Keith Kim

Robotics in advanced gastrointestinal surgery: the bariatric experience.

AbstractRobotic surgery for laparoscopic procedures such as advanced gastrointestinal surgery and abdominal malignancies is currently on the rise. The first robotic systems have been used since the 1990s with increasing number of clinical cases and broader clinical applications each year. Although high-evidence-level data are scarce, studies suggest that the technical advantages of robotic surgery result in a clinical value for procedures of advanced complexity such as Roux-en-Y gastric bypass and revisional bariatric surgery. Ultimately, the digital interface of the robotic system with the option to integrate augmented reality and real-time imaging will allow advanced applications particularly in the field of gastrointestinal surgery for malignancies.

Clinical outcomes of the Realize Adjustable Gastric Band-C at 2 years in a United States population

BACKGROUND In 2008, the Realize Band (RB) adopted a precurved design (RB-C). We present 2-year outcomes data from the first multiinstitutional study of RB-C. The objective of this study was to analyze weight loss and safety data from bariatric practices in the United States, including academic, nonacademic, public, and private. METHODS The study included adult RB-C patients with a preoperative body mass index (BMI)≥40 kg/m(2) or >35 kg/m(2) with co-morbidity. Exclusions included RB-Cs label contraindications for use. Outcomes parameters were percent excess weight loss (%EWL), BMI change, number and volume of band adjustments, and adverse events. RESULTS A total of 231 patients met inclusion/exclusion criteria. Of these, 161 had 24-month data available. Mean %EWL was 44.4%±26.9% (P<.0001). BMI decreased from 44.1±5.7 kg/m(2) to 35.3±6.9 kg/m(2) (P<.0001). Percent EWL varied by preoperative BMI (P = .0002), bariatric practice (P<.0001), aftercare frequency (P = .0004), and band fill frequency (P = .0271), but %EWL was not influenced by gender, race, or age (P>.20 each). Adverse events were dysphagia (21.2%), gastroesophageal reflux (21.6%), and vomiting (30.7%). Incidence of pouch dilation, esophageal dilation, and slippage was ≤1%. Revisions (2.2%) were for unbuckled band, tube kinking, slippage, and suspected band leak (1 each). No erosions, explants, or mortality were reported. CONCLUSION RB-C appears to be as well tolerated and effective as the first generation RB for weight loss. The near 45% EWL at 2 years is consistent with other high-quality publications on the RB. Preoperative BMI and frequency of postoperative care, including frequency of band fills, influence %EWL. Significant weight loss is achievable with RB-C despite variable postoperative management practices. The low morbidity and the absence of mortality at 24 months reflect positively on the RB-C characteristics.

Resultados iniciais da primeira série de casos brasileira de cirurgia bariátrica totalmente robótica

RACIONAL: Atualmente a cirurgia bariatrica e o tratamento mais eficaz para a obesidade morbida. Embora ainda tenha algumas dificuldades, a abordagem laparoscopica tem-se tornando o padrao-ouro para o by-pass gastrico em Y-de-Roux. O uso da robotica representa grande evolucao no campo da cirurgia bariatrica minimamente invasiva e seu uso tem sido cada vez mais difundido. OBJETIVO: Relatar a primeira experiencia brasileira em cirurgia bariatrica totalmente robotica. METODOS: Foram avaliados todos os pacientes submetidos a cirurgia bariatrica totalmente robotica em dois centros de excelencia em cirurgia bariatrica. Foram registrados a incidencia demografica, indice de massa corporal, tempos operatorios, duracao da internacao hospitalar, mortalidade e todas as complicacoes em ate 30 dias. As equipes cirurgicas receberam treinamento especifico para aprendizagem da tecnica robotica e todos os procedimentos foram feitos com supervisao. RESULTADOS: O procedimento foi realizado por cinco equipes cirurgicas em 68 pacientes (52 mulheres - 76,5%), com idade media de 40,5 anos e IMC medio de 41,3. O tempo medio operatorio total foi de 158 minutos e a media de permanencia hospitalar foi de 48 h. O percentual de complicacoes perioperatorias foi de 5,9%. Nao houve mortalidade, fistulas ou estenoses. CONCLUSAO: Mesmo com cirurgioes em periodo inicial da curva de aprendizagem, o by-pass gastrico por abordagem totalmente robotica e opcao tecnica segura e reproduzivel no tratamento cirurgico da obesidade morbida, desde que respeitado modelo de treinamento bem estruturado.

