Julie Kim

Standardized outcomes reporting in metabolic and bariatric surgery

ASMBS, SOARD, outcome reporting standards Standardized outcomes reporting in metabolic and bariatric surgery Stacy A. Brethauer, MD*, Julie Kim, MD, Maher el Chaar, MD, Pavlos Papasavas, MD, Dan Eisenberg, MD, Ann Rogers, MD, Naveen Ballem, MD, Mark Kligman, MD, Shanu Kothari, MD for the ASMBS Clinical Issues Committee Bariatric and Metabolic Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio Department of Surgery, Tufts University, Boston, Massachusetts Department of Surgery, St. Luke’s Hospital, Allentown, Pennsylvania Department of Surgery, Hartford Hospital, Hartford, Connecticut Department of Surgery, Stanford University and Palo Alto VA Health Care Center, Palo Alto, California Department of Surgery, Penn State University, Hershey, Pennsylvania Center for Advanced Surgical Weight Loss, Montclair, New Jersey Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland Department of Surgery, Gundersen Health System, La Crosse, Wisconsin Received February 2, 2015; accepted February 2, 2015

Nutrition and Gastrointestinal Complications of Bariatric Surgery

At present, bariatric surgery is the only treatment that can achieve meaningful and sustainable weight loss for the millions of morbidly obese individuals. The current popular operative procedures (the Roux-en-y gastric bypass, laparoscopic adjustable gastric band, and the biliopancreatic diversion with or without duodenal switch) are all relatively safe and effective. However, all of these procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract. This fact, along with postoperative dietary changes, makes these patients vulnerable to a multitude of potential complications. As more and more patients undergo these procedures, an increasing number of clinicians will be asked to care for them. It is therefore imperative that all clinicians have a general understanding of the operative procedures and the potential problems these patients may develop. This article will describe these operative procedures and will discuss the more common consequences.

Reinforcing Gastric Staple-Lines with Bovine Pericardial Strips May Decrease the Likelihood of Gastric Leak after Laparoscopic Roux-en-Y Gastric Bypass

Background: Staple-line leakage is a potentially devastating complication of Roux-en-Y gastric bypass (RYGBP). Bovine pericardial strips (BPS) have been used to reinforce staple-lines in pulmonary resections and have been shown to decrease air-leaks.This study examined the use of BPS to decrease gastric staple-line leaks. Methods: 250 consecutive patients undergoing laparoscopic RYGBP had BPS used for the gastric pouch. Ease of use, operative complications, and visual bleeding were recorded. In addition, the postoperative leak rate was compared to 100 consecutive patients operated on prior to the study when BPS was not used. Results: Patient characteristics were the same for both groups and comparable with most published data. With the use of BPS, there were no operative complications and no meaningful increase in operating time. BPS reinforced staple-lines had no visual bleeding. In the 100 cases without BPS, there were 2 staple-line leaks (2%) both of which required emergency exploration. One additional patient was subsequently found to have a gastrogastric fistula. In the 250 patients who had BPS-reinforced staple-lines, there were no acute leaks.Three patients were subsequently found to have gastrogastric fistula. None required emergency surgery. Conclusion: In this non-randomized trial, BPS were found to be easy and safe to use. In addition, staple-line hemorrhage was essentially non-existent. Although the reduction in gastric staple-line leak rate may also be attributed to learning curve, there were no acute leaks in 250 patients with BPS, which is below the published norms.

Standardized outcomes reporting in metabolic and bariatric surgery.

When appropriate for the study design, the percentage of patients comprising the original study group who complete each follow-up period reported for the study should be reported (i.e., report the numerator and denominator available for follow-up at each time point reported). For prospective studies, percent follow-up should represent the percentage of patients from the original study group(s) who remained in the study until the study endpoint(s) are reached or for the final reported follow-up interval. The reasons for patient attrition from the study should be reported when possible. For

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

Comparison of permanent and nonpermanent staple line buttressing materials for linear gastric staple lines during laparoscopic Roux-en-Y gastric bypass

