and longer-term follow-up to see an effect.

Dr. Phil Schauer: Which cancers are most affected?
Dr. Dan Schauer: We found the greatest reduction in postmenopausal breast, endometrial, colon, and pancreatic cancers, as well as esophageal adenocarcinoma. These are all cancers that are strongly associated with obesity.

Dr. Phil Schauer: How does this benefit from bariatric surgery compare to other benefits such as diabetes remission?
Dr. Dan Schauer: While cancer occurs much less frequently than diabetes in patients with severe obesity, it is a real concern and will continue to be a long-term problem with the current trends in obesity prevalence. It is likely that some of the mechanisms are similar between diabetes remission and cancer reduction although further research needs to look into this.

Dr. Phil Schauer: Can you tell us about your follow-up study looking at whether the decrease in cancer risk is associated with weight loss?
Dr. Dan Schauer: In our follow-up study we wanted to determine if the reduction in cancer risk is solely related to weight loss or if there are other mechanisms associated with bariatric surgery that are independent of weight loss as is seen frequently with diabetes. We found that weight loss accounted for the reductions in cancer risk.

Dr. Phil Schauer: Are you surprised by any of your findings on this subject matter?
Dr. Dan Schauer: We were surprised at the magnitude of risk reduction that we found especially when it came to the individual cancers.

Dr. Phil Schauer: From your perspective, what are the implications of these findings as it pertains to both our population’s long-term health and also our healthcare system’s ability to account for these links?
Dr. Dan Schauer: From my perspective, these findings reinforce the importance of treating obesity as a disease. Many of the long-term complications of obesity, such as cancer, can be prevented with effective weight loss treatment using bariatric surgery. The evidence is overwhelming that surgical treatment of severe obesity is effective and can have a large impact on the health of this population.

Dr. Phil Schauer: What is still on the horizon regarding cancer and weight/obesity?
Dr. Dan Schauer: There remain a lot of unanswered questions regarding weight loss and cancer risk. It remains unclear if there is a benefit in men and if the various bariatric surgery procedures have differing effects.

Dr. Phil Schauer: Thank you Dan! We look forward to hearing more on your findings at the upcoming MISS in Las Vegas.

Suggested Readings

 

Foregut

Article: Moderating the enthusiasm of sleeve gastrectomy: up to fifty percent of reflux symptoms after ten years in a consecutive series of one hundred laparoscopic sleeve gastrectomies. Mandeville Y, Van Looveren R, Vancoillie PJ, et al. Obes Surg. 2017 Jul;27(7):1797-1803.
https://www.ncbi.nlm.nih.gov/pubmed/28190216
Dr. Ricardo Cohen: The number of sleeve gastrectomies (SG) being performed continues to grow in numbers internationally, except in Brazil, which has the second largest volume of bariatric surgery worldwide following that of the US. The growth is surprising, as SG carries the same number of complications and mortality when compared to the Roux-en-Y gastric bypass (RYGB). Additionally, in retrospective, prospective, and even randomized controlled trials, SG delivers a less ideal weight loss and metabolic control when compared to RYGB. That said, it gets worse when gastroesophageal reflux (GERD) after SG is detailed. Among other papers published in the last few years, Mandeville et all describe, after 10 years of followup, significant increase in reflux symptoms and use of PPIs after SG. Seventeen percent suffered from reflux disease preoperatively, versus 50% at the end of the postoperative follow-up. The chance of developing de novo reflux after SG was 47.8%. Reflux disease was present in 7 of the 26 patients who underwent a secondary RYGB. In 4 of these 7 patients, reflux disease disappeared completely after the secondary RYGB.
Although in their experience, the authors describe a reasonably good weight loss, new onset of GERD was seen in over 40% of the SG population.
This paper is a warning sign for the liberal use of SG. The potential complications, such as Barrett’s esophagus and its relation to cancer, and the complications reported lately on the chronic use of PPIs should really curb enthusiasm for SG.

