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Background: Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study., Methods: A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated., Results: Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm 2 vs botulinum toxin A 289.7 ± 162.4 cm 2 ; P = .73) (mean volume: 1,498.3 + 2,043.4 cm 3 vs 2,914.7 + 6,539.4 cm 3 ; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13)., Conclusion: In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Jejunojejunal intussusception (JI) is a serious but rare complication that may occur following Roux-en-Y gastric bypass (RYGB) surgery. Causes of JI and best management strategy are not clearly defined., Methods: Electronic health records were queried for ICD 9/10 codes for intussusception after RYGB surgery (2009-2019), and charts retrospectively reviewed. Patient demographics, operative technique, presentation, radiology, and JI management were analyzed., Results: Of the 2,327 RYGB patients identified at our institute, 34 (1.5%) were treated for JI. The mean age was 45.0 ± 8.6 years, mean BMI (RYGB surgery) was 43.1 ± 8.2 kg/m 2 , mean BMI at JI was 28.3 ± 5.8 kg/m 2 , and 30/34 were female, The mean time between RYGB and JI was 5.5 ± 4.3 years (range 1-17 years). Of the JI patients identified, 9 had operative notes that did not include jejunojejunostomy linear stapler length (JJ-LSL). Of the remaining 25 JI patients, 9 had a 60-mm JJ-LSL and 16 had a 120-mm JJ-LSL. Rate of intussusception was higher in the 120-mm versus 60-mm JJ-LSL group (p < 0.05). Acute abdominal pain was present in all JI patients and 32/34 had radiologic findings (CT scan) that corroborated for JI. The majority of JI patients were managed operatively (26/34) with 22/26 using laparoscopy (2/22 were converted to open). Intraoperative findings included intussusception (15/26), and 9/26 had other pathologies (internal hernia (2/26), cholecystitis (4/26), marginal ulcer (3/26)). Operative management of JI was either reduction and enteropexy (7/15), reduction only (5/15), or JJ revision (3/15). Recurrence of JI occurred in 7/23 patients, of who 4/7 were managed operatively., Conclusions: In our experience, JI appears to be a relatively rare complication after RYGB surgery. However, for patients developing JI, the majority had a JJ length ≥ 120 mm, and most patients required operative management which was associated with a higher rate of conversion to open and risk of JI recurrence. Reduction only technique had the highest risk of JI recurrence and therefore is not recommended.

Background: Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution., Methods: A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed., Results: 180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m 2 (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m 2 and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001)., Conclusions: RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.

Background: Correlating patient outcomes with length of stay (LoS) is an important consideration in metabolic and bariatric surgery. At present, conflicting data exists regarding patient safety for ambulatory (AMB) metabolic and bariatric surgery., Objective: Outcomes for AMB-metabolic and bariatric surgery patients (LoS <1 d) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were compared with matched patients with LoS ≥1 day (non-AMB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry., Setting: MBSAQIP national database., Methods: The MBSAQIP registry was queried for patients undergoing SG or RYGB (2015-2017) and patients grouped as AMB/non-AMB. Exclusion criteria included LoS >4 days, age <18 or >75 years, revision surgery, gastric banding, body mass index <35 kg/m 2 , and day of surgery mortality. Variables were combined into major/minor complications and 30-day mortality. Analysis was performed using univariate and multivariate logistic regression and propensity matching., Results: After exclusions were applied 408,895 patients remained (9973 AMB). Overall, 111,279 patients underwent RYGB (1032 AMB) and 297,616 underwent SG (8941 AMB), with similar demographic characteristics and co-morbidities between groups. For AMB patients, there was no increase in 30-day mortality, reoperation, or readmission, and fewer drains were placed versus matched non-AMB patients. In AMB-SG patients more surgical site infections were reported versus non-AMB-SG, although AMB-SG patients had fewer intensive care unit admissions. For AMB-RYGB, no differences in complications were detected versus non-AMB-RYGB., Conclusion: Based on our analysis of the MBSAQIP database, patients undergoing laparoscopic RYGB or SG procedures can be safely discharged on the day of their procedure without increased incidence of mortality, reoperation, or readmission., (Published by Elsevier Inc.)

