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Abstract Background Robotic Roux-en-Y gastric bypass (RRYGB) is performed in an increasing number of bariatric centers worldwide. Previous studies have identified a number of demographic and clinical variables as predictors of postoperative complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Some authors have suggested better early postoperative outcomes after RRYGB compared to LRYGB. The objective of the present study was to assess potential predictors of early postoperative complications after RRYGB. Methods A retrospective analysis of two prospective databases containing patients who underwent RRYGB between 2006 and 2019 at two high volumes, accredited bariatric centers was performed. Primary outcome was rate of 30 day postoperative complications. Relevant demographic, clinical and biological variables were entered in a multivariate, logistic regression analysis to identify potential predictors. Results Data of 1276 patients were analyzed, including 958 female and 318 male patients. Rates of overall and severe 30 day complications were 12.5% (160/1276) and 3.9% (50/1276), respectively. Rate of 30 day reoperations was 1.6% (21/1276). The overall gastrointestinal leak rate was 0.2% (3/1276). Among various demographic, clinical and biological variables, male sex and ASA score >2 were significantly correlated with an increased risk of 30 day complication rates on multivariate analysis (OR 1.68 and 1.67, p=0.005 and 0.005, respectively). Conclusion This study identified male sex and ASA score >2 as independent predictors of early postoperative complications after RRYGB. These data suggest a potentially different risk profile in terms of early postoperative complications after RRYGB compared to LYRGB. The robotic approach might have a benefit for patients traditionally considered to be at higher risk of complications after LRYGB, such as those with BMI >50. The present study was however not designed to assess this hypothesis and larger, prospective studies are necessary to confirm these results.

Background: The American Foregut Society (AFS) is dedicated to advancing patient care and digestive health within the realm of foregut disease. One of the most common and debilitating esophageal conditions is gastroesophageal reflux disease (GERD). The Hill grade is an endoscopic classification of the esophagogastric junction (EGJ) based on the appearance of the gastroesophageal flap valve from a retroflexed view of the hiatus. This endoscopic classification provides insight into the anatomic disruption of the EGJ which has been shown to correlate with GERD. However, clinical utilization of this classification by endoscopists has been limited due to the perceived relevance and subjectivity of the classification. With the advent of endoscopic treatment options for GERD, there is renewed enthusiasm to develop a grading system of the EGJ that can objectively define anatomical impairment and reduce interobserver grading variability. Methods: The AFS convened a 13-member working group tasked with reviewing the Hill grade classification and formulating a proposal for its revision utilizing a modified Delphi method. This white paper summarizes the output from this working group. Results: The working group concluded that all components of the antireflux barrier—the lower esophageal sphincter and its sling fibers, the crural diaphragm, and the gastroesophageal flap valve—contribute to EGJ integrity. Using defined objective parameters of extent of hiatal axial herniation and crural disruption and presence or absence of a flap valve, the new AFS classification stratifies EGJ integrity from normal (grade 1) to increasing degrees of EGJ disruption (grade 2-4) beginning with loss of the flap valve and progressing to increasing degrees of crural disruption and hiatus hernia. This AFS classification also stipulates appropriate endoscopic methodology to utilize in making the assessment and provides a basic nomenclature for communication among endoscopists. Conclusions: The AFS endoscopic classification of the EGJ expands on the Hill classification by including assessment of axial hiatal hernia length (L), hiatal aperture diameter (D), and presence or absence of the flap valve (F) making it more comprehensive - LDF components. Future directions include validation studies correlating the ability of the AFS classification in predicting the presence and severity of GERD.

