Stephen P. Haggerty

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BackgroundApproximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.MethodsThis evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.ResultsBariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk–benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.ConclusionsLaparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Guidelines for laparoscopic peritoneal dialysis access surgery.

The use of peritoneal dialysis (PD) as a primary mode of renal replacement therapy has been increasing around the world. The surgeon’s role in caring for these patients is to provide access to the peritoneal cavity via a PD catheter and to diagnose and treat catheter complications. Since the early 1990s, laparoscopy has been applied by many adult and pediatric surgeons for insertion of PD catheters as well as for salvage of malfunctioning catheters. This document is an evidence-based guideline based on a review of current literature and the opinions of experts in the field. It provides specific recommendations to assist surgeons who take care of adult and pediatric PD patients. Disclaimer

Laparoscopy to Evaluate Scrotal Edema During Peritoneal Dialysis

Diagnostic laparoscopy was found to be helpful in confirming the source of acute scrotal edema in patients on continuous ambulatory peritoneal dialysis.

Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system

BackgroundDespite the popularity of laparoscopic cholecystectomy, rates of common bile duct injury remain higher than previously observed in open cholecystectomy. This retrospective chart review sought to determine the prevalence of, and risk factors for, biliary injury during laparoscopic cholecystectomy within a high-volume healthcare system.Methods800 of approximately 3000 cases between 2009 and 2015 were randomly selected and retrospectively reviewed. A single reviewer examined all operative notes, thereby including all cases of BDI regardless of ICD code or need for a second procedure. Biliary injuries were classified per Strasberg et al. (J Am Coll Surg 180:101–125, 1995). Logistic regression models were utilized to identify univariable and multivariable predictors of biliary injuries.Results31.0% of charts stated that the Critical View of Safety was obtained, and 12.4% of charts correctly described the critical view in detail. Three patients (0.4%) had a cystic duct leak, and 4 (0.5%) had a common bile duct injury. Of the four CBDI, three patients had a partial transection of the CBD and one had a partial stricture. Patients who suffered BDI were more likely to have had lower hemoglobin, urgent surgery, choledocholithiasis, or acutely inflamed gallbladder. Multivariable analysis of BDI risk factors showed higher preoperative hemoglobin to be independently protective against CBDI. Acutely inflamed gallbladder and choledocholithiasis were independently predictive of CBDI.ConclusionsThe rate of CBDI in this study was 0.5%. Acutely inflamed conditions were risk factors for biliary injury. Multivariable analysis suggests a protective effect of higher preoperative hemoglobin. There was no correlation of CVS with prevention of biliary injury, although only 12.4% of charts could be verified as following the technique correctly. Better implementation of CVS, and increased caution in patients with perioperative inflammatory signs, may be important for preventing bile duct injury. Additionally, counseling patients with acute inflammation on increased risk is important.

Topic: Inguinal Hernia - Post op chronic pain: incidence, evaluation, legal consequences, therapy, follow up.

Chronic pain is common after groin hernia surgery, affecting approximately 10% of patients. The type of anesthesia has been shown to affect short term pain (within 30 days) where Local Anesthesia ( ...

Primary obesity surgery endoluminal.

IntroductionPrimary obesity surgery, endoluminal (POSE) is a promising procedure for weight loss surgery because it is outpatient, is incisionless and has short recovery time. We demonstrate the POSE procedure as a potential option for the bariatric patient.Materials and methodsUsing an endoluminal camera, we videotaped one of our surgeons performing the POSE procedure. With rows of sutures in the fundus and antrum, the stomach’s volume is reduced.ResultsWe demonstrate a successful POSE procedure in its entirety.ConclusionsThe POSE procedure is a promising option for the bariatric patient. Long-term studies are needed to show its efficacy.

Mechanical Complications of Peritoneal Dialysis

Peritoneal dialysis (PD) is a renal replacement technique that has occupied an important place in the management of end-stage renal failure since the 1970s. When safely instituted, it can be used either as a first-line, temporary, or permanent modality. However, between 1 in 3 and 1 in 4 patients develop a mechanical complication of peritoneal dialysis (MCPD) at some point during their therapy (Singh et al., J Vasc Access 11:316–322, 2010; Santarelli et al., Nephrol Dial Transplant 21:1348–1354, 2006), leading to a conversion rate to hemodialysis of up to 20% (Flanigan and Gokal, Perit Dial Int 25:132–139, 2005; McCormick and Bargman, JASN 18:3023–3025, 2007). PD related mechanical complications can be discouraging for patients, negatively clouding their first experience with PD and affecting their willingness to persist with therapy. This chapter will focus on prevention, workup, and management of common PD mechanical complications including dialysate leak, hydrothorax, external tubing damage, external cuff extrusion and pain during PD.

