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Mo1549 Meta-Analysis of the Orbera Intragastric Balloon for the Endoscopic Management of Obesity Badr Al-Bawardy*, Saurabh S. Mukewar, Alfred Genco, Manoel P. Galvao Neto, Gontrand Lopez-Nava, Nitin Kumar, Christopher C. Thompson, Erik B. Wilson, Sohail Shaikh, Natan Zundel, Christopher J. Gostout, Barham K. Abu Dayyeh Mayo Clinic, Rochester, MN; Sapienza University of Rome, Rome, Italy; Gastro Obesity Center, Sao Paulo, Brazil; Bariatric Endoscopy Unit, Madrid Sanchinarro University Hospital, Madrid, Spain; Brigham and Women’s Hosptial, Boston, MA; Univesrity of Texas, Houston, TX; FIU Herbert Wertheim College of Medicine, Miami, FL Background and Aims: The Orbera Intragastric Balloon (IGB) System has been widely used outside the United States (US) as an effective adjunct to life-style modification in the management of mild to moderate obesity. We performed a systematic review and meta-analysis to summarize the out of the US safety and efficacy experience with this IGB system in anticipation of its possible use in the US after regulatory approval. Methods: A comprehensive search of Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science was conducted. The search strategy was designed and conducted by an experienced librarian with input from the study’s team. Two independent reviewers reviewed all citation and identify full-length clinical studies, published in English, investigating use of the Orbera IGB system for obesity. A random-effect meta-analysis and meta-regression were performed. Results: Eighty studies including 8506 patients were included in this meta-analysis. The pooled percent total body weight (%TBW) lost after a single six-months IGB insertion was 12.7% [95% CI 8.5-16.9], 13% [95% CI 11.7-14.7], 10 [95% CI 6.6-13.6], and 6.2 [95% CI 1.4-10.9] at 3, 6, 12, and 36 months respectively. The pooled incidences of side-effects were as following: pain 33.7%, nausea 29%, GERD 18.5%, early removal 7.5%, gastric ulcers 2%, migration 1.4%, small bowel obstruction 0.3%, perforation 0.1%, and death 0.08%. Five included studies were randomized controlled trials (RCTs) that compared the Orbera IGB system to sham or life-style interventions. The mean extra weight lost after Orbera over that in the control arm at 6 months was -8.5kg [95% CI -13 -4.23] (p!0.001). Three different RCTs evaluated the efficacy sequential use of the Orbera IGB system compared to single use. The mean decrease in body mass index (BMI) after two sequential treatments with Orbera IGB was -4 [95% CI -7.7 -0.04] (pZ 0.047) over that seen with single treatment at 12 months after insertion. A meta-regression showed that higher IGB fill volumes are associated with greater weight loss at six months (p % 0.001) (figure). A funnel plot did not reveal any evidence of publication bias. Conclusions: The Orbera IGB system seems to produce predictable and significant weight loss with a favorable safety profile that should make it a valuable tool for the management of obesity once approved for use in the United States.

Patients after laparoscopic Roux-en-Y gastric bypass (LRYGB) can have nonspecific, upper gastrointestinal (UGI) complaints. During postoperative endoscopy, we have noted the erosion of nondissolvable material, such as Peri-Strips® or silk sutures, into the gastric pouch. This study reports the incidence and presentation of foreign material erosion into the gastric pouch after a LRYGB and the outcome after therapeutic endoscopy. From a prospective LRYGB database, postoperative endoscopies from February 2002 to June 2005 that found foreign material in the gastric pouch were reviewed. Presenting symptoms, time until endoscopy, and patient outcomes were evaluated. A therapeutic endoscopy was performed by using endo-shears and biopsy forceps to remove the foreign material. A total of 23 patients underwent 29 therapeutic endoscopies. From February 2002 to November 2004, 208 LRYGB were performed using silk suture for the outer layer of the gastrojejunostomy, and 21 patients (10%) had silk suture found on endoscopy. Peri-Strips were used from February 2002 to December 2003 (n = 153) and 6 patients (4%) had erosions. Since converting to Vicryl suture and Seamguard®, we have had 173 and 228 patients, respectively, without pouch erosion. The most common presenting symptom was abdominal pain (n = 15, 65%). Other symptoms included nausea (n = 13, 57%), vomiting (n = 12, 52%), dysphagia (n = 5, 22%), and melena (n = 3, 13%). Foreign material was found by a mean of 34 weeks. Of 29 therapeutic endoscopies, 20 resulted in resolution of symptoms (69%), 4 led to improvements (14%), and 5 had no effect (17%). There were no endoscopic complications and no anastomotic leaks. Nonabsorbable material used during a LRYGB can migrate into the gastric pouch and cause UGI complaints. A therapeutic endoscopy will resolve most UGI symptoms. Using absorbable material in the creation of the gastric pouch and the gastrojejunostomy will avoid foreign material erosion.