 

Article: Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS). Aryaie AH, Singer JL, Fayezizadeh M, Lash J, Marks JM. Surg Endosc. 2017 Feb;31(2):612-617.
https://www.ncbi.nlm.nih.gov/pubmed/27317034
Dr. Cory Richardson: Staple line and anastomotic leaks continue to represent some of the most difficult foregut complications to manage. Recent advances in endoscopic management have allowed many patients to avoid reoperation and its associated morbidity and mortality. The authors present their experience with self-expandable metal stents (SEMS) over a 5-year period managing patients with leaks after a variety of surgeries, including esophagectomy, esophageal diverticulectomy, gastric sleeve, gastric bypass, partial gastrectomy, and total gastrectomy. Outstanding efficacy was noted, with clinical resolution of leaks seen in 90% of patients. A 60% complication rate, ranging from mucosal friability to stent migration to aorto-enteric fistula, was observed, stressing the need for careful selection and close followup of all SEMS patients.


Endoscopy

Article: Feasibility of a complete pancreatobiliary linear endoscopic ultrasound examination from the stomach. Dhir V, Adler DG, Pausawasdi N3, Maydeo A, Ho KY. Endoscopy. 2017 Sep 21. doi: 10.1055/s-0043-118592.
https://www.ncbi.nlm.nih.gov/pubmed/28934821
Dr. Douglas Adler: This paper describes a heretofore previously thought to be impossible way to endoscopic ultrasound (EUS) the entire pancreas from just within the stomach. Truly groundbreaking.

 

Article: Use of fully covered self-expanding metal stents for benign biliary etiologies: a large multi-center experience. Haseeb A, Siddiqui A, Taylor LJ, et al. Minerva Gastroenterol Dietol. 2017 Sep 5. doi: 10.23736/S1121-421X.17.02428-X.
https://www.ncbi.nlm.nih.gov/pubmed/28875690
Dr. Douglas Adler: This article describes a multicenter study on fully covered biliary stents for benign diseases—off-label but very interesting.

 

Hernia

Article: Online surgeon ratings and outcomes in hernia surgery: An Americas Hernia Society Quality Collaborative analysis. Haskins IN, Krpata DM, Rosen MJ, Perez AJ, Tastaldi L, Butler RS, Rosenblatt S, Prabhu AS. J Am Coll Surg. 2017 Aug 31. pii: S1072-7515(17)31769-6.
https://www.ncbi.nlm.nih.gov/pubmed/28983795
Dr. Michael Rosen: With the growing pressure to measure patient experience and utilize it as a measure of physician quality for value-based payments, there is a critical need to have transparent understanding of what will comprise the process. These authors evaluated the results of several online patient-reported websites to surgeon-reported quality outcomes for ventral hernia repairs. Interestingly, the authors did note that online physician websites do tend to correlate with each other in their measures of patient satisfaction with individual surgeons. However, they did also note that there was no correlation with the patient reported satisfaction with the surgeon and the surgeon’s outcomes or quality. This article should help to counsel patients that utilizing rating websites to identify “high-quality” surgeons can be misleading. It is also important for physicians and surgical organizations to design risk-adjusted, reasonable means for the consumers of healthcare (patients) to make informed decisions about surgical quality.

 

Article: Lichtenstein versus total extraperitoneal patch plasty versus transabdominal patch plasty technique for primary unilateral inguinal hernia repair: a registry-based, propensity score-matched comparison of 57,906 patients. Köckerling F, Bittner R, Kofler M, Mayer F, Adolf D, Kuthe A, Weyhe D. Ann Surg. 2017 Sep 26. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/28953552
Dr. Ajita Prabhu: This is an important article, because it is the largest series to date comparing the 3 most common approaches to inguinal hernia repair. In the past we had accepted that if a surgeon selected a procedure and became skilled at it, that that would be sufficient. Here, with larger data, we are able to see that there may be specific advantages conferred by minimally invasive approaches over open for inguinal hernia repair. As always, we have to be a bit cautious in drawing very broad conclusions from registry-based data, however I think this makes a good argument that surgeons in training should at the very least learn one minimally invasive approach to inguinal hernia repair so that they are able to choose their approach from a position of having options rather than simply performing open surgery because it is how they learned to do the operation. The adoption of MIS approaches for inguinal hernia repair has remained lower than one would expect or hope for, and perhaps this will give some incentive for surgeons to consider learning minimally invasive approaches.