Background: Although bariatric surgery is safe, some patients fear serious complications., Objectives: This retrospective study used the 2015 Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database to evaluate patient outcomes for gastric bypass (GB) and sleeve gastrectomy and to develop a risk prediction model for serious adverse events (SAEs) and readmission rates 30 days after surgery., Setting: MBSAQIP national patient database., Methods: We created separate exploratory multivariable logistic regression models for SAEs and readmissions. We then externally validated both models using the 2016 MBSAQIP Participant Use Data File., Results: Significant predictors of SAEs were preoperative body mass index (adjusted odds ratio [AOR] 1.07, P < .0001); GB surgery (AOR 2.08, P < .0001); cardiovascular disease (AOR 1.43, P < .0001); smoking (AOR 1.12, P = .04); diabetes (AOR 1.15, P = .0001); hypertension (AOR 1.17, P < .0001); limited ambulation (AOR 1.48, P < .0001); sleep apnea (AOR 1.12, P = .001); history of pulmonary embolism (AOR 2.81, P < .0001); and steroid use (AOR 1.40, P = .001). Significant predictors of readmissions were GB surgery (AOR 1.81, P < .0001); female sex (AOR 1.26, P < .0001); diabetes (AOR 1.08, P = .04); hypertension (AOR 1.11, P = .004); preoperative body mass index (AOR 1.05, P < .0001); sleep apnea (AOR 1.11, P = .002); history of pulmonary embolism (AOR 2.35, P < .0001); cardiovascular disease (AOR 1.61, P < .0001); smoking (AOR 1.14, P = .01); and limited ambulation (AOR 1.55, P < .0001). External validation supported these covariates, with similar model discriminative power., Conclusions: Our exploratory regression models may be used by clinicians to counsel patients about surgical risks, although future external validation should occur in non-North American populations., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Roux-En-Y gastric bypass (RYGB) is an alternative to reoperative fundoplication. The aim of this study was to expand long-term outcomes of patients undergoing RYGB after failed fundoplication and assess symptom resolution., Methods: A single institution prospective study was performed of patients undergoing fundoplication takedown and RYGB between March 2007 and September 2016. Demographics, body mass index (BMI), preoperative symptoms, operative duration and findings, and postoperative outcomes were recorded. Data were assessed using standard statistical methods., Results: 87 patients with failed antireflux surgery underwent RYGB. Median age 58 years (range 25-79 years). Median preoperative BMI 32.4 kg/m 2 (range 21.6-50.6 kg/m 2 ). Comorbidities included hypertension (48.3%) and diabetes (11.5%). Sixty-six patients had undergone 1 prior fundoplication, 18 had 2 prior fundoplications, and 3 had 3 prior fundoplications. At least one previous open antireflux procedure had been performed in 16.1% of patients. The most common recurrent symptoms were reflux (85.1%), dysphagia (36.7%), pain (35.6%), and regurgitation (29.9%). Median symptom-free interval from last antireflux surgery was 3 years (range 0-25 years). RYGB was performed laparoscopically in 47.1% of cases, robotically in 44.8% of cases, and open in 5.9%. Operative duration was longer in the robotic group (p = 0.04). During RYGB, 85.1% patients were found to have an associated hiatal hernia, 34.5% had intrathoracic migration of the fundoplication, 32.2% a slipped fundoplication onto proximal stomach, and 13.8% had wrap disruption. Median length of stay (LOS) was 4 days (range 1-33 days). Median follow-up was 35.8 months, 11 patients (12.6%) had recurrent reflux symptoms. Excess body weight loss (%EWL) was 80.4%. There was no mortality but 8 patients required reoperation during follow-up., Conclusions: Fundoplication takedown with RYGB was successful for long-term reflux resolution. Most can be performed via a minimally invasive approach with acceptable perioperative morbidity, symptom resolution, and the additional benefit of %EWL.

