Frank J. Borao

Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results.

BACKGROUND Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset. METHODS The patients who had regained significant weight >or=2 years after RYGB after losing >or=50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up. RESULTS A total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds. CONCLUSIONS Incisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

Simultaneous laparoscopic paraesophageal hernia repair and sleeve gastrectomy in the morbidly obese

BACKGROUND Morbid obesity is associated with increased rates of hiatal and paraesophageal hernias. Although laparoscopic sleeve gastrectomy is gaining popularity as the procedure of choice for morbid obesity, there is little data regarding the management of paraesophageal hernias found intraoperatively. The aim of this study was to evaluate the feasibility and benefits of a combined sleeve gastrectomy and paraesophageal hernia repair in morbidly obese patients. METHODS From May 2011 to February 2013, 23 patients underwent laparoscopic sleeve gastrectomy combined with the repair of a paraesophageal hernia. Only 4 patients had a large hiatal hernia documented preoperatively on esophagogastroduodenoscopy (EGD). The body mass index (BMI), operative time, length of stay, and complications were evaluated. RESULTS The average operative time was 165 minutes (115-240 minutes) and length of stay was 2.83 days (2-6 days). All patients were female except for one, with an average age of 53.4 years and a BMI of 41.9 kg/m(2). There were no complications during the procedures. Mean follow-up was 6.16 months (1-19 months), and mean excess weight loss was 39%. The average cost of admission for a combined procedure (

Laparoscopic repair of paraesophageal hernias.

10,056), was slightly higher than a laparoscopic sleeve gastrectomy (

Five Years, Two Surgeons, and over 500 Bariatric Procedures: What Have We Learned?

8905) or laparoscopic paraesophageal hernia repair (

Complex incisional hernias repaired in conjunction with the Bony Anchoring Reinforcement System (BARS) prevents hernia recurrence

8954) done separately. CONCLUSIONS Laparoscopic sleeve gastrectomy combined with a paraesophageal hernia repair is well-tolerated and feasible in morbidly obese patients. Surgeons should be aware that preoperative EGD is not effective at diagnosing large hiatal or paraesophageal hernias. Surgeons with the skill set to repair paraesophageal hernias should do a combined procedure because it is well-tolerated, feasible, and can reduce the cost of multiple hospital admissions.

Abdominal Catastrophe During Pregnancy Due to a Gastric Band

Background and Objectives: Laparoscopy has quickly become the standard surgical approach to repair paraesophageal hernias. Although many centers routinely perform this procedure, relatively high recurrence rates have led many surgeons to question this approach. We sought to evaluate outcomes in our cohort of patients with an emphasis on recurrence rates and symptom improvement and their correlation with true radiologic recurrence seen on contrast imaging. Methods: We retrospectively identified 126 consecutive patients who underwent laparoscopic repair of a large paraesophageal hernia between 2000 and 2010. Clinical outcomes were reviewed, and data were collected regarding operative details, perioperative and postoperative complications, symptoms, and follow-up imaging. Radiologic evidence of any size hiatal hernia was considered to indicate a recurrence. Results: There were 95 female and 31 male patients with a mean age (± standard deviation) of 71 ± 14 years. Laparoscopic repair was completed successfully in 120 of 126 patients, with 6 operations converted to open procedures. Crural reinforcement with mesh was performed in 79% of patients, and 11% underwent a Collis gastroplasty. Fundoplications were performed in 90% of patients: Nissen (112), Dor (1), and Toupet (1). Radiographic surveillance, obtained at a mean time interval of 23 months postoperatively, was available in 89 of 126 patients (71%). Radiographic evidence of a recurrence was present in 19 patients (21%). Reoperation was necessary in 6 patients (5%): 5 for symptomatic recurrence (4%) and 1 for dysphagia (1%). The median length of stay was 4 days. Conclusion: Laparoscopic paraesophageal hernia repair results in an excellent outcome with a short length of stay when performed at an experienced center. Radiologic recurrence is observed relatively frequently with routine surveillance; however, many of these recurrences are small, and few patients require correction of the recurrence. Furthermore, these small recurrent hernias are often asymptomatic and do not seem to be associated with the same risk of severe complications developing as the initial paraesophageal hernia.