The field of bariatric surgery has seen peaks and troughs in the types of metabolic procedures performed. Our primary aim was to evaluate bariatric case volumes among fellows enrolled in bariatric Fellowship Council (FC)-accredited programs. Our secondary aim was to assess trends in revisional case volumes.We reviewed de-identified FC case logs for all bariatric surgery-accredited programs from 2010 through 2019. The number of primary sleeve gastrectomy, gastric band, gastric bypass, biliopancreatic diversion, and major revisional bariatric surgical procedures (defined as a revision with creation of a new anastomosis) were graphed for each academic year. Fellows were stratified into quartiles based on the number of revisional operations per year and graphed over ten years. Volumes of primary gastric bypass, major revisions, and total anastomotic cases were compared over time using ANOVA with p 0.05 considered significant.Case volumes for 822 fellows were evaluated. Sleeve gastrectomy had a significant surge in 2010 and plateaued in 2016. The fellows' number of primary gastric bypasses had a non-significant decrease from 84 to 75 cases/fellow from 2010 to 2019. This decrease was offset by a significant increase in major revisional surgery from 8 to 19 cases/fellow. As a result, the number of anastomotic cases did not change significantly over the study time period. Interestingly, as revisional volume has grown, the gap between quartiles of fellowship programs has widened with the 95th percentile growing at a much faster rate than lower quartiles.The volume of bariatric procedures performed in the last decade among FC fellows follows similar trends to national data. Major revisional cases have doubled with the most robust growth isolated to a small number of programs. As revisional surgery continues to increase, applicants interested in a comprehensive bariatric practice should seek out training programs that offer strong revisional experience.

Endoscopic sleeve gastroplasty (ESG) is an endolumenal, organ-sparing therapy for obesity, with wide global adoption. We aimed to explore the efficacy and safety of ESG with lifestyle modifications compared with lifestyle modifications alone.We conducted a randomised clinical trial at nine US centres, enrolling individuals aged 21-65 years with class 1 or class 2 obesity and who agreed to comply with lifelong dietary restrictions. Participants were randomly assigned (1:1·5; with stratified permuted blocks) to ESG with lifestyle modifications (ESG group) or lifestyle modifications alone (control group), with potential retightening or crossover to ESG, respectively, at 52 weeks. Lifestyle modifications included a low-calorie diet and physical activity. Participants in the primary ESG group were followed up for 104 weeks. The primary endpoint at 52 weeks was the percentage of excess weight loss (EWL), with excess weight being that over the ideal weight for a BMI of 25 kg/mBetween Dec 20, 2017, and June 14, 2019, 209 participants were randomly assigned to ESG (n=85) or to control (n=124). At 52 weeks, the primary endpoint of mean percentage of EWL was 49·2% (SD 32·0) for the ESG group and 3·2% (18·6) for the control group (p0·0001). Mean percentage of total bodyweight loss was 13·6% (8·0) for the ESG group and 0·8% (5·0) for the control group (p0·0001), and 59 (77%) of 77 participants in the ESG group reached 25% or more of EWL at 52 weeks compared with 13 (12%) of 110 in the control group (p0·0001). At 52 weeks, 41 (80%) of 51 participants in the ESG group had an improvement in one or more metabolic comorbidities, whereas six (12%) worsened, compared with the control group in which 28 (45%) of 62 participants had similar improvement, whereas 31 (50%) worsened. At 104 weeks, 41 (68%) of 60 participants in the ESG group maintained 25% or more of EWL. ESG-related serious adverse events occurred in three (2%) of 131 participants, without mortality or need for intensive care or surgery.ESG is a safe intervention that resulted in significant weight loss, maintained at 104 weeks, with important improvements in metabolic comorbidities. ESG should be considered as a synergistic weight loss intervention for patients with class 1 or class 2 obesity. This trial is registered with ClinicalTrials.gov, NCT03406975.Apollo Endosurgery, Mayo Clinic.