Background: Robotic technology leads to improved visualization and precision over laparoscopy but also higher cost of care. The benefits of this technology to patient outcomes are controversial. Our objective was to assess whether the application of robotic surgery to Roux-en-Y gastric bypass (RYGB) would lead to improved patient outcomes., Methods: A prospectively collected database at a bariatric center of excellence was reviewed for all RYGB procedures performed by one surgeon between 2007 and 2015. Procedures performed laparoscopically (transoral circular stapling technique) versus robotically (hand-sewn anastomosis) were compared; the transition in technique occurred in 2011. Patient demographics, baseline weight, BMI, operation duration, estimated blood loss (EBL), length of hospital stay (LOS), morbidity and mortality, and percent excess weight loss (%EWL) at 1-year follow-up were compared between groups. Morbidity up to 1-year postop was assessed using the Clavien-Dindo classification., Results: Of 246 patients, 125 underwent robotic and 121 laparoscopic RYGB. Patients in the robotic group were older and heavier but achieved similar  %EWL to the laparoscopic group. The operative duration was longer but the mean patient LOS was shorter with the robotic approach. There were no leaks and no mortality. Based on the Clavien-Dindo classification, fewer overall and fewer severe complications occurred in the robotic compared with the laparoscopic approach., Conclusion: In our experience, the use of robotic technology for the creation of gastric bypass led to longer operative times, similar %EWL but decreased LOS and number and severity of complications compared with the laparoscopic approach. Since our findings may have been influenced by the type of anastomotic technique used with each approach they need confirmation by a controlled trial.

Introduction: There is a trend toward shorter-stay bariatric surgery. However, reducing LOS may increase complications and post-discharge resource utilization. Our goal was to compare outcomes before and after implementation of short-stay bariatric surgery., Methods and Procedures: A retrospective chart review of a single-surgeon series of laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB). The two cohorts "target discharge POD 1" and "target discharge POD 2" were analyzed for on time discharges (feasibility) and complications. Patients who were successfully discharged in each cohort were further analyzed for post-discharge resource utilization., Results: Early discharge was initiated in November of 2014 with 107 patients identified in this group. An additional 107 patients from those immediately preceding represented the target DC POD 2 group. The target DC POD 2 patients had a significantly higher percentage of patients who met their target LOS. The SD group (overall and LRYGB) had a significantly higher rate of hospital readmissions; this was the only significant difference in primary outcomes between the two groups. There was no difference in mortality, leaks or reoperation., Conclusions: This study suggests that short-stay bariatric surgery is feasible and safe. Reducing the LOS from 2 to 1 day did not significantly increase the rate of hospital readmissions, ED visits or patient calls to our office. Further research is necessary to determine whether LOS can be further abbreviated to allow outpatient LSG and LRYGB.

Large hiatal hernias are notorious for their high recurrence rates after conventional repair. Recurrence rates have been described to be higher in obese patients due to increased intra-abdominal pressure. We hypothesized that patients who undergo hiatal hernia repair (HHR) with bariatric surgery (BAR) will have a lower hernia recurrence rate when compared to patients who undergo HHR with fundoplication (FP) due to the decrease in intra-abdominal pressure observed with weight loss. This was an Institutional Review Board approved retrospective review. The outcomes of patients who underwent HHR+BAR as well as patients who had HHR+FP only from 2007 to 2014 were reviewed. Patients who had small hiatal hernias (<2 cm), underwent an anterior repair, or had gastropexy only were excluded. The primary outcome was hernia recurrence and reflux resolution. The outcomes of 58 patients who had HHR+BAR were compared with 30 patients with HHR+FP. Hernia recurrence rate for HHR+BAR was 12 per cent, whereas hernia recurrence rate for HHR+FP was 38 per cent (P < 0.01). Reflux resolution for HHR+FP was 78 per cent, whereas reflux improvement rate for HHR+BAR was 84 per cent (P = n.s.). Combining HHR with BAR leads to a lower hernia recurrence rate when compared to patients who undergo HHR with FP.