Colon

Article: Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Hubner M, Blanc C, Roulin D, Winiker M, Gander S, Demartines N. Ann Surg 2015;261(4):648-653.
https://www.ncbi.nlm.nih.gov/pubmed/25119117
Dr. Sean Langenfeld: This study is now 2 years old, but carries an important message as enhanced recovery pathways (ERP) become more prevalent in colorectal surgery. Early ERPs showed benefit to thoracic epidural analgesia (TEA) for open colorectal surgery, but this has not been shown for laparoscopic surgery, perhaps because of improvements in multi-modal analgesia as well as decreased overall pain due to smaller incisions. This well-designed randomized controlled trial looked specifically at laparoscopic colorectal surgery in the setting of a mature ERP. The authors found that when compared to a patient-controlled opioid-based analgesia (PCA), epidural analgesia was associated with a higher rate of complications and no difference in postoperative pain scores. In general, TEA is not beneficial for laparoscopic colorectal surgery in the setting of an ERP, and may even be detrimental to patient recovery.


Bariatric

Article: Gastrointestinal symptoms and food intolerance 2 years after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Boerlage TC, van de Laar M, Westerlaken S, Gerdes A, Brandjes D. Br J Surg. 2017 Mar;104(4):393-400. Epub 2016 Dec 19.
https://www.ncbi.nlm.nih.gov/pubmed/27990637
Dr. Flavia Soto/Dr. Megan Flores: Bariatric surgery is the most effective treatment for morbid obesity in the long term, of which laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the surgeries preferred.
LRYGB patients can commonly experience food intolerance post-surgery. This study was designed to investigate gastrointestinal complaints and food intolerance more than 2 years after LRYGB, and to compare these with complaints and food intolerance in a pre-bariatric surgery group.
In this cross-sectional study, patients who underwent primary LRYGB had more complaints postoperatively in comparison to patients at a baseline preoperatively. Most interestingly, the patients who reported symptoms of food intolerances were centered on common food sources that trigger dumping syndrome (fried foods, carbonated beverages, sugar-filled cakes, and pastries). Results suggested that flatulence and borborygmus were the most notable gastrointestinal complaints. Addressing dietary restrictions of foods that trigger dumping syndrome and possible food intolerance with patients is vital, and should be included in comprehensive pre/postoperative education counseling of bariatric patients.
In addition, the article explains that postoperative gastrointestinal symptoms may be simply related to food choices and food intolerance. This may guide clinicians to make quick and effective assessments for complaints of gastrointestinal symptoms postoperatively and minimize time and cost to rule out severe complications.

 

Article: Reoperation and Medicare expenditures after laparoscopic gastric band surgery. Ibrahim AM, Thumma JR, Dimick JB. JAMA Surg. 2017 Sep 1;152(9):835-842.
https://www.ncbi.nlm.nih.gov/pubmed/28514487
Dr. Dana Telem: This article highlights the downstream impact of new technology introduction and highlights the importance of post-market approval device monitoring. Nearly a quarter of Medicare patients who underwent gastric band surgery required a device-related reoperation. Additionally, half of payments associated with the band were related to the reoperation. Given the initial popularity of the band, I believe this article serves as a cautionary tale.

 

MISS NEWS

Vol. 8 No. 16

 

Introduction

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

 
Interview with Dr. Matthew Kroh

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

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

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

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

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

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

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

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

 

Suggested Readings


Foregut

Article: Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: A randomized controlled trial. Watson DI, Thompson SK, Devitt PG, Smith L, Woods SD, Aly A, Gan S, Game PA, Jamieson GG. Ann Surg. 2015 Feb;261(2):282-9.
https://www.ncbi.nlm.nih.gov/pubmed/25119120
Dr. Ricard Corcelles: Currently, there remains hesitancy about the preferred technique for repair of very large hiatus hernia. Surgeons disagree about whether or not to use mesh, and what type of mesh is best. In order to answer this demand, Watson and colleagues piloted a prospective double-blinded randomized trial (n=126) designed to define the effectiveness of mesh repair for large hiatus hernia. The primary outcome for the study was recurrence of hiatus hernia using barium meal radiology and upper gastrointestinal endoscopy. At one-year follow-up, no significant differences for mesh versus sutured repair were identified. However, absorbable mesh was associated with the highest recurrence rate 31%, versus 23% after suture repair, and 13% after no absorbable mesh. The strengths of this study are the high follow-up rate (at least 90% per treatment arm), it is double blinded, and it is a multicentre trial.