Clinical outcomes of the REALIZE adjustable gastric band-C at one year in a U.S. population

BACKGROUND In 2008, the REALIZE Band (RB) adopted a precurved design (RB-C). The present study is the first multi-institutional report of RB-C outcomes. Our objective was to analyze the 1-year weight loss and safety data from adult RB-C patients treated at multiple U.S. centers (7 typical U.S. bariatric practices, including academic, nonacademic, public, and private practice). METHODS Patients implanted with the RB-C (preoperative body mass index ≥ 40 kg/m(2) or >35 kg/m(2) with co-morbidity) were recruited. The exclusion criteria included the RB-C label contraindications for use. The outcomes parameters were the percentage of excess weight loss (%EWL), change in body mass index, number and volume of band adjustments, and incidence of complications. RESULTS Of the 239 patients enrolled in the 2-year study, 158 had 1-year data available for analysis in November 2010. The mean %EWL was 39.2% ± 20.5% (range -7.7 to -116.8, P < .0001). The body mass index decreased from 44.4 ± 5.5 kg/m(2) to 36.4 ± 5.8 kg/m(2) (P < .0001). The variability in the %EWL was significant among the study centers (P < .0001). The average band fill volume at 1 year was 8.0 ± 2.0 mL (range .0-11.1). The total fill volume was >11 mL in 1 patient. No band erosions/migrations, explants, or deaths occurred. CONCLUSION RB-C appears to be as safe and effective as the first-generation RB. The near 40% EWL at 1 year was consistent with other high-quality publications of the RB. Good weight loss results are achievable, despite the varying postoperative management practices. The low morbidity and the absence of mortality at 12 months reflect positively on the RB-C characteristics. Our findings suggest that the learning curve, related to the postoperative management of the RB-C, might vary by practice and that a greater frequency and smaller band fills might result in better weight loss at 12 months.

Robotic Roux-en-Y Gastric Bypass

In 2017 there were about 875,000 robotic procedures performed worldwide with the da Vinci Surgical System, with gynecology being the specialty with the highest volume followed by general surgery and urology. Of these robotic general surgery procedures, only an estimated 10% were bariatric procedures. Given the complexity of bariatric procedures as well as the challenges of the obese body habitus, it would seem there would be great interest in the advantages of the robotic platform; however, until recently there have been relatively low levels of enthusiasm among bariatric surgeons. Although high-level data proving clinical benefit of the robotic approach to the RYGB is lacking, interest in the robotic approach seems to be increasing. Certainly, from an ergonomic standpoint, there is clear benefit to the surgeon, and the increased prevalence of the hand-sewn versus stapled gastrojejunal anastomoses with the robotic approach offers self-evident data on the enhanced dexterity provided by the robotic system. As more companies emerge with robotic operating systems, and as the cost barriers decrease and access to robotic systems increase, it will only be a matter of time before the robotic approach replaces the laparoscopic approach, much like the way the laparoscopic approach replaced the open approach.

Early Weight Regain Following Roux-en-Y Gastric Bypass

bariatric surgery within 3 years after initial evaluation. They produced statistically and meaningfully higher scores on MMPI2-RF substantive scales across a number of hypothesized scales (e. g., Antisocial Behaviors, Family Problems, Anxiety)when compared to patients who proceeded with surgery (Cohen’s ds: range .20 .50). Logistic regression analyses indicated that 15% of the variance (R 1⁄4 .15) in not preceding with surgery were accounted for by a current substance use disorder diagnosis, history of psychiatric inpatient hospitalizations, lack of current psychotropic medication use, and a lower BMI. MMPI-2-RF substantive scales (controlling for inter-correlations between scales) were entered by scale set in the second block of the equation. MMPI-2-RF scores incrementally predicted a greater likelihood of failure to follow through with surgery (change in R 1⁄4 .02-.06.) after controlling for information gathered from their medical charts such as psychological diagnoses and history of psychiatric inpatient hospitalizations. MMPI-2-RF scales that assess constructs associated with demoralization, neuroticism, cognitive complaints, familial discord, disaffiliativeness, disinhibition, and substance use were useful in predicting patients who fail to follow through with bariatric surgery beyond information obtained from the psychological clinical interview and past medical chart information. Discussion: Consistent with the literature, bariatric surgery candidates cleared for surgery, but who do not follow through with surgery, report more psychopathology on the MMPI-2-RF and during the psychodiagnostic interview relative to patients who proceed with surgery. Previous literature suggests that a majority of patients who do not proceed for surgery may do so because they are unwilling to complete psychological treatment prior to surgery. Our findings highlight the importance of educating bariatric surgery candidates who show signs of psychopathology on the MMPI-2-RF on the rationale of treatment and impact on surgical outcomes. Evidence of incremental validity of psychological testing indicated that using objective assessment instruments that are broadband can be useful. For example, psychological testing suggested that factors such as neuroticism, behavioral noncompliance, and spousal solicitation are additional predictors of not following through with surgery in addition to psychological disorders and patients medical history. Moreover, psychological testing can provide a dimensional framework for assessing the severity of these factors. Future research may be helpful in early identification of those who will not successfully achieve surgery.

