2019 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Baltimore, Maryland, USA, 3–6 April 2019: 2019 Posters



Delay in Emergency Hernia Surgery is Associated with Worse Outcomes

Ira L Leeds, MD, MBA, ScM, Christian D Jones, MD, MS, Elliott R Haut, MD, PhD, Joseph V Sakran, MD, MPA, MPH, Sandra R Dibrito, MD, PhD, Ryan Fransman, MD, Alistair J Kent, MD, MPH; Johns Hopkins University School of Medicine

Introduction: The purpose of this study was to determine if variation in the practice of deferring surgery for preoperative optimization or surgeon availability impacts surgical outcomes.

Methods: The national NSQIP databases from 2011 to 2016 were queried for emergent surgeries for abdominal hernia resulting in obstruction or gangrene by primary post-op diagnosis. Diaphragmatic hernias, elective cases and cases without the specific designation emergent were also excluded. Patients were grouped by time in days from date of admission to date of surgery: Same day, next day, and second day or longer. These groups were then examined for differences in NSQIP defined major morbidities and mortality. We used a multinomial propensity score weighting for covariates’ clustering across the timing groups then performed weight-adjusted multivariate logistic regression.

Results: The effective population size was 79,145; selected unadjusted characteristics are shown (Table). After adjusted analysis, the odds of major complication were increased by 25% (aOR = 1.25, 95% CI 1.07-1.47, p = 0.005) for delays to the next day, and 50% for delays to the second day or longer (aOR = 1.50, 95% CI 1.22-1.86, p < 0.001). There was no difference of risk of 30-day mortality when adjusting for other factors for next day surgery (aOR 1.37, CI 0.52-3.60, p = 0.51) or surgery deferred ≥ 2 days (aOR 1.79, CI 0.56-5.74, p = 0.32).

Conclusions: Delay in surgery for emergent hernias substantially and progressively increased odds of major morbidity but not mortality in a propensity adjusted analysis of NSQIP data, though limitations exist based on NSQIP structure and reporting mechanisms. Patients presenting with hernia and indications for urgent surgical intervention be taken to the operating room as soon as physiologically feasible. Delays for resuscitation and optimization beyond physiologic tolerance of the procedure may increase the risk of major morbidity.

Variable (%)

n = 79,145



Further delayed


Preoperative sepsis














< 0.001











Active smoker






Retroperitoneal Duodenal Foreign Body Perforation - A Novel Laparoscopic Approach

Nicholette Goh, MBBS, Sunder Balasubramaniam, Wee Ming Tay, Mui Heng Goh; Tan Tock Seng Hospital

Introduction: Gastrointestinal perforation from foreign bodies can lead to life threatening sepsis, and pose a significant challenge given the need to drain the septic source as well as safely extract the offending object.

Case Description: A 71-year-old Chinese lady presented with abdominal pain and constitutional symptoms without peritonitis or fever. A computed tomographic (CT) scan of the abdomen revealed two retroperitoneal abscesses with a 4 cm fishbone within (Image 1). The cavities were (5.8 by 2.4 cm) and (10 by 7 cm) in size, one of which was surrounding the right external iliac artery. There was a visible connection from the third portion of the duodenum to the superior abscess cavity.

She underwent radiology-guided drainage of the collections, followed by a gastrograffin swallow which did not demonstrate an ongoing leak. Retrieval of the fishbone was first attempted endoscopically. This was done by placing a 5 mm laparoscopic port into the cavity to insufflate it with gas, followed by introduction of a flexible choledochoscope. Unfortunately, the bone could not be visualised, and the procedure was hence converted to open retroperitoneal approach via a 4 cm incision. The bone was successfully retrieved (Image 2), and a repeat CT done post-operatively showed near resolution of the abscess and complete removal of the fishbone. The patient was fit for discharge on the 4th post-operative day.

Discussion: Intestinal perforation from the ingestion of a foreign body most commonly affects the colon and terminal ileum. If the perforation is intra-peritoneal, peritonitis usually results; however retroperitoneal perforations may seal off and hence present in a more insidious fashion.