Background: Rapid weight loss after bariatric surgery is associated with gallstone formation, and cholecystectomy is required in up to 15% of patients. Prophylactic cholecystectomy or prophylactic ursodiol administration in the postoperative period have been suggested to address this problem. The objectives of this study were to investigate the frequency and timing of cholecystectomies after bariatric surgery and to determine the associated risk factors in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric band (LAGB), or laparoscopic sleeve gastrectomy (LSG)., Methods: Data prospectively collected in an institutional database were analyzed. Differences among the 3 procedures and the effects of ursodiol administration, patient demographic characteristics, postoperative weight loss, and individual surgeon practices on cholecystectomy rates were examined. Survival analysis and proportional hazard models were used., Results: Of 1398 patients, 109 (7.8%) underwent cholecystectomy with a median follow-up of 49 (range 12-103) months. Cholecystectomy frequency was 10.6% after LRYGB, significantly higher than 2.9% after LAGB (P < .001), and 3.5% after LSG (P = .004). The frequency was highest within the first 6 months (3.7%), but declined over time to < 1% per year after 3 years. Ursodiol administration did not affect cholecystectomy rates (P = .97), and significant intersurgeon variability was noted. Excess weight loss (EWL)>25% within the first 3 months was the strongest predictor of postoperative cholecystectomy (P<.001). Cox hazards model revealed 1.25 odds ratio per 10% EWL within 3 months, and odds ratio .77 per decade of life. In addition, white patients had 1.45 times higher cholecystectomy rates than did black patients. Preoperative body mass index, gender, and surgeon did not affect cholecystectomy rates., Conclusion: Bariatric surgery is associated with a low frequency of postoperative cholecystectomy, which is highest early after surgery and mainly determined by the amount of EWL within the first 3 months. The results of the present study do not support routine prophylactic cholecystectomy at the time of bariatric surgery in asymptomatic patients., (© 2014 American Society for Bariatric Surgery Published by American Society for Metabolic and Bariatric Surgery All rights reserved.)

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-C's 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., (Copyright © 2013 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate safety, weight loss, and cardiometabolic changes in obese subjects implanted with the duodenal-jejunal bypass liner (DJBL) for 1 year., Background: The DJBL is an endoscopic implant that mimics the duodenal-jejunal bypass component of the Roux-en-Y gastric bypass. Previous reports have shown significant weight loss and improvement in type 2 diabetes for up to 6 months., Methods: Morbidly obese subjects were enrolled in a single arm, open label, prospective trial and implanted with the DJBL. Primary endpoints included safety and weight change from baseline to week 52. Secondary endpoints included changes in waist circumference, blood pressure, lipids, glycemic control, and metabolic syndrome., Results: The DJBL was implanted endoscopically in 39 of 42 subjects (age: 36 ± 10 years; 80% female; weight: 109 ± 18 kg; BMI: 43.7 ± 5.9 kg/m); 24 completed 52 weeks of follow-up. Three subjects could not be implanted due to short duodenal bulb. Implantation time was 24 ± 2 minutes. There were no procedure-related complications and there were 15 early endoscopic removals. In the 52-week completer population, total body weight change from baseline was -22.1 ± 2.1 kg (P < 0.0001) corresponding to 19.9 ± 1.8% of total body weight and 47.0 ± 4.4% excess of weight loss. There were also significant improvements in waist circumference, blood pressure, total and low-density lipoprotein cholesterol, triglycerides, and fasting glucose., Conclusions: The DJBL is safe when implanted for 1 year, and results in significant weight loss and improvements in cardiometabolic risk factors. These results suggest that this device may be suitable for the treatment of morbid obesity and its related comorbidities. This study was registered at www.clinicaltrials.gov (NCT00985491).

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., (Copyright © 2012 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The percentage of excess weight loss (%EWL) is a common metric for reporting weight loss after bariatric surgery. The %EWL can vary depending on the definitions of ideal body weight (IBW) used and the preoperative weight. The present study examined the effect of variations in IBW and the preoperative weight on the %EWL at a tertiary care teaching hospital., Methods: After institutional review board approval, we reviewed the prospectively collected data from consecutive patients who had undergone laparoscopic adjustable gastric banding or laparoscopic Roux-en-Y gastric bypass (RYGB) at our center from 2005 to 2008 with a single surgeon (T.K.). All patients with ≥12 months of follow-up were included. The IBW was calculated using the mean weight of the "medium frame" and the maximum weight of the "large frame" for the corresponding height from the Metropolitan Life Insurance tables. The preoperative weight was defined as the weight on the day of surgery or the greatest recorded preoperative weight between the initial consult and the day of surgery. The postoperative weight was defined as the 12-month follow-up weight. Four methods were used to calculate the %EWL. Repeated measures analysis of variance was used to analyze the methods., Results: A total of 173 patients met inclusion criteria. Of these 173 patients, 126 underwent RYGB and 47 underwent laparoscopic adjustable gastric banding. The calculated 12-month %EWL for these was 65-82% for RYGB and 31-46% for laparoscopic adjustable gastric banding using the calculation method., Conclusion: For a given postoperative weight loss, significant variance will be found in the %EWL (≤17%), depending on the definition of IBW used and the preoperative weight value used. This highlights the need for a standardized approach for reporting weight loss in bariatric studies. Investigators should define their methods clearly, and readers should keep this variability in mind when interpreting the %EWL., (Copyright © 2011. Published by Elsevier Inc.)

