Alan A. Saber

Early experience in the use of the Advanced Breast Biopsy Instrumentation: A report of one hundred twenty-seven patients

BACKGROUND Recently there has been a great interest in developing alternative breast biopsy techniques that yield the appropriate histologic information in the least invasive and most cost-effective manner. The objective of this study was to evaluate the efficacy and results with the Advanced Breast Biopsy Instrumentation (ABBI) method for stereotactic excisional biopsies of nonpalpable mammographically detected breast lesions. METHODS All patients with nonpalpable mammographic abnormalities who fulfilled the selection criteria for the ABBI procedure were studied. Pathologic diagnosis, the size of the specimen, the length of the procedure, postoperative complications, patient satisfaction, and the cost of the ABBI procedure were analyzed. RESULTS One hundred twenty-seven of 139 patients (94.2%) underwent the ABBI procedure. Twelve patients (8.61%) required conversion to the needle localization procedure. Mammographically, 64 lesions revealed microcalcifications, 51 showed nodular densities, and 12 demonstrated both findings. Histologically, 21 lesions (16.5%) were malignant, whereas 106 were benign (83.5%). The mean operative time for the procedures was 62.5 minutes. Postoperatively 5 patients had local ecchymosis and 1 had a hematoma. The average cost per patient was found to be

Endoscopic subfascial surgery for incompetent perforator veins in patients with active venous ulceration.

1000, considerably less than for needle localization biopsy. CONCLUSION With proper patient selection the ABBI procedure has proved to be a valuable tool in the armamentarium of the breast surgeon. Its efficiency, accuracy, and patient acceptance have been well documented in our hands.

Portomesentric and splenic vein thrombosis (PMSVT) after bariatric surgery: a systematic review of 110 patients

BackgroundPreviously, subfascial ligation of perforator veins to treat venous ulceration in the lower extremities required long skin incisions through diseased skin and subcutaneous tissue. This was known as “the Linton operation.” In 1985, Hauer described an endoscopic technique for ligating incompetent perforator veins; this seminal contribution marked the advent of subfascial endoscopic perforator surgery (SEPS).MethodsFrom 1996 to 1998, we prospectively collected data on 41 patients with chronic venous insufficiency (CVI) who underwent a SEPS procedure at our institution. Preoperative assessment consisted of color-flow duplex ultrasound scanning, as well as ascending and descending phlebography.ResultsSome 45 SEPS procedures were performed on the 41 patients. Ages ranged from 42 to 84 years (mean, 60). Active venous ulcers were present in 37 legs; healing occurred within 9 weeks in 33 of them. No new ulcers developed in the follow-up period, a mean of 44 weeks.ConclusionThe results suggest that the SEPS procedure incorporated into the overall treatment plan for patients with CVI produces active healing with a minimum of postoperative complications. The study demonstrates the safety and efficiency of this procedure; it also underscores the important role incompetent perforator veins have in the formation of venous ulcers.

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) By American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgery (ACS)

BACKGROUND Portomesenteric and splenic vein thrombosis (PMSVT) is a rare but potentially serious complication after bariatric surgery. No study has systematically analyzed its incidence and risk factors. OBJECTIVES To pool the data regarding PMSVT after bariatric surgery and determine its incidence and risk factors. METHODS A meta-analysis and systematic review was conducted to retrieve studies on PMSVT after bariatric surgery. RESULTS A total of 41 eligible studies including 110 patients with postbariatric PMSVT were enrolled; the estimated incidence rate based on 13 studies was .4%. The use of oral contraception was reported in 35.4% of patients, previous surgery in 61.1%, smoking in 37.2%, and history of coagulopathy in 43%. PMSVT mostly occurred after sleeve gastrectomy (78.9%) and within the first postoperative month (88.9%). Pneumoperitoneum pressure was>15 mm Hg in 6% of patients. The portal vein was the most commonly affected vessel (41.5%). Prothrombin 20210 mutation and protein C/S deficiency were the most common thrombophilic conditions. Unfractionated heparin (59.1%), vitamin K antagonists (50.9%), and low molecular weight heparin (39.1%) were the most common treatments for PMSVT. The morbidity and mortality rates for postbariatric PMSVT were 8.2% and 3.6%, respectively. CONCLUSION PMSVT usually occurs within the first postoperative month and is mostly reported after sleeve gastrectomy. The portal vein is the most commonly involved vessel. A previous hypercoagulable state can be an important risk factor. Most patients can be treated with anticoagulation therapy. Further studies with comprehensive data review of patient information are required.