Utility and usability of laser speckle contrast imaging (LSCI) in detecting real-time tissue perfusion in robot-assisted surgery (RAS) and laparoscopic surgery are not known. LSCI displays a color heatmap of real-time tissue blood flow by capturing the interference of coherent laser light on red blood cells. LSCI has advantages in perfusion visualization over indocyanine green imaging (ICG) including repeat use on demand, no need for dye, and no latency between injection and display. Herein, we report the first-in-human clinical comparison of a novel device combining proprietary LSCI processing and ICG for real-time perfusion assessment during RAS and laparoscopic surgeries.ActivSight™ imaging module is integrated between a standard laparoscopic camera and scope, capable of detecting tissue blood flow via LSCI and ICG in laparoscopic surgery. From November 2020 to July 2021, we studied its use during elective robotic-assisted and laparoscopic cholecystectomies, colorectal, and bariatric surgeries (NCT# 04633512). For RAS, an ancillary laparoscope with ActivSight imaging module was used for LSCI/ICG visualization. We determined safety, usability, and utility of LSCI in RAS vs. laparoscopic surgery using end-user/surgeon human factor testing (Likert scale 1-5) and compared results with two-tailed t tests.67 patients were included in the study-40 (60%) RAS vs. 27 (40%) laparoscopic surgeries. Patient demographics were similar in both groups. No adverse events to patients and surgeons were observed in both laparoscopic and RAS groups. Use of an ancillary laparoscopic system for LSCI/ICG visualization had minimal impact on usability in RAS as evidenced by surgeon ratings of device usability (set-up 4.2/5 and form-factor 3.8/5). LSCI ability to detect perfusion (97.5% in RAS vs 100% in laparoscopic cases) was comparable in both RAS and laparoscopic cases.LSCI demonstrates comparable utility and usability in detecting real-time tissue perfusion/blood flow in RAS and laparoscopic surgery.

Background Postoperative morbidity after laparoscopic bariatric surgery is considered higher for patients undergoing revisional versus primary procedures. The objective of this retrospective cohort study was to compare outcomes between patients undergoing primary versus revisional robotically assisted laparoscopic (RAL) Roux-en-Y gastric bypass (RYGB). Methods Data of all patients who underwent RAL primary and revisional RYGB between 2009 and 2019 at two accredited, high-volume bariatric surgery centers—the Memorial Hermann – Texas Medical Center, Houston, TX, and the Tower Health, Reading Hospital, Reading, PA, were analyzed. Primary outcomes were early ( Results Data of 1072 patients were analyzed, including 806 primary and 266 revisional RAL RYGB procedures. Longer operative times (203 versus 154 min, P P = 0.101). Early (P = 0.318). There were no statistically significant differences between groups in overall and severe complication rates. Conclusion Patients undergoing RAL primary and revisional RYGB had comparable overall outcomes, with a non-significant higher early complication rate in the revisional group. Despite the study being underpowered to detect differences in specific complication rates, the morbidity seen in the revisional RYGB group remains markedly below literature reports of revisional laparoscopic RYGB and might suggest a benefit of robotic assistance. Further prospective studies are needed to confirm these results.

Laparoscopic repair of recurrent as opposed to primary paraesophageal hernias (PEHs) are historically associated with increased peri-operative complication rates, worsened outcomes, and increased conversion rates. The robotic platform may aid surgeons in these complex revision procedures. The aim of this study was to compare the outcomes of patients undergoing robotic assisted laparoscopic (RAL) repair of recurrent as opposed to primary PEHs. Patients undergoing RAL primary and recurrent PEH repairs from 2009 to 2017 at a single institution were reviewed. Demographics, use of mesh, estimated blood loss, intra-operative complications, conversion rates, operative time, rates of esophageal/gastric injury, hospital length of stay, re-admission/re-operation rates, recurrence, dysphagia, gas bloat, and pre- and post-operative proton pump inhibitor (PPI) use were analyzed. Analysis was accomplished using Chi-square test/Fischer’s exact test for categorical variables and the Mann–Whitney U test for continuous variables. There were 298 patients who underwent RAL PEH repairs (247 primary, 51 recurrent). They were followed for a median (interquartile range) of 120 (44, 470) days. There were no significant differences in baseline demographics between groups. Patients in the recurrent PEH group had longer operative times, increased use of mesh, and increased length of hospital stay. They were also less likely to undergo fundoplication. There were no significant differences in estimated blood loss, incidence of intra-operative complications, re-admission rates, incidence of post-operative dysphagia and gas bloat, and incidence of post-operative PPI use. There were no conversions to open operative intervention or gastric/esophageal injury/leaks. Although repair of recurrent PEHs are historically associated with worse outcomes, in this series, RAL recurrent PEH repairs have similar peri-operative and post-operative outcomes as compared to primary PEH repairs. Whether this is secondary to the potential advantages afforded by the robotic platform deserves further study.