To our knowledge, this is the first such report of retroperitoneal abscess due to a foreign body managed by minimally invasive techniques. Fluoroscopic extraction by the radiologist was considered in this case but deemed unsuitable due to the risk of fragmentation and having pieces left behind. The retroperitoneal approach combined with interventional radiology allowed us to avoid the morbidity of laparotomy and speed the patient’s recovery.

As expertise develops further, it is hoped that minimally invasive techniques like those used in retroperitoneoscopic adrenalectomy or pancreatic debridements can be used in such cases in the future. These can also be considered for trauma patients with projectile injuries who face a similar problem.

Conclusion: Multidisciplinary collaboration allowed for a novel method of extraction of a fishbone, and hence faster recovery than would be expected with traditional laparotomy and extraction.


Perforated Appendicitis Wash or Dry Abdominal Cavity: Myth or Reality

Carlos A Rosero, MDFACS, Andres G Moreno, MDFACS; Hospital Carlos Andrade Marín, Quito, Ecuador

Introduction: Seeking the best treatment of the peritoneal cavity in case of secondary peritonitis is a surgeons’ permanent concern and it is essential for the adequate management of the patient.

Objective: To compare the results of thoroughly washing the peritoneal cavity vs simply just drying the peritoneal cavity in cases of secondary peritonitis due to acute perforated appendicitis.

Materials and methods: A retrospective observational study was carried out in the General Surgery Department at Carlos Andrade Marín Specialties Hospital, from January 2016 to December 2017. The study main end-point was assessing the postoperative complication between peritoneal lavage versus cavity drying.

Results: The records of 301 patients, 212 (70.4%) who underwent peritoneal lavage and 89 (29.6%) with just drying the peritoneum. The frequency of complications between both groups did not reach statistical significance. The only significant variable was the operative time (OR 1.01, p < 0.005).

Conclusions: No statistically significant differences were found with the type of cavity management in patients with peritonitis secondary to perforated appendicitis (lavage versus cavity drying).

Keywords: Peritoneal lavage, Peritoneal cavity drying, Perforated appendicitis, Peritoneal cavity.


Guidelines for Acute Care Surgery Implementation are Necessary

Holly B Cunningham, Joshua J Weis, Luis R Taveras, Steven Boll, Tarik D Madni, Jonathan B Imran, Meaghan Colletti, Maryanne L Pickett, Joseph P Minei, Michael W Cripps; University of Texas Southwestern

Introduction: The creation of an acute care surgery (ACS) service has been associated with improved hospital efficiency and clinical outcomes; however, specific guidelines for implementing this model have not been developed. As a result, there has been significant variation in how individual institutions apply the principals of an ACS model to their practice. We sought to evaluate the impact of an ACS model at a private, non-trauma hospital with no in-house, overnight attending.

Methods: A retrospective review of all general surgery (GS)/ACS admissions and consults was conducted at an academic, private, non-trauma hospital from July 2015 to July 2018. An ACS service was established in July 2016. Clinical, demographic, and financial variables were queried from the electronic medical record. Parametric and non-parametric analyses were used when appropriate. Prior to July 2016, the GS service was staffed during weekdays by a single surgeon who was responsible for managing consults as well as maintaining an elective GS practice. Weekend and night coverage was home-call shared between this surgeon and other surgical subspecialists. Within the ACS model, weekday elective cases and clinics were maintained by the GS staff while emergency GS consults were assigned to a separate, dedicated ACS surgeon. Overnight and weekend home-call was divided amongst ACS staff, many of whom were critical care boarded.