Humbilical & Epigastric Hernia.

Methods: We retrospectively analyzed 104 patients from 2009 to 2014 after LVHR as part of an Institutional Review Board-approved, multi-hospital, multi-surgeon study, Patients were abstracted from a prospectively collected database, Evaluated data included patient demographics, preoperative data, perioperative data, postoperative data, and follow-up clinic visit data, Quality of life (QoL) was assessed using three different health surveys: Short form-36 (SF36), Surgical Outcomes Measurement System (SOMS), and the Carolinas Comfort Scale® (CCS), Patients undergoing concomitant procedures were excluded,

Tu1813 Efficacy of a Required Preoperative Weight Loss Program for Patients Undergoing Bariatric Surgery

The efficacy of mandatory medically supervised preoperative weight loss (MPWL) prior to bariatric surgery continues to be a controversial topic. The purpose of this observational study was to assess the efficacy of a MPWL program in a single institution, which mandated at least 10 % excess body weight loss before surgery, by comparing outcomes of patients undergoing primary bariatric surgery with and without a compulsory preoperative weight loss regimen. We analyzed our database of 757 patients who underwent primary bariatric surgery between March 2008 and January 2015. Patients were placed into two cohorts based on their participation in a MPWL program requiring at least 10 % excess weight loss (EWL) prior to surgery. Patients were evaluated at 3, 6, 12, and 24 months after surgery for weight loss, comorbidity resolution, and the occurrences of hospital readmissions. A total of 717 patients met the inclusion criteria of whom 465 underwent surgery without a preoperative weight loss requirement and 252 participated in the MPWL program. One year after surgery, 67.1 % of non-participants and 62.5 % of MPWL participants showed a resolution of at least one of five associated comorbidities (p = 0.45). Non-participants showed an average of 58.6 % EWL, while MPWL participants showed 59.1 % EWL at 1 year postoperatively (p = 0.84). Readmission rates, excluding those which were ulcer-related, at 30 days (3.4 vs. 6.40 %, p = 0.11) and 90 days (9.9 vs. 7.5 %, p = 0.29) postoperatively were not significantly different between the non-participants and MPWL patients, respectively. A mandatory preoperative weight loss program prior to bariatric surgery did not result in significantly greater %EWL or comorbidity resolution 1 year after surgery compared to patients not required to lose weight preoperatively. Additionally, the program did not result in significantly lower 30- or 90-day readmission rates for these patients. The value of a MPWL program must be weighed against the potential loss of bariatric surgery candidates. Patients who fail to lose 10 % excess weight preoperatively are thus ineligible for a procedure from which they would otherwise benefit. Our data suggest these patients will have similar positive outcomes.

231 Reflux Control Is an Important Component of the Management of Barrett's Esophagus – Results From a Retrospective Cohort of 1834 Patients

Introduction: Barretts esophagus (BE) is the most predictive risk factor for development of esophageal adenocarcinoma, a malignancy with the fastest increasing incidence rate in the US. Based on the assumption that all patients progress through low-grade dysplasia (LGD) to high-grade dysplasia (HGD) and finally to esophageal adenocarcinoma (EAC), we were interested in studying factors that may affect the rate of progression to LGD or greater. We were particularly interested in investigating the question of whether control of reflux, either surgically or medically, protects patients from progression to dysplastic disease or adenocarcinoma. Methods: We retrospectively collected and analyzed data from a cohort of BE patients participating in this single-center study comprised of all patients diagnosed with BE at a single health systems hospitals and clinics over a 10 year period. Patients were followed in order to identify those progressing from BE to LGD, HGD, and EAC. Mean follow up period was 5.4 years (9903 patient-years). We collected information from the patients electronic medical records regarding demographic data, endoscopic findings, histological findings, smoking and alcohol history, medication use including PPIs, and history of bariatric and antireflux surgery. Risk adjusted model was performed using multivariable logistic regression in SAS 9.3 (Cary, NC). Results: This study included 1834 total BE patients, 105 of which had their BE progress to LGD, HGD, or EAC (confirmed by biopsy) with an annual incidence rate of 1.1%. Compared to the group that did not progress, the group that progressed was older (63.8±13.5 vs. 68.8±13.1. p<.001) and likely to be male (61% vs. 69%, p=0.098). In the multivariable analysis, patients who had a history of antireflux surgery (n=44) or PPI use without surgery (n=1708) were found to progress at lower rates than patients who did not have antireflux surgery or were not taking PPIs (OR=0.23, 95% CI 0.12-0.42). Conclusions: In patients with BE without dysplasia, reflux control was associated with decreased risk of progression to LGD, HGD, or EAC. The results support the use of reflux control strategies such as PPI therapy or surgery in patients with non-dysplastic BE.