Objective Patients with obesity have a higher risk of trocar site hernia. The objective of the present study was to compare a standard suture passer versus the neoClose® device for port site fascial closure in patients with obesity undergoing laparoscopic bariatric surgery. Methods This is a randomized, controlled trial with two parallel arms. Thirty five patients with BMI ≥ 35 kg/m2 and undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass were randomized to each group. Port site fascial closure for trocars ≥ 10 mm was performed with the neoClose® device in the study group and the standard suture passer in the control group. Primary outcomes were time required to complete closure and intensity of postoperative pain at the fascial closure sites. Secondary outcomes were intraabdominal needle depth and incidence of trocar site hernia. Results The use of the neoClose® device resulted in shorter closure times (20.2 vs 30.0 s, p = 0.0002), less pain (0.3 vs 0.9, p = 0.002) at port closure sites, and decreased needle depth (3.3 cm vs 5.2 cm, p Conclusion Use of the neoClose® device resulted in faster fascial closure times, decreased intraoperative needle depth, and decreased postoperative abdominal pain at 1 week as compared to the standard suture passer. These data need to be confirmed on larger cohorts of patients with longer follow-up, especially in terms of long-term hernia recurrence rates.

Some clinical indicators suggest hypercoagulability/hyperaggregability in patients with morbid obesity. Thromboelastography (TEG®) has been used to profile coagulation status in surgical patients. We aimed to assess coagulation profiles in patients with morbid obesity undergoing bariatric surgery by correlating demographic and patient characteristics to pre-operative TEG® values. Pre-operative TEG® values from 422 patients undergoing bariatric surgery were evaluated. TEG® results were analyzed by gender, use of medications known to alter the coagulation profile, and body mass index (BMI). Patients have a mean of 45.03 ± 11.8 years, female (76.3%), and with a mean BMI of 42 kg/m 1. The overall coagulation profile of female patients was significantly different from males, even in the sub-cohort without use of medications known to alter coagulation. The majority of patients (94%) with a G value > 15 dynes/cm 1 (clot strength) were female. In females, there was no association between BMI and TEG® values; however, in men, there was a statistically significant difference in TEG® values for those with BMI 50 kg/m2. TEG®-based analysis of coagulation profiles offers unique insights. Compared to laboratory normal values (R time, angle, maximal amplitude, and G values), patients with morbid obesity may have a tendency for hypercoagulability/hyperaggregability, with mean values at the higher limit. A significant hypercoagulable difference in TEG® values was identified in female as compared to male patients. Male patients with a BMI greater than 50 kg/m2 were also found to be increasingly hypercoagulable.

Some clinical indicators suggest hypercoagulability/hyperaggregability in patients with morbid obesity. Thromboelastography (TEG®) has been used to profile coagulation status in surgical patients. We aimed to assess coagulation profiles in patients with morbid obesity undergoing bariatric surgery by correlating demographic and patient characteristics to pre-operative TEG® values.Pre-operative TEG® values from 422 patients undergoing bariatric surgery were evaluated. TEG® results were analyzed by gender, use of medications known to alter the coagulation profile, and body mass index (BMI).Patients have a mean of 45.03 ± 11.8 years, female (76.3%), and with a mean BMI of 42 kg/mTEG®-based analysis of coagulation profiles offers unique insights. Compared to laboratory normal values (R time, angle, maximal amplitude, and G values), patients with morbid obesity may have a tendency for hypercoagulability/hyperaggregability, with mean values at the higher limit. A significant hypercoagulable difference in TEG® values was identified in female as compared to male patients. Male patients with a BMI greater than 50 kg/m