Results: In total, 3164 hospital account records (HARs) were reviewed. There were 1016 HARs in the pre-ACS group and 2148 HARs in the post-ACS group. During the pre-ACS time period, there were 505 admissions and 511 consults. Post-ACS implementation, there were 1135 admissions and 1013 consults. Groups were similar in age (p = .88), gender (pre-ACS 57.6% male, post-ACS 58.8% male), and race (70% white). Total hospital charges between groups were statistically similar (p = .51). Net revenue and contribution margins between groups were also similar (p = .44, p = .07, respectively). Analysis of total length of stay (LOS) and intensive care unit LOS revealed no difference (p = .96, p = .94, respectively). In subset analyses, no differences were seen in total LOS for cholecystectomies (4.25 vs 4.14 days, p = .84) or bowel obstructions (5.30 vs 4.95 days, p = .71).

Conclusions: The creation of an ACS service in a private, non-trauma hospital without concurrent institutional culture change does not result in the financial benefits or clinical outcome improvements previously reported. Guidelines for optimal implementation should be established. Further studies will aim to define appropriate measures of successful ACS implementation as well as predictors of success in various hospital settings.


The Great Imitator: Acute Gangrenous Cholecystitis

Allyne Topaz, MD, Lauren Poliakin, MD, Luca Milone, MD; The Brooklyn Hospital Center

Acute gangrenous cholecystitis mimicking acute cardiovascular diseases may lead to a delay in surgical management of cholecystitis. Common symptoms associated with ischemic heart disease, such as chest pain and shortness of breath, may also be associated with noncardiac conditions, like cholecystitis. Acute cholecystitis can causes transient or dynamic ECG changes, likely secondary to gallbladder distension. We have reported 2 cases in a period of 2 months, where the patients presented with cardiac-like symptoms. Both patients were admitted for management of acute cardiovascular conditions, and eventually diagnosed with acute cholecystitis on abdominal ultrasound. The patients were female and obese. Minimally invasive cholecystectomy was performed for both patients, which subsequently led to improvement of symptoms postoperatively.

Case 1: An 81 year old obese female presented to the emergency department with tachycardia and complaints of chest pain and right upper quadrant pain. Her ECG showed atrial fibrillation. Immediate focus and workup surrounded the atrial fibrillation; including imaging to rule out mesenteric ischemia. Abdominal ultrasound showed multiple gallstones with features of acute cholecystitis. After resuscitation, the patient underwent a laparoscopic subtotal cholecystectomy for acute gangrenous cholecystitis. The degree of inflammation necessitated stapled removal of the gallbladder with placement of a JP drain. The patient recovered well postoperatively.

Case 2: A 59 year old obese female with a long standing cardiac history presented to the emergency department with complaints of chest pain and epigastric pain. The patient was admitted for further work-up and management of acute coronary syndrome. After life threatening cardiac conditions were ruled out, an abdominal ultrasound showed multiple gallstones with evidence of acute cholecystitis. Robotic assisted subtotal cholecystectomy was performed. The patient had a left sided gallbladder. Given the degree of inflammation, a partial cholecystectomy including lysis of adhesions, and needle decompression was performed. A postoperative ERCP was later performed revealing a small bile leak necessitating sphincterotomy. The patient did well postoperatively and was discharged uneventfully.

Acute gangrenous cholecystitis may manifest with cardiac-like symptoms postponing the patient’s work-up and treatment of cholecystitis. Cholecystitis is a common surgical condition that requires prompt recognition and diagnosis. Timely recognition of gangrenous cholecystitis provides proper treatment and can prevent unnecessary interventions.


Small Bowel Obstructions Following the Use of Barbed Sutures: A Systematic Review

Benjamin Clapp, MD, Loyd Christensen, BS, Robert Jones, Carlos Lodeiro, BS, Ellen Wicker, DO, William Klingsporn, MD, Alan Tyroch, MD; Texas Tech HSC Paul Foster School of Medicine

Introduction: Barbed sutures were introduced in 2004. Their adoption and use has been widespread across all surgical specialties. One of the infrequent complications seen with the use of barbed sutures are small bowel obstructions. In this study, we perform a systematic review of the literature to characterize small bowel obstructions (SBO) after the use of barbed sutures in a variety of operative procedures.