Totally laparoscopic gastrectomy for gastric cancer.

BackgroundBariatric surgery has become an increasingly popular method for weight loss and mitigation of co-morbidities in the obese population. Like any field, there is a desire to standardize and accelerate the postoperative period while maintaining safe outcomes.MethodsAll laparoscopic sleeve gastrectomies (LSG) and gastric bypasses (LGB) were performed over a 5-year period were logged along with several aspects of postoperative care. Trends were followed in aspects of postoperative care over years as well as any documentation of complications or re-admissions.ResultsA total of 545 LSGs and LBPs were performed between 2012 and 2016. Improvements were noted in nearly every field over time, including faster Foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (PCAs), and faster advancement of diet. There was also an abandonment of utilization of the ICU and step down setting for these patients, leading to significant decreases in hospital cost. There was no change in complications, re-operations, or re-admission in this time period.ConclusionsThe surgeons involved in this project have built a busy bariatric surgery practice, while continually evolving the postoperative algorithm. Nearly every aspect of postoperative care has been deescalated while decreasing length of stay and cost to the hospital. All of this has been obtained without incurring any increase in complications, re-operations, or re-admissions. The authors of this paper hope to use this article as a launching point for a formal advanced recovery pathway for bariatric surgery at their institution and others.

Prospective single-site case series utilizing an endolumenal tissue anchoring system for revision of post-RYGB stomal and pouch dilatation

BackgroundComplex abdominal wall reconstruction and incisional hernia repair have been plagued by high recurrence rates, especially after multiple repair attempts and in those patients with high body mass index. We present an adjunct technique to validated procedures of hernia repair.MethodsThis study is a retrospective analysis of 63 patients between January 2006 and August 2012. Patients had bony suture anchoring of synthetic polypropylene mesh to the anterior superior iliac spine bilaterally, and the pubic symphysis after the abdominal fascia was reconstructed.ResultsPatient mean follow-up was 3.1 years (range 6 months to 6 years). None of the 63 patients had recurrent abdominal wall hernias. One patient, from early in the series, had post-operative bulging, which was retreated successfully using the current revised bone anchoring protocol. Five patients developed mesh infections; none of whom required radical debridement or removal of mesh.ConclusionsThe BARS technique for abdominal wall reconstruction provides an excellent reinforcement of fascial reconstruction with decreased hernia recurrence rates.Level of Evidence: Level IV, therapeutic study.

Laparoscopic repair of a free perforation of a marginal ulcer after Roux-en-Y gastric bypass: a safe alternative to open exploration.

Introduction: Laparoscopic adjustable gastric banding is popular bariatric procedure for patients with morbid obesity. The procedure is appealing to patients and surgeons because of its customizable approach to weight loss. The rate of complications after laparoscopic adjustable gastric banding has been reported to be up to 12.2%. Without a high degree of suspicion, the complications can go unrecognized until they have progressed to a catastrophic state. Case Description: We present a 32-year-old pregnant woman, with a history of laparoscopic adjustable gastric banding, who presented with complaints of persistent nausea and vomiting causing significant weight loss. She was treated with intravenous hydration and antiemetic medication. After 3 days of in-hospital treatment, she was discharged home after resolution of symptoms. She then returned to the hospital with severe abdominal pain. The fetal heart tones were lost, and she delivered a stillborn fetus. Radiologic testing suggested abdominal hollow organ perforation, and the patient was taken to the operating room. Diagnostic laparoscopy discovered a prolapsed gastric band causing obstruction and an anterior gastric perforation proximal to the band. The perforation was repaired primarily, and an omental patch was used as a buttress. Conclusion: Although nausea and vomiting are common symptoms during pregnancy, their cause must be fully investigated in bariatric patients. The complications in bariatric patients can be catastrophic if not recognized and treated appropriately. As weight loss surgery increases in popularity and age limits are decreased, more women of childbearing age will present after bariatric procedures, and all complications must be ruled out.

Analysis of Reoperations After Laparoscopic Adjustable Gastric Banding

Totally laparoscopic gastrectomy appears to be a reasonable option for the treatment of gastric malignancy, with early data demonstrating acceptable survival rates and perioperative outcomes.