Roux-en-Y gastric bypass (RYGB) is the second most common procedure performed for the surgical treatment of patients with morbid obesity. Robotic techniques are increasingly used to perform laparoscopic RYGB. In the case of persistent gastroesophageal reflux disease (GERD), especially after a prior fundoplication, in the setting of severe non-achalasia-related esophageal dysmotility or in the patient with morbid obesity, RYGB can provide resolution of GERD-related symptoms as the small gastric pouch can rapidly empty, and the gastroesophageal junction is tethered into the abdomen. This chapter outlines the diagnosis of GERD, the preoperative workup, operative steps including robotic setup and postoperative care of patients undergoing robotic RYGB as an antireflux procedure. In this chapter, we do not focus on the treatment of post-gastric band (fixed/adjustable) or post-sleeve gastrectomy reflux with conversion to RYGB.

The treatment of gastroesophageal reflux disease is multifactorial and includes diet/lifestyle modification, weight loss, endolumenal therapies, magnetic sphincter augmentation, formal surgical fundoplication (Nissen, Toupet, and related procedures), and weight loss surgery (Roux-en-Y gastric bypass). Endolumenal therapies, such as transoral fundoplication and radiofrequency treatment of the lower esophageal sphincter, represent an option for carefully selected patients (with early disease and favorable anatomy) who do not desire formal anti-reflux surgery but desire to stop taking daily anti-acid medications. This chapter provides an overview of the available endolumenal therapies for the treatment of patients with reflux.

This article will review the current evidence supporting the use of robotic platforms in bariatric surgery and discuss the technical aspects of robotic platforms in the current bariatric procedures performed. The use of robotic platforms for minimally invasive bariatric surgery continues to increase. This can be attributed to the perceived advantages of robotic platforms including three-dimensional high-definition visualization, tremor filtration, direct camera control by the primary surgeon, multi-quadrant access, and wristed instruments which make complex and redo surgery potentially easier to perform. Robotic systems may also provide ergonomic advantages in patients with obesity who have significant abdominal wall mass. Despite a longer operative time, the preponderance of the data suggest robotic surgery is a safe and effective methodology to perform bariatric procedures. The greatest potential for clinical benefit appears to be in revisional bariatric surgery and in patients with higher body mass index. There may also be advantages in the learning curve of these complex procedures. Robotic platform improvement, training, and cost-effective usage may overcome the higher initial costs.

The adoption of robotic surgery continues to increase, with over 1 million robotic-assisted surgical procedures performed worldwide (2018 estimate). Over 70 companies are developing/introducing platforms for robotic-assisted surgery in nearly every procedural speciality. In this chapter, we review concepts that are important to consider when discussing the future of robotic surgical platforms, including design of the surgeon, surgical team, and patient interfaces, integrated versus modular designs, reality augmentation, cost, and data analytics.

In this article, we review the role of robotics in bariatric surgery. After a brief overview of the evolution of minimally invasive bariatric surgery, we discuss possible advantages of robotic systems and subsequently go into more details about each procedure, including adjustable gastric bands, sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. We also discuss outcomes of robotics in reoperative bariatric surgery. Considerations about training are presented as well.