Background: The duodenal-jejunal bypass liner is an endoscopically placed and removable intestinal liner that creates a duodenal-jejunal bypass, leading to diabetes improvement and weight loss. The aim of the present study was to evaluate the clinical effects and safety of the duodenal-jejunal bypass liner combined with a restrictor orifice (flow restrictor)., Methods: The device was endoscopically implanted in 10 patients (body mass index 40.8 +/- 4.0 kg/m(2)) and removed after 12 weeks. Dilation of the restrictor orifice was performed as clinically indicated with a 6-, 8-, or 10-mm diameter through-the-scope balloon. The measured outcomes included the percentage of excess weight loss, total weight loss, adverse events, and gastric emptying (GE) at baseline, weeks 4 and 12 of implantation, and 3-5 months after device removal. GE was measured by scintigraphy at 1, 2, and 4 hours after implantation., Results: The percentage of excess weight loss and total weight loss at explantation was 40% +/- 3% (range 21-64%) and 16.7 +/- 1.4 kg (range 12.0-26.0), respectively. The 4-hour GE was 98% +/- 1% at baseline, 72% +/- 6% at 4 weeks (P = 0.001 versus baseline), and 84% +/- 5% at 12 weeks (P <.05 versus baseline). After explantation, the rate of GE returned to normal in 7 of 8 subjects, but remained slightly delayed in 1 subject (84% at 4 hours). Episodes of nausea, vomiting, and abdominal pain required endoscopic dilation of the restrictor orifice with a 6-mm through-the-scope balloon in 7 patients and a 10-mm balloon in 1, with no clinically significant adverse events., Conclusion: Endoscopic implantation of a combination flow restrictor and duodenal-jejunal bypass liner induced substantial weight loss. The implanted patients exhibited delayed GE that was reversed after device removal., (Copyright 2010 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The need for surgical outcomes data is increasing due to pressure from insurance companies, patients, and the need for surgeons to keep their own "report card". Current data management systems are limited by inability to stratify outcomes based on patients, surgeons, and differences in surgical technique. Surgeons along with research and informatics personnel from an academic, hospital-based Department of Surgery and a state university's Department of Information Technology formed a partnership to develop a dynamic, internet-based, clinical data warehouse. A five-component model was used: data dictionary development, web application creation, participating center education and management, statistics applications, and data interpretation. A data dictionary was developed from a list of data elements to address needs of research, quality assurance, industry, and centers of excellence. A user-friendly web interface was developed with menu-driven check boxes, multiple electronic data entry points, direct downloads from hospital billing information, and web-based patient portals. Data were collected on a Health Insurance Portability and Accountability Act-compliant server with a secure firewall. Protected health information was de-identified. Data management strategies included automated auditing, on-site training, a trouble-shooting hotline, and Institutional Review Board oversight. Real-time, daily, monthly, and quarterly data reports were generated. Fifty-eight publications and 109 abstracts have been generated from the database during its development and implementation. Seven national academic departments now use the database to track patient outcomes. The development of a robust surgical outcomes database requires a combination of clinical, informatics, and research expertise. Benefits of surgeon involvement in outcomes research include: tracking individual performance, patient safety, surgical research, legal defense, and the ability to provide accurate information to patient and payers.