 

Article: Endoscopic submucosal dissection versus surgical resection for early gastric cancer: a retrospective multicenter study on immediate and long-term outcome over 5 years. Seung Jee Ryu, Byung-Wook Kim, Boo Gyeong Kim, et al. Surg Endosc. 2016 Dec;30(12):5283-5289.
https://www.ncbi.nlm.nih.gov/pubmed/27338583
Dr. Ricard Corcelles: Endoscopic submucosal dissection (ESD) has been acknowledged as a treatment option for selected early gastric cancers (EGC). Nevertheless, extended indications for ESD are not broadly accepted (mucosal cancer > 2 cm without ulcer; mucosal cancer with an ulcer < 3 cm; and minimal submucosal invasive cancer). The aim of this study was to evaluate long-term oncologic outcomes after ESD (n=81) versus surgical resection (n=144). After more than 5 years of follow-up, Ruy et al. reported no difference in overall survival rate for EGC lesions that met the expanded criteria. However, these results must be cautiously appraised as per recurrence and disease-free survival rate: five-year cancer recurrence rate of the ESD group was 12.3% versus 2.1% of the surgical group (p<0.01); five-year disease-free survival rate of the surgical group was 97% versus 85% of the ESD group (p<0.01). In summary, the study shows that ESD might be an acceptable option for EGC considering overall survival rates but with higher risk of recurrences.


Hernia

Article: Laparoscopic extraperitoneal repair versus open inguinal hernia repair:20 year follow-up of a randomized controlled trial. Barbaro A, Kanhere H, Bessell J, et al. Hernia (2017) 21: 723-727.
https://www.ncbi.nlm.nih.gov/pubmed/28864955
Dr. Bret Cardwell: Authors reopened a randomized controlled trial that was finished in 1994. They specifically looked at the 20-year hernia recurrence rate. Data was available on 98 or 104 (94%) of the original study participants, a surprisingly high percentage. The value of this is an important and intriguing look at the lifetime durability of TEP vs open mesh inguinal hernia repairs. Yes, this was early in the history of laparoscopic hernia repair. When I ask my patients which is more important to them—low recurrence or low early postoperative pain, the answer is usually, “Doc, I only want to go through this surgery once!” If low recurrence rates our patients’ “gold standard” of inguinal hernia repair, then open repair remains the champion.

 

Article: Factors associated with hernia recurrence after laparoscopic total extraperitoneal repair for inguinal hernia:a 2-year prospective cohort study. Schjøth-Iversen L, Refsum A, Brudvik K. Hernia (2017) 21: 729-735.
https://www.ncbi.nlm.nih.gov/pubmed/28752424
Dr. Bret Cardwell: This is detailed, in-depth, and is a large (1194) cohort of patients. The study results support three preoperative factors for postoperative hernia recurrence after TEP: 1) BMI >30; 2) type of inguinal hernia “medial” (direct); and 3) repair of recurrent hernia. This was a well-done study, and the large size allowed the variables to show a clear result. The problem became that that a clear result was not carried over into the conclusion, as the conclusion stated information that was not studied in the project. Focus on what matters, and if obesity, hernia type, and recurrent hernias are what matter, how do we as surgeons improve our outcomes using that information?


Bariatric

Article: What are the long-term results 8 years after sleeve gastrectomy? Noel P, Nedelcu M, Eddbali I, Manos T, Gagner M. Surg Obes Relat Dis. 2017 Jul;13(7):1110-1115.
https://www.ncbi.nlm.nih.gov/pubmed/28755888
Dr. Javed Ahmed Raza: Sleeve gastrectomy has become the most commonly performed bariatric procedure in the world. There is very little data about the long-term effectiveness and complications of sleeve gastrectomy. This article highlights successful weight loss maintenance in 59% of cases at 8 years. 20% of the patients required revisional surgery. In addition, 31% of patients reported gastroesophageal reflux symptoms at 8 years. These are some of the important areas that need to be discussed when counseling patients for sleeve gastrectomy.