Background and Aims The objective of this study was to examine expert opinion and agreement on the treatment of distinct GERD profiles from surgical and therapeutic endoscopy perspectives. Methods We used the RAND/University of California, Los Angeles Appropriateness Method over 6 months (July 2018 to January 2019) to assess the appropriateness of antireflux interventions among foregut surgeons and therapeutic gastroenterologists. Patients with primary atypical or extraesophageal symptoms were not considered. Patient scenarios were grouped according to their symptom response to proton pump inhibitor (PPI) therapy. The primary outcome was appropriateness of an intervention. Results Antireflux surgery with laparoscopic fundoplication (LF) and magnetic sphincter augmentation (MSA) were ranked as appropriate for all complete and partial PPI responder scenarios. Transoral incisionless fundoplication was ranked as appropriate in complete and partial PPI responders without a hiatal hernia. Radiofrequency energy was not ranked as appropriate for complete or partial responders. There was lack of agreement between surgery and interventional gastroenterology groups on the appropriateness of LF and MSA for PPI nonresponders. Rankings for PPI nonresponders were similar when results from impedance-pH testing on PPI therapy were available, except that LF and MSA were not ranked as appropriate for PPI nonresponders if the impedance-pH study was negative. Conclusions This work highlights areas of agreement for invasive therapeutic approaches for GERD and provides impetus for further interdisciplinary collaboration and trials to compare and generate novel and effective treatment approaches and care pathways, including the role of impedance-pH testing in PPI nonresponders.

Patients with obesity have a higher risk of trocar site hernia. The objective of the present study was to compare a standard suture passer versus the neoClose® device for port site fascial closure in patients with obesity undergoing laparoscopic bariatric surgery. This is a randomized, controlled trial with two parallel arms. Thirty five patients with BMI ≥ 35 kg/m2 and undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass were randomized to each group. Port site fascial closure for trocars ≥ 10 mm was performed with the neoClose® device in the study group and the standard suture passer in the control group. Primary outcomes were time required to complete closure and intensity of postoperative pain at the fascial closure sites. Secondary outcomes were intraabdominal needle depth and incidence of trocar site hernia. The use of the neoClose® device resulted in shorter closure times (20.2 vs 30.0 s, p = 0.0002), less pain (0.3 vs 0.9, p = 0.002) at port closure sites, and decreased needle depth (3.3 cm vs 5.2 cm, p

Roux-en-Y gastric bypass is a common bariatric procedure. Its configuration creates an excluded gastric remnant, which is subject to potential acute complications such as bleeding, perforation, and necrosis. A retrospective analysis of a prospective database including all patients presenting between 2007 and 2019 to our institution with acute gastric remnant complications after RYGB was performed. Seven patients were included, including 3 hemorrhages, two of which were treated with double-balloon enteroscopy, as well as 3 perforations and 1 necrosis, all of which required emergent surgery. Overall gastric remnant complication rate was 0.3% in this series. Acute gastric remnant complications after RYGB are infrequent, but their diagnosis and management can be challenging. Double-balloon enteroscopy has diagnostic and therapeutic value for selected patients. Emergent surgery remains the standard of care for unstable patients and should not be delayed.

The utilization of robotic platforms for general surgery procedures such as hernia repair is growing rapidly in the United States. A limited amount of data are available evaluating operative outcomes in comparison to standard laparoscopic surgery. We completed a retrospective review comparing robotic and laparoscopic ventral hernia repair to provide safety and outcomes data to help design a future prospective trial design. A retrospective review of 215 patients undergoing ventral hernia repair (142 robotic and 73 laparoscopic) was completed at two large academic centers. Primary outcome measure evaluated was recurrence. Secondary outcomes included incidence of primary fascial closure, and surgical site occurrences. Propensity for treatment match comparison demonstrated that robotic repair was associated with a decreased incidence of recurrence (2.1 versus 4.2%, p

BACKGROUND AND AIMS: Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature. METHODS: Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used. RESULTS: 130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18 months after TORe was 9.31 ± 6.7 kg (N = 84), 7.75 ± 8.4 kg (N = 70), 8 ± 8.8 kg (N = 46) (p < 0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12 months was 8.4 kg (95% CI 6.5–10.3) with no significant heterogeneity across included studies (p = 0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported. CONCLUSION: When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