Background: Gynoid lipodystrophy (cellulite) affects most women, and many seek plastic surgery consultation to improve appearance. Various products are offered, but the literature on the cause and treatment is limited. Understanding the biological and biophysical factors that affect severity may facilitate the development of effective therapies. There has been a dramatic increase in the number of people who have lost significant weight as a result of bariatric surgery or medically supervised weight programs. The effect of weight loss on cellulite severity has not been systematically studied and remains a common patient concern. The authors hypothesized that cellulite severity would decrease with weight loss and subsequent decrease in subcutaneous fat in most subjects., Methods: The authors examined the cellulite changes in female subjects who were enrolled in medically supervised weight loss programs using quantitative surface roughness by three-dimensional laser surface scanning, tissue composition by dual energy x-ray absorptiometry, dermal-subcutaneous structure with three-dimensional ultrasound, and tissue elasticity with biomechanical measurements., Results: The majority of subjects had an improvement in cellulite with weight loss, but the condition worsened for others. Improvement was associated with significant reductions in weight and percentage of thigh fat, significantly higher starting body mass index, and significantly greater initial severity. Cellulite worsened with a significantly smaller starting body mass index, smaller reductions in weight accompanied by no change in percentage of thigh fat, and significant increases in tissue compliance., Conclusions: Cellulite is a complex condition, and treatments such as weight loss have variable effects on the improvement or worsening of this condition. Additional studies are required to understand how the factors that influence and modulate cellulite severity, particularly those at the level of the subcutaneous tissue septa, can be manipulated to improve this condition.

Background: Chronic postoperative pain has been reported in as many as 62.9% of patients after inguinal herniorrhaphy. Moderate to severe neuropathic pain requiring intervention develops in 2.2% to 11.9% of patients as a result of ileoinguinal and genitofemoral nerve entrapment. Cryoanalgesic ablation has been successful in treating chronic pain from craniofacial neuralgia, facet joint syndrome, and malignant pain syndromes. We report our experience using cryoanalgesic ablation for chronic ileoinguinal and genitofemoral neuralgia after inguinal herniorrhaphy., Methods: Ten patients with ileoinguinal, genitofemoral, or combined neuralgia underwent 12 cryoanalgesic ablations between April 1996 and June 2001. These patients were referred from a multidisciplinary pain clinic, and focused low-volume nerve blocks were used to map nerve involvement preoperatively. After surgical exposure, nerves and surrounding tissues were cooled to ?70 degrees C for 3 min using the Lloyd Neurostat. Patients were seen 2 weeks postoperatively and offered monthly follow-up assessments., Results: Nine men and one woman, ages 20 to 54 (mean, 42.6 years) were treated during 58 months, with a mean follow-up period of 8.2 months, for ileoinguinal (n = 4), genitofemoral (n = 1), and combined (n = 5) neuralgia. Patients reported one to five prior herniorrhaphies (mean, 1.8), experienced neuropathic pain 0 to 14 years (mean, 6.3 years), and underwent up to 3 (mean, 1.3) ablative pain procedures before referral. After cryotherapy, patients reported overall pain reduction of 0% to 100% (mean, 77.5%; median, 100%); 80% reported decreased analgesic use, and 90% reported increased physical capacity. Two patients underwent additional cryotherapy, one for incomplete relief and one for recurrent pain, both with 100% efficacy. Wound infection (n = 1) was the only complication., Conclusions: Cryoanalgesic ablation successfully eliminates ileoinguinal and genitofemoral neuralgia in most patients, and should be considered early in the treatment of patients with postherniorrhaphy neuropathic pain.