Bariatric manipulation of gastric arteries: A systematic review on the potential concept for treatment of obesity

Metabolic and bariatric surgery procedures provide highly effective solutions for durable weight loss. This helps in resolving obesity-related comorbidities and reducing mortality in the morbidly obese population. Therefore, more and more healthcare facilities are gearing up to meet the increasing demand for such services. In order to achieve a single national accreditation standard for bariatric surgery centers in the United States and Canada, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) was started by combining the accreditation programs of the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS).

Comparison of two specimen retrieval techniques in laparoscopic sleeve gastrectomy: what is the role of endobag?

BACKGROUND Gastric artery embolization (GAE) has recently received attention as a minimally invasive intervention in bariatric setting. AIMS The current systematic review aimed to gather and categorizes the existing data in the literature regarding bariatric gastric artery manipulation. This will highlight the importance of this potential concept as a therapeutic modality. METHODS A PubMed/Medline search was conducted to identify animal and human studies investigating the effect of gastric artery manipulation on weight, ghrelin, obesity, and tissue adiposity. RESULTS A total of 9 studies including 6 animal experiments with 71 subjects and 3 human studies with a total of 25 patients were retrieved. Animal subjects underwent chemical embolization while particle embolization was only used in human subjects. Five animal studies and 1 human study reported decreased ghrelin concentration. Three animal experiments and 2 human studies showed a significant weight change following GAE. There was no report regarding a serious adverse event requiring surgical or interventional management. CONCLUSION Currently, data regarding the potential role of gastric artery manipulation in decreasing the ghrelin and potential weight loss is scarce.

Response to the “Letter to the Editor Concerning the Publication: Efficacy of First-Time Intragastric Balloon in Weight Loss: a Systematic Review and Meta-Analysis of Randomized Controlled Trials”

BackgroundLaparoscopic sleeve gastrectomy (LSG) has become a popular stand-alone treatment for morbid obesity. However, removal of the gastric specimen could be a challenging step due to its large size relative to the width of the trocar site.ObjectivesWe aimed to compare a simplified retrieval technique for extraction of the gastric specimen without an endobag with conventionally performed specimen retrieval using an endobag.MethodsA case-control study was conducted recruiting patients undergoing LSG. Patient’s demographics, preoperative characteristics, intra-operative, and postoperative variables were compared between the two groups according to the technique of gastric specimen removal.ResultsA total of 193 patients (60.6% female) were enrolled into case (n = 100) and control groups (n = 93). Mean ± SD age and BMI of patients were 35.64 ± 11.84 years and 47.28 ± 8.22 Kg/m2, respectively with no significant difference between groups. Median (25th, 75th inter-quartile), extraction time was significantly reduced in the non-endobag group compared to the endobag group (3.5 [2.5–4.5] min vs. 6.5 [3.4–8.2] min, p = 0.03).Patients of both groups had similar intra-operative and trocar site complications (hernia and wound infection) (3% for endobag group and 3.3 % for non-endobag group). The median (25–75% [IQR]) LOS was also comparable between endobag and non-endobag patients (3[2–3] vs. 3[2–4] days, p = 0.84). No difference was observed between the two groups for weight loss and comorbidity resolution.ConclusionNon-endobag technique for gastric specimen retrieval is safe and feasible with substantial saving in operative time and comparable intra-operative and postoperative outcomes to the conventional retrieval technique.

Laparoscopic sleeve gastrectomy in patients with abdominoplasty: a case-control study