While the majority of patients achieve good outcomes with the LAP-BAND®, there is a subset of patients who experience complications or fail to lose sufficient weight after the banding procedure. This study examines the feasibility and outcome of performing laparoscopic Roux-en-Y gastric bypass (RYGBP) as a single-step revision surgery after a failed LAP-BAND procedure. In the past five years we have performed more than 1400 LAP-BAND procedures. We laparoscopically converted 33 (30 females) of these patients (mean age = 43.8 years) from LAP-BAND to RYGBP because of inadequate weight loss and/or complications. Key steps in the revision procedures were (1) identification and release of the band capsule; (2) careful dissection of the gastrogastric sutures; (3) creation of a small gastric pouch; and (4) Roux-en-Y anterior colic anterior gastric pouch-jejunum anastomosis. Revisions took place at a mean 28.2 months (range = 11–46; SD = 11.3) after the original gastric banding. Change in body mass index (BMI) between pre- and postrevision was evaluated with paired t tests. Among the 33 patients who would undergo revision surgery, the mean BMI before the LAP-BAND procedure was 45.7 kg/m2 (range = 39.9–53.0; SD = 3.4) and the mean weight was 126 kg (range = 99–155; SD = 17). The lowest BMI achieved by this group with the LAP-BAND before revision was 39.7 kg/m2 (range = 30–49.2; SD = 4.9); however, the mean BMI at the time of revision was 42.8 kg/m2 (range = 33.1–50; SD = 4.8). The mean revision operative time was 105 min (range = 85–175), and the mean hospital stay was 2.8 days (range = 1–10). Complications included one patient who underwent open reoperation and splenectomy for a bleeding spleen and one patient who required repair of an internal hernia. After conversion to RYGBP, mean BMI decreased to 33.9 kg/m2 at 6 months (p < 0.001) and 30.7 kg/m2 (range = 22–39.6; SD = 5.3) at 12 months or more of followup (average = 15.7 months; p < 0.0001). Laparoscopic conversion from LAP-BAND to RYGBP is safe and can be an alternative for patients who failed the LAP-BAND procedure. However, revision surgery is technically challenging and should be performed only by surgeons who have completed the learning curve for laparoscopic RYGBP.

Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) has a reported learning curve of 100 cases. Robotic-assisted surgery decreases the learning curve in complex laparoscopic surgeries. We hypothesize that robotic-assisted, hand-sewn gastrojejunostomy during a LRYGB will improve results during the initial 100 cases when compared with the literature. Methods Our first 100 robotic-assisted gastrojejunostomies performed during LRYGB were reviewed from a prospective database. Patient demographics, operative times, length of stay, reoperations, anastomotic leak, pulmonary embolus, and death were all evaluated. Results The mean age and body mass index were 42 and 50, respectively. Operative times ranged from 148 minutes to 437 minutes (mean = 254). There were no leaks or deaths. Four patients had complications, including reoperation (1), incisional hernia (1), pulmonary embolus (1), and recurrent umbilical hernia (1). Conclusions Robotic-assisted LRYGB is feasible and safe, as evidenced by the excellent outcomes from this series during the initial learning curve for LRYGB.

Background Although several studies have addressed the role of spouses in physicians' career choices, there is limited data about spousal perception of surgeons' careers after training. This study examined satisfaction with surgeons' careers and potential contributing factors from a spousal standpoint. Study design A survey of spouses of academic surgeons in 38 participating departments was conducted. Questions included demographic information and perceptions of career satisfaction and contributing factors. Data were analyzed using descriptive statistics, Student's t-test or Mann-Whitney U test, and chi-square or Fisher's exact test. Results Three hundred seventy-nine surveys (27%) were returned, with the majority (81%) perceiving their surgeon spouses to be satisfied. Contributing factors to surgeon dissatisfaction included: work hours/call (42%); practice limitations (18%); reimbursement/income (12%); and malpractice/insurance (7%). Dissatisfied surgeons, as perceived by their spouses, did not differ from satisfied surgeons in terms of work hours, income expectations, geographic desirability, or home involvement. On the other hand, predictors of dissatisfied spouses included lack of input into career decisions, less satisfaction with location, and lack of their surgeon spouses' participation in household and child-care activities. Conclusions There are many positive and negative aspects to being an academic surgeon. Yet, despite the time commitment, work hours per se do not appear to contribute to either surgeon or spousal satisfaction. Spousal satisfaction is dependent on surgeon contribution to household and childcare activities. Despite the multiple potential detractors from an academic surgical career, most surgeons, as perceived by their spouses, would not have chosen differently and are satisfied with their career choices.