Robotics in Bariatric Surgery

While bariatric procedures were originally performed via open surgery, minimally invasive techniques have largely replaced the open approach, and the advantages of a minimally invasive approach have been well validated with reduced postoperative pain, shorter hospital stay, and lower postoperative mortality. Despite its general feasibility, there are a number of technical limitations associated with performing laparoscopic surgery on obese patients including limited motion of laparoscopic instruments due to a thick abdominal wall, hepatomegaly, and increased amounts of intra-abdominal fat with limited workspace, reduced surgical dexterity, and poorer ergonomics placing significant musculoskeletal stress upon the surgeon. Several publications from the field of gynecology have described clinical benefits of robotic surgery when operating on obese patients. Interestingly, the first robotic procedure was a robotic placement of an adjustable gastric band in 1998 using an early version of the da Vinci® System prior to its actual market launch. Since then, all of the commonly performed bariatric surgical procedures including Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch have been performed robotically and demonstrated to be feasible and safe.

Perspectives of Robotic Bariatric Surgery

Robotic surgery is an emerging and promising technology in bariatric surgery. Current studies have confirmed its feasibility and safety with a relatively short learning curve. The advantages for the surgeon are already well established with better ergonomics. The potential benefits to the patient are still being studied. Robotic surgery seems to offer more advantages for complex cases, such as super obesity and revisional surgery.

Difficult Peritoneal Access

Since the initial published foray into laparoscopic surgery in the 1970s, laparoscopic techniques have been applied to almost every procedure performed in the abdominal cavity. While advances in techniques and instrumentation have made laparoscopy generally safe in experienced surgeons’ hands, and the benefits of laparoscopy over open surgery have been amply documented, there are complications that are unique to laparoscopy, namely, trocar injuries. The US Food and Drug Administration (FDA) requires manufacturers and user facilities to report deaths and serious injuries related to devices that are kept in the Manufacturer and User Facility Device Experience (MAUDE) database.

Editorial for special surgical issue

Laparoscopy has dramatically changed the paradigm of surgery. Beliefs that a bigger incision provides better exposure have slowly but assuredly been replaced by the pursuit of smaller and fewer incisions. The advantages of laparoscopy over open surgery were easily demonstrated with less postoperative pain, shorter hospital stays, quicker recovery, and even beyond with demonstrations of decreased adhesion formation and decreased inflammatory response to surgery. Although it has been 13 years since the first robotic general surgery procedure was performed, robotic surgery still remains, to a large extent, a new and relatively unexplored frontier in surgery. Led by urologists and robotic prostatectomy, however, other fields of surgery are slowly starting to follow suit. The challenges have largely been the costs and the availability of the robotic systems; however, acceptance of robotic surgery has also been hampered by attempts to measure the incremental benefits of robotic technology in similar terms to that of laparoscopy. The advantages of the robotic system are obvious to anyone that sits at a console: tremor filtration, scaling of motion, seven degrees of freedom, high definition, and magnified three-dimensional stereoscopic vision. All of these simply translate into the surgeon’s ability to see much better, work more precisely, and accommodate smaller working spaces. However, the benefits of robotic surgery will unlikely be measured by decreased pain, quicker recovery, or even perhaps better clinical outcomes. The impact of robotic surgery will go far beyond that. Robotic surgery heralds a different era of surgery that will profoundly change not only the way a surgeon operates, but also the way the surgeon will interact with the surgical environment and the patient. Integration of data, including stored and real-time imaging, into the surgical procedure; simulation-based presurgical planning; real-time collaboration with peers through console-based links; and further miniaturization and eventual wireless control of the patient-side instruments, will transform the MIS bedside surgeon into a conductor positioned in a surgical ‘‘cockpit’’ separated from the patient with access to a wide breadth of data orchestrating a complex interaction of events that will translate into very efficiently and precisely executed actions. As we stand at the eve of this surgical evolution, we are proud to present some of the global thought leaders of general surgery in robotic surgery with a special robotic general surgery section.