We appreciate the opportunity of replying to the editorial comment on our published study entitled BEfficacy of Firsttime Intra-gastric Balloon in Weight Loss: a Systematic Review and Meta-analysis of Randomized Controlled Trials^. The aforementioned BLetter to the Editor^ has commented on our study regarding the mixed inclusion of randomized controlled trial (RCT) on air-filled and fluidfilled IGBs. Moreover, the authors mentioned that 289 patients have undergone insertion of the historical IGBs accounting for 24% of the whole population included in metaanalysis. Additionally, the letter speculates that the comparison of air-filled and fluid-filled IGBs is indeed a comparison between the modern and historical IGBs. Our meta-analysis has clearly stratified the two groups of IGB to perform a sub-group analysis to compare the weight loss outcome and complication rate between air-filled and fluid-filled IGBs. Moreover, most of the time, it is not feasible to implement a very strict criteria in the systematic literature reviews to exclude studies based on a historical basis. On the other words, although we agree that the new generation of airfilled IGBs has evolved over the last decades, these types of balloons have been continuously used as an alternative option for fluid-filled IGBs as a temporary treatment of obesity. That being said, exclusion of air-filled IGBs which have been concurrently evolved to shape the current generation of IGBs, does not seem practical. To provide an example, a recent RCT comparing fluid-filled IGBs and air-filled IGBs identified similar weight loss outcome between the two types of balloons [1]. However, it demonstrated a longer extraction time, higher deflation rate, and patient discomfort for air-filled IGB probably due to its difficult passage through the cardia and the lower pharynx. The results of this recent RCT sheds light on the fact that despite the improvement in IGBs design and shape which resulted in similar weight loss outcome, the modern air-filled balloons still require modification to avoid the spontaneous deflation and ameliorate the patient tolerance. This is in the same direction with our study finding which emphasizes on the comparable weight loss outcome of airfilled and fluid-filled IGBs but warning a higher complication rate for air-filled balloons. Excluding the study of Gliebter et al. which has used a fluid-filled type of IGB [2], it should be noted that the total number of patients pertinent to an air-filled IGB is 249 (20%) not 289 (24%). Nevertheless, such a subdivision of patients becomes meaningful only when the whole included population is pooled together in a single analysis. But, as our metaanalysis clearly shows, different sub-group analysis based on weight loss measurement unit and IGB type dilutes the weight of such a calculated sub-population. We appreciate that Geliebter et al. have used an IGBs which is made out of breast implant [2] and this type of IGBs have been abandoned long time ago by FDA. However, it is noteworthy that not all the available IGBs in the market are FDA-approved as they are mostly manufactured in the European and South American countries [3]. Furthermore, we should revoke the aim of our metaanalysis to be the comparison of IGBs versus conservative medical treatment in weight loss. With that in mind, comparison of air-filled IGBs against fluid-filled IGBs was not within the main scope of our study. In fact, the sub-group analysis based on the IGB type was for the sake of clarity of the effect of the IGB type in the weight loss outcome. * Alan A. Saber saber6231@gmail.com

Reduced Port Laparoscopic Bariatric Surgery

BACKGROUND Abdominoplasty is increasingly performed after weight loss surgery. However, performing a laparoscopic sleeve gastrectomy (LSG) after abdominoplasty poses technical challenges. OBJECTIVE The present study aimed to compare operative events and postoperative outcomes between LSG patients with and without a history of prior abdominoplasty. SETTING University hospital, Qatar. METHODS A case-control study was conducted on 2 groups of patients with (n = 33) and without (n = 69) prior abdominoplasty who underwent LSG. Patient demographics, baseline characteristics, as well as operative and postoperative events were compared between the 2 groups. RESULTS A total of 102 patients with an average age of 39.6±7.7 years and body mass index (BMI) of 42.8±5.9 kg/m2 were included. There were no significant differences between the 2 groups in terms of demographic characteristics, preoperative BMI, and co-morbidities. The number of ports required was significantly higher in the LSG patients with a history of prior abdominoplasty than in the nonabdominoplasty patients. The operation time was also significantly longer in the abdominoplasty patients than in the nonabdominoplasty patients (90.3±36.7 minutes versus 57.1±17.7 minutes; P<.0001). However, no significant differences were observed in terms of postoperative complications, length of hospital stay, and weight loss results. CONCLUSION LSG after abdominoplasty is associated with longer operative times and the need for additional port placement to overcome the decreased working space. However, operative strategies should be considered to overcome the technical challenges during LSG in patients who underwent a prior abdominoplasty.

Efficacy of First-Time Intragastric Balloon in Weight Loss: a Systematic Review and Meta-analysis of Randomized Controlled Trials

Reduced port laparoscopic surgery (RPLS) is a new surgical approach in bariatric surgery that minimizes abdominal wall trauma. It has the potential to cause reduced postoperative pain and improved cosmesis without compromising the outcome. It is useful for a selected group of patients, especially women with a short distance between the xiphoid process and umbilicus. RPLS bariatric approach is contraindicated in patients who have undergone upper abdominal open surgery or upper abdominal ventral hernia mesh repair and in super obese patients. Postoperative weight loss with this approach is similar to that occurring after conventional multiport laparoscopic procedures. More importantly, no major intraoperative or postoperative complications have been reported. However, the data is scarce, early intraoperative and postoperative experience with RPLS bariatric surgery has shown that RPLS sleeve gastrectomy, adjustable gastric banding, and gastric bypass procedures are feasible and associated with reasonable degree of safety.