BACKGROUND Several publications have suggested that staple line buttressing might decrease staple line bleeding, increase burst pressure, and decrease the likelihood of acute failure resulting in leak. Currently, permanent and nonpermanent options are available. However, concern has been raised about the permanent buttress material and its potential for delayed strip expulsion. This study analyzed our experience with 3 different buttressing materials for creating the gastric division during laparoscopic Roux-en-Y gastric bypass. METHODS From July 5, 2001 to May 30, 2007, 1451 consecutive patients underwent laparoscopic gastric bypass with buttressing material used for the stapled creation of the gastric pouch. Peristrips Dry (PSDs), permanent bovine pericardial strips, were used in 926 cases from July 5, 2001 to October 11, 2005. Seamguards, a synthetic bioabsorbable product, were used in 145 cases from November 2, 2004 to July 18, 2006, and PSD Veritas, remodelable, nonpermanent bovine pericardial strips, were placed in 380 patients from October 11, 2005 to May 30, 2007. All products were applied to the 60-mm-long, 3.5-mm cartridges of the EndoGIA II stapler. The ease of use, operative complications, visual bleeding, and postoperative leaks were recorded. RESULTS The patient characteristics were comparable for all groups. All products were easy to load on the stapler, and no operative complications related to the use of the buttress materials occurred. The incidence and severity of staple line bleeding was not specifically calculated but was visually noted to be minimal in all cases. Of the 3 groups, 4 contained leaks occurred in the Seamguards group, and all were successfully managed nonoperatively. No acute leaks were discovered in the PSD or PSD Veritas groups. This difference was statistically significant (p <.001). CONCLUSION Neither the PSDs or PSD Veritas group exhibited staple line complications. However, 4 leaks occurred in the patients who had Seamguards incorporated into their gastric pouch linear staple lines.

ASMBS updated position statement on insurance mandated preoperative weight loss requirements

ASMBS Guidelines/Statements ASMBS updated position statement on insurance mandated preoperative weight loss requirements Julie J. Kim, M.D., F.A.C.S., F.A.S.M.B.S.*, Ann M. Rogers, M.D., Naveen Ballem, M.D., Bruce Schirmer, 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, Penn State University, Hershey, Pennsylvania Clara Mass Medical Center, Glen Ridge, New Jersey Department of Surgery, University of Virginia Health System, Charlottesville, Virginia Received April 18, 2016; accepted April 18, 2016

Metabolic bone changes after bariatric surgery

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery for enhancing quality of care in bariatric surgery. In this statement, suggestions for management are presented that are derived from available knowledge, peer-reviewed scientific literature and expert opinion regarding monitoring and treatment of metabolic bone changes after bariatric surgery procedures. The statement may be revised in the future should additional evidence become available.

Primary midline peritoneal access with optical trocar is safe and effective in morbidly obese patients

BACKGROUND The bladed optical access trocar is widely used and provides convenient, safe peritoneal entry. However, it has only been approved for use after insufflation. We used this device as our primary method of entry before insufflation in bariatric surgery and provide an overview of our cumulative experience. In addition, we provide a comprehensive analysis of the published data with respect to optical access as both primary and secondary methods of peritoneal access. METHODS From July 30, 2001 to April 4, 2008, laparoscopic access for all bariatric surgery at a single center was achieved using the 5-12-mm optical bladed trocar without previous insufflation for 2207 cases, including 1692 laparoscopic gastric bypass procedures and 515 laparoscopic adjustable gastric band placements. RESULTS Four vascular injuries occurred (.18%) in our series. Three required conversion to laparotomy and vascular repair, and one was managed laparoscopically. All injuries occurred with off-midline placement. No mortalities occurred secondary to the use of the optical trocar. CONCLUSION The present report is as the greatest volume series detailing the safe and effective use of the bladed optical trocar without previous insufflation as the primary method of peritoneal access in the morbidly obese. The insertion of this device in the midline appears to be a safe method of entry.

American Society for Metabolic and Bariatric Surgery position statement on long-term survival benefit after metabolic and bariatric surgery.

The following position statement has been issued by the American Society for Metabolic and Bariatric Surgery in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the benefit of metabolic and bariatric surgery on long-term survival. An overview of the current available published peer-reviewed scientific evidence is presented.