 

Article: Comparison of economic and clinical outcomes between patients undergoing laparoscopic bariatric surgery with powered versus manual endoscopic surgical staplers. Roy S, Yoo A, Yadalam S, Fegelman EJ, Kalsekar I, Johnston SS. J Med Econ. 2017 Apr;20(4):423-433.
https://www.ncbi.nlm.nih.gov/pubmed/?term=28270023
Dr. Javed Ahmed Raza: This is a large-scale study of over 30,000 patients undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy comparing the outcomes with the use of either manual or powered staplers. The powered stapler group was associated with lower costs and lower rate of bleeding/transfusion especially in the sleeve gastrectomy group.


Endoscopy

Article: Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Kumar N, Thompson CC. Gastrointest Endosc. 2016 Apr;83(4):776-9.
https://www.ncbi.nlm.nih.gov/pubmed/26344204
Dr. Matthew Kroh: Bariatric surgery, and in particular, Roux en-Y gastric bypass, is a proven, durable therapy for obesity and weight-related diseases. With the current obesity epidemic, hundreds of thousands of patients worldwide undergo successful surgical procedures that improve their overall health and ultimately mortality. However, there is a subset of patients, probably on the order of 5 to 25%, who will have weight regain and accruement of weight related comorbid diseases. For these patients, options are limited. Endoluminal revision offers compelling advantages in that the procedure is performed transorally, avoiding the operative field, and typically requires a short or no-hospital stay with excellent safety profiles. However, efficacy and durability of these interventions has been limited to date.
Kumar et al present their experience in this study with endoscopic gastrojejunostomy revision after previous Roux en-Y gastric bypass, and subsequent weight regain. The group has previously published their earlier experiences, and this cohort of 150 patients at 3 years represents one of the largest series of patients at the furthest time point from intervention. Inclusion criteria included gastrojejunostomy >15mm, and average weight regain was nearly 50% of excess weight loss after weight nadir. Adverse events were mild and rare. The authors show an 8.7% total body weight loss at 3 months after the procedure. At 36-month follow-up, with 110 of the 150 original patients available for evaluation, the total body weight loss was maintained at 8.6%, with a larger standard deviation. The authors do not report on weight-related comorbid diseases, nor do they describe other interventions that might have been instituted by a multidisciplinary team, including nutritional education, exercise programs, and pharmacotherapy interventions.
Endoscopic revision of bariatric surgical procedures is a compelling intervention with improving outcomes. This study reports on a large group of patients at 3 years, representing longer-term data for these evolving procedures. Further studies, including longer duration of follow-up and further generalizability beyond specialized centers, will likely dictate whether these procedures will be more commonly used to treat patients with weight regain after previous surgery.

 

Article: Teaching peroral endoscopic myotomy (POEM) to surgeons in practice: an "into the fire" pre/post-test curriculum.
Kishiki T, Lapin B, Wang C, Jonson B, Patel L, Zapf M, Gitelis M, Cassera MA3, Swanström LL, Ujiki MB. Surg Endosc. 2017 Sep 15. doi: 10.1007/s00464-017-5823-3. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/28916889
Dr. Matthew Kroh: Per oral endscopic myotomy (POEM) for achalasia is increasingly being used to treat all types of achalasia. Groups worldwide are accruing experience and reporting data that show the efficacy, and increasingly, the durability of the procedure. The skill set necessary to treat patients and perform this advanced endoscopic procedure is being gained across a spectrum of practitioners, trained in surgical and gastroenterological paradigms. Little data exists on the optimal training mechanism to further propagate this procedure and other similar advanced techniques, especially in the post-graduate period.
In this report from Kishiki et al, the investigators report a series of courses taught by 11 experienced POEM endoscopists (personal experience >50) from two centers, and the results of a proposed training curriculum to teach POEM. With a program of pre-procedural training, didactic lectures, and hands-on experience with ex vivo and in vivo models, 65 participants were evaluated. Even with pre-test disparities between their “expert” and “novice” groups, the proposed curriculum resulted in similar post-course testing results, indicating that the curriculum and skills testing improved both groups, but in particular the lower skill set group. Data on specific trainee experience in advanced endoscopic procedures would be helpful to better gauge pre-course skill sets, and it would also be interesting to see how many of the participants eventually ended up performing POEM after the training session.
In an era when increasingly complex endoluminal surgical procedures are being performed, training and expertise development remains a challenge. Increasingly, validated and readily available programs will need to be established to allow for these minimally invasive therapies to be widely available to our patients.