Appendicitis remains a common disease with over 250,000 cases in the United States per year. Surgical intervention has been the primary treatment for over a century, and clinical evaluation has been the mainstay for diagnosis of acute appendicitis for decades. Appendiceal imaging modalities have become increasingly popular to assist with the diagnosis of appendicitis, and the surgeon is no longer the sole diagnostician for this disease. Radiologists and emergency medical physicians have entered the arena. This review examines the surgical and radiological literature to evaluate the current atmosphere of how surgeons, radiologists, and emergency physicians interact in the diagnosis of appendicitis.

Hypothesis Relative merits and indications exist for ultrasonography (US) and computed tomography (CT) in the diagnosis of appendicitis. Design Prospective study. Setting General community and tertiary care hospital. Methods Ninety-nine patients (50 males and 49 females) were studied. Following consent, the initial disposition was recorded, designating the patient for operation, observation, or discharge from the hospital. Each patient was studied by CT and US. Studies were independently evaluated by 2 radiologists, and the results were designated as positive, negative, or equivocal. The surgeon reevaluated patients before and after learning the results of US and CT, recording whether the CT scan, US, or reexamination influenced the final disposition. Results Fifty patients had appendicitis; 6 appendixes were perforated. The initial clinical impression called for 44 operations, 49 observations, and 6 discharges. Thirty-four patients had their treatment plan changed from the initial disposition. Ultrasonography did not affect the initial impression. In contrast, 18 patients were rediagnosed solely on CT scan findings. Seven patients were rediagnosed by reexamination. Of 44 patients initially designated for operation, the CT scan and reexamination spared 6 females from surgery; the negative appendectomy rate potentially decreased from 50% to 17% (P= .03). The CT scan, US, or reexamination failed to spare 2 males from exploration with negative results. Of the 49 patients initially designated for observation, 23 were rediagnosed after reevaluation, 13 were discharged from the hospital, and 10 underwent expedient operation. One patient was spared from inappropriate discharge from the hospital. The reliability of the CT scan was good, with high sensitivities and specificities. Equivocal scan results lowered the diagnostic value. Conclusions Selective use of a CT scan with a second examination can improve the diagnostic accuracy and management of suspected cases of appendicitis by (a) reducing the negative appendectomy rate in females, (b) moving patients from observation to earlier operation or discharge from the hospital, and (c) preventing inappropriate discharge of patients with appendicitis.

the adolescent’s self-report (p 0.05). Conclusion: Surgical weight loss using LAGB offered significant early and short term improvement in QOL based on self-report and parental report for morbidly obese adolescent. Despite reported improvement in QOL by both adolescences and parents at followup, significant discrepancies between parent and adolescent QOL scores and perceived improvement existed. PII: S1550-7289(08)00239-6

Background Preoperative factors predicting symptomatic improvement after transoral fundoplication (TF) in chronic gastroesophageal reflux disease (GERD) patients with persistent symptoms on proton-pump inhibitors (PPIs) therapy have not been elucidated fully. Methods Univariate and multivariate logistic regression analyses were performed on data from 158 consecutive patients who underwent TF with the EsophyX device between January 2010 and June 2012 in 14 community centers. Variables included age, gender, body mass index, GERD duration, PPIs therapy duration, presence of hiatal hernia, esophagitis, Hill grade, quality of life scores (QOL) on PPIs, % total time pH 13 on PPIs (OR = 2.4, CI = 1.1–5.2, p = 0.027), and Gastroesophageal Reflux Symptom Score ≥ 18 on PPIs (OR = 2.6, CI = 1.2–5.8, p = 0.018). Age and GERD-HRQL score remained significant predictors by multivariate analysis. For patients with atypical symptoms, only GERD-HRQL score ≥ 15 on PPIs (OR = 9.9, CI = 0.9–4.6, p = 0.036) was associated with successful outcomes. Conclusions Elevated preoperative QOL scores on PPIs and age ≥ 50 were most closely associated with successful outcome of TF in patients with persistent symptoms despite medical therapy.