Background The effect of laparoscopic sleeve gastrectomy (SG) on reflux symptoms is unclear. Many surgeons offer SG only to patients with minor or no reflux symptoms, fearing that patients with severe reflux symptoms will experience worsening of their condition after SG. Many also advocate crural repair at the time of SG to prevent de novo or worsening reflux symptoms. These decisions are made without suitable data to form such conclusions. Objective To determine the effect of SG with or without hiatal hernia repair on reflux symptoms. Setting University of Texas Health Sciences Center in Houston. Methods The Gastrointestinal Symptom Rating Scale (GSRS) was administered to 100 consecutive, preoperative SG patients who were then randomly assigned into a crural repair group or nonrepair group in a parallel design. The patients were subsequently followed-up every 3 months for 1 year. We compared reflux symptoms of the 2 groups on the basis of demographic characteristics, body mass index, weight loss, presence and size of hiatal hernia, and GSRS for 12 months. Results At 1 year, with 78% follow-up, the data demonstrated a significant decrease in the GSRS for both groups ( P P = .35). Age, starting body mass index, percent excessive weight loss, and hiatal hernia size did not correlate with change in the GSRS score. The only variable that affected outcome was the preoperative GSRS. At 12 months, 38% of patients with a preoperative GSRS score less than the median score of the study population experienced worsening of their symptoms compared with only 2% of patients who had a preoperative GSRS score greater than the median. Overall, 19% experienced worsening reflux (5% de novo), 14% had no change, and 66% reported an improvement in symptoms. Conclusion These data suggest that a crural repair at the time of SG does not significantly reduce reflux symptoms compared with SG alone. Preoperative patients with significant reflux symptoms experienced a more significant improvement in symptoms after surgery compared with those who did not report significant reflux symptoms before surgery. The high incidence of reflux after SG observed in the current literature may be a result of a specific patient subpopulation who undergoes SG because of surgeon bias rather than an inherent property of SG itself or the presence of a hiatal hernia.

Patients with obesity have a higher risk of trocar site hernia. The objective of the present study was to compare a standard suture passer versus the neoCloseThis is a randomized, controlled trial with two parallel arms. Thirty five patients with BMI ≥ 35 kg/mThe use of the neoCloseUse of the neoClose

Robotic-assisted laparoscopic (RAL) surgery continues to increase in popularity, often at a rate that outpaces the data to support its use. While there are a multitude of purported advantages with RAL techniques, there are key barriers to adoption including increased operative times and potential costs, and issues related to training and the learning curve. The authors review advantages and disadvantages as well as specific suggestions related to training and adoption of robotics in surgical practice.

Suprapubic hernias are an uncommon type of ventral/incisional hernia and are associated with operative challenges due to location. The authors review the specific challenges associated with the repair of suprapubic ventral/incisional hernias, the role and data surrounding minimally invasive/laparoscopic repair, as well as setup and operative technique for robotic-assisted laparoscopic repair of these challenging hernias.

Laparoscopic repair of recurrent as opposed to primary paraesophageal hernias (PEHs) are historically associated with increased peri-operative complication rates, worsened outcomes, and increased conversion rates. The robotic platform may aid surgeons in these complex revision procedures. The aim of this study was to compare the outcomes of patients undergoing robotic assisted laparoscopic (RAL) repair of recurrent as opposed to primary PEHs.Patients undergoing RAL primary and recurrent PEH repairs from 2009 to 2017 at a single institution were reviewed. Demographics, use of mesh, estimated blood loss, intra-operative complications, conversion rates, operative time, rates of esophageal/gastric injury, hospital length of stay, re-admission/re-operation rates, recurrence, dysphagia, gas bloat, and pre- and post-operative proton pump inhibitor (PPI) use were analyzed. Analysis was accomplished using Chi-square test/Fischer's exact test for categorical variables and the Mann-Whitney U test for continuous variables.There were 298 patients who underwent RAL PEH repairs (247 primary, 51 recurrent). They were followed for a median (interquartile range) of 120 (44, 470) days. There were no significant differences in baseline demographics between groups. Patients in the recurrent PEH group had longer operative times, increased use of mesh, and increased length of hospital stay. They were also less likely to undergo fundoplication. There were no significant differences in estimated blood loss, incidence of intra-operative complications, re-admission rates, incidence of post-operative dysphagia and gas bloat, and incidence of post-operative PPI use. There were no conversions to open operative intervention or gastric/esophageal injury/leaks.Although repair of recurrent PEHs are historically associated with worse outcomes, in this series, RAL recurrent PEH repairs have similar peri-operative and post-operative outcomes as compared to primary PEH repairs. Whether this is secondary to the potential advantages afforded by the robotic platform deserves further study.