Colon

Article: Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial. Ponsioen CY, de Groof EJ, Eshuis EJ, LIR!C study group, et al. Lancet Gastroenterol Hepatol. 2017;2(11):785-792.
https://www.ncbi.nlm.nih.gov/pubmed/28838644
Dr. Shafik Sidani: Nonstricturing short segment Crohn’s disease of the terminal ileum intractable to conservative management is generally treated by escalation to biologic agents. This study offers laparoscopic ileocecal resection as an alternative to treatment with biologics with comparable patient-reported quality of life outcomes and morbidity in this group of patients. It will be interesting to hear about the cost-effectiveness data comparing the two groups in the future.

 

Article: One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis. Schultz JK, Wallon C, Blecic L, Forsmo HM, Folkesson J, Buchwald P, Kørner H, Dahl FA, Øresland T, Yaqub S; SCANDIV Study Group. Br J Surg. 2017;104(10):1382-1392.
https://www.ncbi.nlm.nih.gov/pubmed/28631827
Dr. Shafik Sidani: Surgical management of Hinchey III diverticulitis has become controversial with the emergence of laparoscopic lavage as an alternative to resection. This study comparing the two approaches reports one-year results showing that severe morbidity and mortality are similar. It highlights the shortcomings of each approach, increased unplanned reinterventions in the lavage group, and an increased stoma rate in the resection group. It cautions about the specific risks associated with lavage.

MISS NEWS

Vol. 8 No. 15

 

Introduction

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

 

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

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

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

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

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

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

 

Suggested Readings


Foregut

Article: Risk of death among users of proton pump inhibitors: a longitudinal observational cohort study of United States veterans. Xie Y, Bowe B, Li T, Xian H, Yan Y, Al-Aly Z. BMJ Open. 2017 Jul 4;7(6):e015735.
https://www.ncbi.nlm.nih.gov/pubmed/28676480
Dr. Ajita Prabhu: This article is interesting because after proton pump inhibitors (PPI) came along, there was a substantial shift away from anti-reflux surgery in favor of medical therapy. As PPIs have become widely available over the counter, their use has also increased. Most medications, as we know, have some side effect profile, and likely anything we do to change our body's natural physiology comes with some consequence. Because this is an observational study and not a prospective head-to-head comparison, it's difficult to draw any hard conclusions that can inform the use of PPIs. Also, there is some potential that the patients who took PPIs in this study had greater risk of death for other reasons that are unmeasured variables in this case. That said, I think that considering this article in combination some other recent literature about PPIs, these findings probably warrant a closer look at this line of therapy. I don't think that doctors and patients should abandon PPIs at this point based on these findings. Rather, more prospective studies are needed, and also maybe it would be helpful to take a pause before just assuming all meds are ok to take. It's probably a good idea to consider potential consequences of the use of these drugs instead of assuming that they are all harmless just because they are widely available.

