Dan E. Azagury

Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes.

BACKGROUND AND STUDY AIMS Marginal ulcers are one of the most common complications after gastric bypass. Reported incidence varies widely (0.6-16 %) and pathogenesis is unclear. The aim of the present study was to describe characteristics, risk factors, management, and outcomes of endoscopically documented ulcers. PATIENTS AND METHODS Data from all patients diagnosed with marginal ulcers at endoscopy between 2003 and 2010 were retrospectively reviewed. RESULTS A total of 103 patients with marginal ulcers presented with pain (63 %) and/or bleeding (24 %), a median of 22 months after surgery. Ulcers were located on the anastomosis (50 %) or the jejunum (40 %); sutures were visible in 35 %, and gastrogastric fistulae in 8 %. The mean pouch length was 5.6 cm. Diabetes (odds ratio [OR] 2.5; P = 0.03), smoking (OR 2.5; P = 0.02), and gastric pouch length (OR 1.2; P = 0.02) were significantly associated with marginal ulcer formation on univariate analysis; diabetes was significantly associated on multivariate analysis (OR 5.6; P = 0.003). The risk of developing a marginal ulcer decreased with time (OR 0.8; P < 0.01) and was not associated with the use of nonsteroidal anti-inflammatory drugs. At first endoscopic follow-up, 67 % of ulcers had healed. Recurrence occurred in four patients and nine patients required surgical revision. CONCLUSIONS The vast majority of marginal ulcers had a favorable outcome after medical treatment. However, 9 % of patients eventually required surgical revision. Therefore, endoscopic follow-up is essential. Diabetes, smoking, and long gastric pouches were significant risk factors for marginal ulcer formation, suggesting increased acid exposure and mucosal ischemia are both involved in marginal ulcer pathogenesis. Management of these factors may prove effective in managing marginal ulcers, and tailoring postoperative proton pump inhibitor therapy to patients with multiple risk factors could be effective.

Preoperative work-up in asymptomatic patients undergoing Roux-en-Y gastric bypass: is endoscopy mandatory?

Background: We aimed to determine before Roux-en-Y gastric bypass (RYGBP) in asymptomatic morbidly obese patients: 1) the prevalence of abnormal findings at upper gastrointestinal (UGI) endoscopy; 2) Helicobacter pylori (HP) status; 3) clinical consequences of these findings; and 4) associated costs. Methods: We retrospectively reviewed 468 consecutive patients, excluded those with UGI symptoms, drug intake or previous UGI endoscopy/surgery, and analyzed findings in the 319 remaining patients (68%). Results: There were abnormal findings in 147 patients (46%), including 54 hiatal hernias and 146 parietal (i.e. mucosal or submucosal) lesions. The most significant were 7 ulcers and 2 gastric polyposis. HP was detected (using CLO-test) in 124 patients (39%). Histopathological examination of biopsies was abnormal in 109/161 patients (68%), and disclosed mainly chronic gastritis (n=98). Abnormal findings were more frequent in HP-positive compared to HP-negative patients (94 vs 51%, P<0.001). Findings had clinical implications in only 4% of patients: delayed surgery (7 ulcers), prophylactic gastrectomy (2 gastric polyposis), unnecessary work-up (3 irrelevant/false-positive diagnoses), and inclusion in a screening program (1 Barretts esophagus). Mean cost of complete UGI work-up was 389 €/patient. Conclusion: Asymptomatic morbidly obese patients frequently harbour UGI lesions warranting UGI work-up before RYGBP. However, routine endoscopy presents drawbacks. We propose a less invasive strategy which reduces costs and limits false-positive results and the subsequent investigations that they require. In our series, it would have missed two gastric polyposis only, for which no formal recommendation has yet been issued. This strategy could be a valuable alternative to routine UGI endoscopy before RYGBP in asymptomatic patients.

ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management.