Background: Occult common bile duct stones (CBDS) discovered during laparoscopic cholecystectomy with intraoperative cholangiography are most often managed by postoperative endoscopic retrograde cholangiopancreatography (ERCP). Expert endoscopists at high-volume centers achieve common bile duct cannulation in nearly all patients undergoing ERCP, but cannulation rates of less than 80% have been observed in low-volume centers. As many as 20% of patients with CBDS referred for postoperative ERCP in low-volume centers may require repeated attempts at ERCP, referral to a high-volume center, percutaneous transhepatic techniques, or reoperation for clearance of CBDS when postoperative ERCP fails., Methods: Laparoscopic cholecystectomy with intraoperative cholangiography performed in 511 consecutive patients over 80 months at a community hospital showed occult CBDS in 66 patients (12.9%). Laparoscopic endobiliary stent placement was successful in 65 patients (98.5%). As part of an earlier study, 16 patients underwent laparoscopic common bile duct exploration with clearance of CBDS before stent placement. Laparoscopic endobiliary stent placement failed in one patient for whom CBDS were cleared with intraoperative ERCP., Results: Initial postoperative ERCP was successful in clearing CBDS in all 65 patients (100%) with laparoscopically placed stents. During the same period, 611 patients underwent ERCP for various indications including CBDS (43%). Selective cannulation was achieved in 78% of all patients during initial ERCP., Conclusions: Laparoscopic endobiliary stent placement is an effective adjunct to the management of occult CBDS. Laparoscopic endobiliary stenting ensures selective cannulation during postoperative ERCP and eliminates the need for repeated attempts at ERCP, referral to specialty centers, use of transhepatic techniques, or reoperation for retained CBDS. Laparoscopic endobiliary stent placement for treatment of occult CBDS significantly improves the success of postoperative ERCP in low-volume centers and eliminates the morbidity and expense of repeated procedures.

Background: Early postoperative small bowel obstruction (EPSBO) occurs in 1% of patients undergoing laparotomy and has a mortality rate exceeding 17%. Nasogastric (NG) decompression is successful in avoiding reoperation in 73% of patients. Repeat laparotomy has been recommended when obstruction does not resolve after 14 days of NG decompression. We report four patients with EPSBO treated successfully with push enteroscopy after failed NG decompression., Methods: Four patients who failed NG decompression underwent push enteroscopy instead of repeat laparotomy. EPSBO was diagnosed if obstruction lasting more than 14 days developed after initial resolution of postoperative ileus, high NG output persisted postoperatively for 21 days in the absence of sepsis, or radiographic signs of obstruction persisted. Small bowel series or computed tomography were utilized when radiographic assessment was necessary. The Olympus SIF 100 push enteroscope was introduced with an overtube using topical anesthesia and intravenous sedation. After maximal insertion, the enteroscope was withdrawn without evacuation of insufflated air. NG tubes were placed after enteroscopy and patients were followed clinically. Flatus, defecation, and tolerance of a general diet defined resolution of EPSBO., Results: EPSBO resolved 24 to 36 h following enteroscopy, and all patients were discharged on general diets 48 h after return of bowel function. Readmission has not been necessary during 18- to 30-month follow-up., Conclusions: Our experience suggests that push enteroscopy is successful in treating EPSBO and should be considered prior to reoperation. Push enteroscopy may eliminate the hazards of repeat laparotomy and reduce the morbidity, treatment cost, and lengthy hospital stays associated with this uncommon surgical complication.

Three years ago we described laparoscopic placement of biliary stents as an adjunct to laparoscopic common bile duct exploration (LCBDE) in 16 patients. We now present a modification of our technique and experience with 48 additional patients. Laparoscopic cholecystectomy with intraoperative fluorocholangiography (LC/IOC) performed in 372 consecutive patients during a 36-month period revealed common bile duct stones (CBDS) in 48 patients (12.9%). In this series, LCBDE was not performed and no attempt was made to clear CBDS prior to transcystic stent placement. Stent placement added 9 to 26 minutes of operative time to LC/IOC alone. Forty-four patients (92%) were discharged after surgery and four (8%) were observed overnight. Outpatient endoscopic retrograde cholangiopancreatography 1 to 4 weeks later succeeded in clearing CBDS in all patients. All stents were retrieved without difficulty and 3- to 36-month follow-up demonstrates no surgical, endoscopic, or stent-related complications to date. Laparoscopic biliary stent placement for the treatment of CBDS is a safe, rapid, technically less challenging alternative to existing methods of LCBDE. It preserves the benefits of minimally invasive surgery for patients, and virtually assures success of postoperative endoscopic retrograde cholangiopancreatography with complete stone clearance.