 

Article: Simulation model for laparoscopic foregut surgery: the University of North Carolina Foregut Model. Schlottmann F, Murty NS, Patti MG. J Lap Adv Surg Techniques. July 2017, 27(7): 661-665.
https://www.ncbi.nlm.nih.gov/pubmed/28537779
Dr. Akshay Chauha/ Dr. Dmitry Oleynikov: Surgical simulation has undergone an enormous transformation since the early 1990s, evolving from manikins and plastic benchtop kits to 3D printing and patient-specific virtual reality systems. While traditional simulators like cadavers and bench-top models were mostly used to train and assess the skills of novice surgeons, new-age simulators help expert surgeons prepare for unique surgical conditions specific to the patient. These new devices are redefining the role of simulations, expanding their use from training to preoperative planning. However, this new technology comes with a huge cost, which is not affordable by many training programs.
The authors in this paper have made an innovative model to bridge the significant gap that presently exists between box-lap and virtual-reality simulators and live surgery. They have developed a high-fidelity, real tissue simulator that allows training in laparoscopic foregut operations. This allows the surgeon to practice laparoscopic foregut procedures preoperatively in a virtual environment with accurate renditions of the patient’s anatomical variations. This will hopefully decrease the cost of physician training while increasing physician quality in the future.


Endoscopy

Article: Efficacy and safety of the over-the-scope clip (OTSC) system in the management of leak and fistula after laparoscopic sleeve gastrectomy: A systematic review. Shoar S, Poliakin L, Khorgami Z, et al. Obes Surg. 2017 Sep;27(9):2410-2418. doi: 10.1007/s11695-017-2651-4.
https://www.ncbi.nlm.nih.gov/pubmed/28353180
Dr. Douglas Adler: The authors provide a good meta-analysis on adverse events after bariatric surgery and how to fix them. Bariatric fistulas are really common and vexing—the paper looks at endoscopic means to fix them and how well they work.

 

Article: Endoscopic submucosal dissection and EMR for large colorectal polyps: "The perfect is the enemy of good." Heitman SJ, Bourke MJ. Gastrointest Endosc. 2017 Jul;86(1):87-89.
https://www.ncbi.nlm.nih.gov/pubmed/28610868
Dr. Emre Gorgun: I like this article from Michael Bourke in which he envisions that essentially all benign and low-risk malignant lesions in the colorectum will be one day recognized, accurately characterized, and ultimately cured without surgery. He acknowledges that endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are remarkable innovations and represent a leap forward toward realizing


Hernia

Article: Does preoperative bowel preparation reduce surgical site infections during elective ventral hernia repair? Krpata DM, Haskins IN, Phillips S, Prabhu AS, Rosenblatt S, Poulose BK, Rosen MJ. J Am Coll Surg. 2017 Feb;224(2):204-211.
https://www.ncbi.nlm.nih.gov/pubmed/27825916
Dr. Michael Rosen: Dr. Krpata et al from the Americas Hernia Society Quality Collaborative (AHSQC) recently examined the potential benefits and pitfalls in utilizing a routine mechanical bowel preparation for patients undergoing elective ventral hernia repairs. This practice is often touted as making it easier to handle the bowel and reducing potential intraoperative or postoperative complications. However, to date, no other group has evaluated the utilization of bowel preparation in elective ventral hernia. It is an important point, as many patients do not like to take a bowel preparation prior to hernia surgery, and it has been postulated to increase ileus and is certainly associated with perioperative dehydration in many patients. Utilizing the AHSQC database, the authors evaluated 3,709 patients that underwent hernia repair and compared those that received a mechanical bowel preparation with a group that did not utilize logistic regression modeling. Their findings were very interesting as they noted that patients that had a clean ventral hernia repair (CDC class I) were significantly more likely to experience a surgical site infection, surgical site occurrence, and surgical site occurrence requiring procedural intervention if they had a preoperative mechanical bowel prep. Even when evaluating the patients with contaminated hernias, a bowel preparation was still more likely to result in surgical site occurrences requiring procedural intervention when compared to those that did not receive a prep. Given this information from a large database with well-matched groups, it seems reasonable to eliminate mechanical bowel preparation from the preoperative optimization of patients undergoing ventral hernia repairs.