Endoscopic sleeve gastroplasty (ESG), an incisionless endoscopic bariatric procedure, has shown impressive results in case series. This study examines the reproducibility, efficacy, and safety in three centers across two countries, and identifies key determinants for procedural success. Patients who underwent ESG between February 2016 and May 2017 at one of three centers (Australia and USA) were retrospectively analyzed. All procedures were performed on an outpatient basis using the Apollo OverStitch device (Apollo Endosurgery, Austin, TX). Primary outcomes included absolute weight loss (ΔWeight, kg), change in body mass index (∆BMI, in kg/m2), total body weight loss (TBWL, %), excess weight loss (EWL, in %), and immediate and delayed adverse events. In total, 112 consecutive patients (male 31%, age 45.1 ± 11.7 years, baseline BMI 37.9 ± 6.7 kg/m2) underwent ESG. At 1, 3, and 6 months, Δweight was 9.0 ± 4.6 kg (TBWL 8.4 ± 4.1%), 12.9 ± 6.4 kg (TBWL 11.9 ± 4.5%), and 16.4 ± 10.7 kg (TBWL 14.9 ± 6.1%), respectively. The proportion of patients who attained greater than 10% TBWL and 25% EWL was 62.2 and 78.0% at 3 months post-ESG and 81.0 and 86.5% at 6 months post-ESG. Weight loss was similar between the three centers. Multivariable analysis showed that male sex, greater baseline body weight, and lack of prior endoscopic bariatric therapy were predictors of greater Δweight at 6 months. Three (2.7%) severe adverse events were observed. ESG is an effective, reproducible, and safe weight loss therapy that is suitable for widespread clinical adoption.

Complications of the laparoscopic adjustable gastric band, including erosion, have been well described. Increasingly, endoscopic techniques are being utilized to manage complications of this and other weight loss procedures. The authors presented what was believed to be one of the first reported cases of successful endoscopic removal of an eroded gastric band during pregnancy. A complete description of the case and review of the relevant literature is provided. Endoscopy for management of eroded adjustable gastric bands needs to be part of the armamentarium of surgeons and endoscopists who deal with complications of weight loss surgery.

The epidemic of obesity continues to be a major health issue. It is now almost uniform that surgical procedures for weight loss are performed with minimally invasive techniques. This article reviews the literature regarding obesity-related health issues, in particular risk of malignancy, and the application of robotic technology in weight loss surgical procedures. With increasing literature and technology in surgical robotics, its application in the field of bariatric surgery continues to evolve. J. Surg. Oncol. 2015; 112:279–283. © 2015 Wiley Periodicals, Inc.

We present our technique for a totally robot-assisted laparoscopic Roux-en-Y gastric bypass. Moreover, data are presented in relation to a single-surgeon experience with use of the robotic platform in bariatric surgery. We reviewed a single surgeon's console and room time from 2009 to 2013 for all robot-assisted Roux-en-Y gastric bypasses (RARYGBs). Revision operations were excluded. There were in total 168 robotic bariatric operations in this time frame. The number of cases performed each year and the cumulative number of each operation were considered as well. The change in console time as related to the number of cases and the change in room time as related to the console time and number of cases were investigated. Complications during this time and their frequency were noted and described. The console time for RARYGB ranged from 131 ± 46 minutes in 2010 to 94 ± 29 minutes in 2013 (P