ASMBS position statement ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management Julie Kim, M.D.*, Dan Azagury, M.D., Dan Eisenberg, M.D., Eric DeMaria, M.D., Guilherme M. Campos, M.D., on behalf of the American Society for Metabolic and Bariatric Surgery Clinical Issues Committee Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts Department of Surgery, Stanford University School of Medicine, Stanford, California Department of Surgery, Bon Secours DePaul Medical Center, Norfolk, Virginia Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia

Obesity Overview: Epidemiology, Health and Financial Impact, and Guidelines for Qualification for Surgical Therapy

The aim of this article is to describe the context in which this issue of Gastrointestinal Endoscopy Clinics of North America is established. The authors review the current worldwide dimensions and trends of the obesity epidemic; associated mortality and comorbid diseases including diabetes, cancer, cardiovascular disease and obstructive sleep apnea; the financial impact of obesity; and current national and international guidelines for referral and qualification for surgical treatment of obesity.

Twelve key nutritional issues in bariatric surgery

In morbidly obese patients, i.e. body mass index ≥35, bariatric surgery is considered the only effective durable weight-loss therapy. Laparoscopic Roux-en-Y gastric bypass (LRYGBP), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS) are associated with risks of nutritional deficiencies and malnutrition. Therefore, preoperative nutritional assessment and correction of vitamin and micronutrient deficiencies, as well as long-term postoperative nutritional follow-up, are advised. Dietetic counseling is mandatory during the first year, optional later. Planned and structured physical exercise should be systematically promoted to maintain muscle mass and bone health. In this review, twelve key perioperative nutritional issues are raised with focus on LRYGBP and LSG procedures, the most common current bariatric procedures.

Robotic single-site cholecystectomy.

Minimally invasive approaches for cholecystectomy are evolving in a surge for the best possible clinical outcome for the patients. As one of the most recent developments, a robotic set of instrumentation to be used with the da Vinci Si Surgical System has been developed to overcome some of the technical challenges of manual single incision laparoscopy.

Robotic revisional bariatric surgery: a comparative study with laparoscopic and open surgery.

Revisional bariatric procedures (RBP) can be technically challenging. While robotics might provide help for complex procedures, the study aim was to report our experience with robotic RBP.

Real-time computed tomography-based augmented reality for natural orifice transluminal endoscopic surgery navigation.

Natural orifice transluminal endoscopic surgery (NOTES) is technically challenging owing to endoscopic short‐sighted visualization, excessive scope flexibility and lack of adequate instrumentation. Augmented reality may overcome these difficulties. This study tested whether an image registration system for NOTES procedures (IR‐NOTES) can facilitate navigation.

Laparoscopic cholecystectomy after a quarter century: why do we still convert?

BackgroundLaparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. However, conversion to open surgery is sometimes needed. The factors underlying a surgeon’s decision to convert a laparoscopic case to an open case are complex and poorly understood. With decreasing experience in open cholecystectomy, this procedure is however no longer the “safe” alternative it once was. With such an impending paradigm shift, this study aimed to identify the main reasons for conversion and ultimately to develop guidelines to help reduce the conversion rates.MethodsUsing the National Surgical Quality Improvement Program (NSQIP) database and financial records, the authors retrospectively reviewed 1,193 cholecystectomies performed at their institution from 2002 to 2009 and identified 70 conversions. Two independent surgeons reviewed the operative notes and determined the reasons for conversion. The number of ports at the time and the extent of dissection before conversion were assessed and used to create new conversion categories. Hospital length of stay (LOS), 30-day complications, operative times and charges, and hospital charges were compared between the new groups.ResultsIn 91% of conversion cases, the conversion was elective. In 49% of these conversions, the number of ports was fewer than four. According to the new conversion categories, most conversions were performed after minimal or no attempt at dissection. There were no differences in LOS, complications, operating room charges, or hospital charges between categories. Of the six emergent conversions (9%), bleeding and concern about common bile duct (CBD) injury were the main reasons. One CBD injury occurred.ConclusionsIn 49% of the cases, conversion was performed without a genuine attempt at laparoscopic dissection. Considering this new insight into the circumstances of conversion, the authors recommend that surgeons make a genuine effort at a laparoscopic approach, as reflected by placing four ports and trying to elevate the gallbladder before converting a case to an open approach.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA).

AbstractBackgroundThe da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci® Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.Methods The SAGES da Vinci® TAVAC sub-committee performed a literature review of the da Vinci® Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.ResultsSeveral conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.ConclusionsGastrointestinal surgery with the da Vinci® Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci® Surgical System; further analyses are needed.