 

Article: Drain placement does not increase infectious complications after retromuscular ventral hernia repair with synthetic mesh: an AHSQC analysis. Krpata DM, Prabhu AS, Carbonell AM, Haskins IN, Phillips S, Poulose BK, Rosen MJ. J Gastrointest Surg. 2017 Oct 5. doi: 10.1007/s11605-017-3601-0. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/28983795
Dr. Michael Rosen: This article tries to answer the age-old question of whether putting drains next to the mesh after an open ventral hernia repair is a good idea or a bad idea. Using the AHSQC database, the authors compared the results of 300 patients that underwent open retromuscular repairs with synthetic mesh, of which 200 had drains and 100 did not. Using a propensity-matched analysis, these authors found that retromuscular drain placement was not associated with any higher rates of surgical site infection, mesh infection, or other negative result. They did note, however, that drains tended to result in lower rates of seroma.


Bariatric

Article: Weight and metabolic outcomes 12 years after gastric bypass.
Adams TD, Davidson LE, Litwin SE, Kim J, Kolotkin RL, Nanjee MN, Gutierrez JM, Frogley SJ, Ibele AR, Brinton EA, Hopkins PN, McKinlay R, Simper SC, Hunt SC. N Engl J Med. 2017 Sep 21;377(12):1143-1155.
https://www.ncbi.nlm.nih.gov/pubmed/28930514
Dr. Ricardo Cohen: Twelve years after gastric bypass weight loss surgery, the benefits persist in most patients, leading to long-term weight loss, less diabetes, lower blood pressure and fewer cholesterol problems, according to a study of the technique that has had the longest follow-up so far. Researchers compared patients who underwent Roux-en-Y gastric bypass with patients who sought but did not undergo surgery (mainly because of insurance coverage issues) and patients who did not seek surgery.
While 26% of patients in the control groups had type 2 diabetes at the 12-year mark, the rate was a mere 3% with surgery. Remission was more likely when a patient with diabetes was not taking insulin and had a shorter history of the disease, probably because those patients still had enough healthy pancreas cells left to produce insulin. Cardiovascular risk markers, such as cholesterol, collectively improved more with the surgery. The reduction in high blood pressure was significantly greater compared to one of the control groups but not the other. The only drawback of the study was a slightly higher suicide rate within the surgical arm, but causes have yet to be studied. Bariatric surgery is a very efficient and durable option for obesity and its comorbid conditions.

 

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


Colon

Article: Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. Berríos-Torres SI, Umscheid CA, Bratzler DW. JAMA Surg. 2017 Aug 1;152(8):784-791.
https://www.ncbi.nlm.nih.gov/pubmed/28467526
Dr. Emre Gorgun: This is an important publication in JAMA as the number of surgical procedures performed in the United States continues to rise, and morbidities likewise. This guideline includes multiple evidence-based recommendations for the prevention of surgical site infections (SSI) and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

 

Article: Uptake of transanal total mesorectal excision in North America: initial assessment of a structured training program and the experience of delegate surgeons. Atallah SB, DuBose AC, Burke JP, et al. Dis Colon Rectum 2017;60:1023-1031.
https://www.ncbi.nlm.nih.gov/pubmed/28891845
Dr. Sean Langenfeld: Transanal total mesorectal excision (taTME) is an innovative approach to minimally invasive rectal cancer surgery, and has gained significant momentum both in practice as well as on the podium. As with all “hot” techniques, there are justified concerns that taTME will become widely disseminated despite a lack of data on long-term outcomes as well as a potential lack of surgeon expertise. Those performing TME from the bottom up will see the anatomy from a brand new perspective, and thus they will encounter new pitfalls, the most dreaded of which is urethral injury in male patients. This study evaluates a well-structured training program, and the authors are to be commended on their leadership and their ability to adapt their program over time. Of note, surgeons in this course are almost all experts in laparoscopic rectal cancer surgery, and yet the workshop involved rectal injury in 4.5% of cadavers and inadvertent prostate mobilization in 20%. A follow-up survey of workshop participants showed that 35% of surgeons reported needing 6 or more cases after the workshop to feel comfortable, while 45% were still uncomfortable with taTME. Additionally, 25% of respondents reported a urethral injury despite completion of the course, so it appears their lack of comfort is justified. To me, it is clear that taTME has an important role in rectal cancer surgery, especially in the narrow male pelvis, but it requires formal training and proper patient selection to avoid serious injury during the surgeon’s ascent of the learning curve.

 

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