In the era of open cholecystectomy, common bile duct stones were approached by traditional choledocholithotomy. Retained or recurrent stones discovered after cholecystectomy were approached by endoscopic extraction techniques or repeat surgery. With the advent of laparoscopic cholecystectomy, the approach to choledocholithiasis became more problematic as techniques for laparoscopic extraction were rudimentary. Preoperative endoscopic retrograde cholangiopancreatography rapidly became an adjunct to laparoscopic cholecystectomy when common duct stones were likely. Experience, however, revealed that many of these procedures were unnecessary. With developing sophistication of laparoscopic techniques, a variety of approaches to common duct stones developed. These included: transcystic extraction, direct laparoscopic choledocholithotomy, intraoperative endoscopic retrograde cholangiopancreatography, antegrade sphincterotomy, and transcystic placement of a common duct stent with subsequent endoscopic sphincterotomy and stone extraction. It is the purpose of this article to define the current role of each of these methods in the laparoscopic approach to choledocholithiasis.

Background and Objectives: Superior mesenteric artery (SMA) syndrome is a rare disorder, recognized as weight loss, nausea, vomiting, and post-prandial pain due to compression and partial obstruction of the third portion of the duodenum by the SMA. If conservative treatment fails, then laparotomy with duodenojejunostomy or lysis of the ligament of Treitz is indicated. Recently, laparoscopic division of the retroperitoneal attachments of the duodenum has been described. We report the first case of laparoscopic duodenojejunostomy as the definitive treatment of vascular compression of the duodenum., Methods: A very thin woman with a diagnosis of SMA syndrome was prepared for surgery after having failed medical therapy. The patient was placed in a supine position, and four laparoscopic ports were required to perform a 5 cm duodenojejunostomy., Results: The patient did well postoperatively. A gastrograffin study revealed no leak with patency of the duodenojejunal anastomosis. She was subsequently discharged home on a regular diet on postoperative day four., Conclusion: Laparoscopic duodenojejunostomy is a viable option to treat vascular compression of the duodenum. It provides definitive treatment while preserving the benefits of minimally invasive surgical techniques in the debilitated patient.

Laparoscopic procedures are increasingly performed in patients who have undergone prior abdominal surgery. Safe entry into the peritoneum includes avoidance of underlying viscera often tethered to the abdominal wall from surgical adhesions. Our group describes an alternative site technique utilizing the open Hasson procedure in a previously unoperated field, thus avoiding potential underlying adhesions. During the past 24 months this technique has been performed successfully in 95 patients, and no open conversions due to visceral or vascular injuries were necessary. Previous abdominal surgery should not be an absolute contraindication to minimally invasive procedures.

Laparoscopic ventral herniorraphy is an attractive alternative to conventional open repair. It preserves the benefits of minimally invasive surgical procedures by offering decreased discomfort and hospital stay while affording a low recurrence rate. Although technically feasible, unrolling a large piece of prosthetic mesh within the peritoneal cavity is often time consuming and the most frustrating step in the procedure. Our group describes a simplified technique for unrolling mesh that is quick, easy to perform, and requires no specialized equipment.

Thirty-two multiple trauma patients with severe head injury and a Glasgow Coma Scale (GCS) score of 8 or less were prospectively studied to assess the occurrence of deep venous thrombosis (DVT) and pulmonary embolism (PE). All patients required mechanical ventilation. A sequential compression device (SCD) was used in 14 patients and 18 patients received no prophylaxis for thromboembolism. Bilateral lower extremity technetium venoscans and ventilation/perfusion (V/Q) lung scans were performed within 6 days of admission and every week for 1 month or until the patient developed DVT or PE or was discharged from the SICU. Deep venous thrombosis occurred in two patients (6%) at 16 and 28 days following trauma. Twenty-five patients had normal or low probability V/Q scans. Six had high probability V/Q scans confirmed by pulmonary arteriograms (PAGs) at 12.5 +/- 4 days. Clinical signs of PE were absent in all patients with a positive PAG. There were no differences in age, Injury Severity Score (ISS), GCS Score, APACHE II Score, or Trauma Score between the patients who developed DVT or PE and those who did not. A SCD was used in four of the eight patients with DVT or PE. All but one patient with DVT or PE underwent placement of a vena caval filter. Multiple trauma patients with severe head injury (GCS score < or = 8) are at high risk for thromboembolism. The available means of prevention and diagnosis of DVT or PE in multiple trauma patients with severe head injury are not entirely effective.