Methods: A review of the literature was performed by searching PubMed and Ovid. We used the search terms: “barbed” “suture” “bowel” and “obstructions.” For each case report we examined the initial surgical procedure, type of barbed suture used, the type of complication, the time to complication, the presentation, and the type of operative interventions required for said complication.

Results: Our review of the literature revealed 18 different cases of small bowel obstruction (SBO) secondary to the use of barbed sutures. The two most index common procedures, with a total of 4 cases each were myomectomy and hysterectomy. The next two most common procedures were TAPP hernia repair and sacral colpopexy. Different types of sutures were reported with the V-Loc barbed suture the most common type, involved in 14 of the 18 cases.

The average time of presentation to SBO was found to be 18.3 days post-op (1–49 days). A total of 15 patients (83.3%) presented with abdominal pain. Other common complaints included vomiting (50%), abdominal distension (27.8%), inability to tolerate food (22.2%) and constipation (16.7%). Most patients had a CT done, with the most common finding being a transition point in the small bowel. A total of 5 cases were also found to have a possible volvulus on CT, and only 1 case was reported to have strangulation.

Of these patients, 14 underwent a diagnostic laparoscopy, 3 of them had a diagnostic laparotomy and one of them had a hepatojejunostomy revision. In most cases, the removal of the redundant barbed suture was enough to release the small bowel and clear the obstruction.

Conclusions: Surgeons should have a high index of suspicion for SBO if a patient presents with obstructive symptoms after a surgery that used barbed sutures. This will often present as a mesenteric volvulus on computed tomography. These particular SBOs require operative exploration, with laparoscopy being successful in the majority of cases.


Use of Departmental Morbidity and Mortality Conference as a Real Time Barometer of Outcomes and Quality in Pediatric Appendectomy

Julie A Disano, MD, Mary C Santos, MD, Vamsi V Alli, MD, Morgan K Moroi, BS, Robert E Cilley, MD; Penn State Hershey Medical Center

Introduction: Weekly morbidity and mortality conferences (M&M) are educational staples, playing an important role in quality improvement. After noticing an increased frequency of pediatric appendectomy complications during M&M, we explored the accuracy of this finding.

Methods: M&M listings were reviewed for complications following appendectomy. Data was collected from January 2013 through December 2016 and analyzed in semiannual intervals (CY1: January-June; CY2: July-December). The total number of appendectomies performed was determined from billing data. Complication rates were compared to institutional Pediatric NSQIP data.

Results: 771 appendectomies were performed during the study period with 63 reported complications (8.17%). M&M data indicated an increase in postoperative complications during the CY2-2015 period to 13.58%, from 11.59% in CY1-2015. This was similarly seen in NSQIP data, with a rise in complications from 2.20% to 8.20% between CY1 and CY2 of 2015.

Conclusions: Observed trends in institutional M&M data recognized an increase in reported postoperative complications in CY2-2015, a finding confirmed by pediatric NSQIP data. Using external national benchmarks we validated a cheap and reliable method of QI and outcomes measures based on regularly collected M&M data. Regular review of M&M data provides a cost effective and accurate means of assessing quality in addition to reinforcing the adoption of practice-based learning and systems-based practice. Additionally, this method is a useful barometer for QI at non-NSQIP participating institutions.


Solitary Ileal Lymphangioma, A Rare Cause of Obscure Intestinal Bleeding Requiring Transfusion Successfully Treated with Laparoscopic Resection

Justin D Sargent, DO 1, Hassan Masoudpoor, MD1, Jeffrey J Kraft, MD2, John Davis, MD1; 1Hackensack Meridian Health Palisades, 2Hackensack University Medical Center

Introduction: Small bowel lymphangioma is a rare benign vascular system tumor that mostly presents in children as head, neck or axillary region masses. Generally they are asymptomatic and don’t require treatment, unless complications arise, such as bleeding or obstruction. Small bowel lymphangiomas are very rare in adults and intestinal bleeding secondary to a solitary ileal lymphangioma presenting with severe anemia requiring transfusion are rarely reported.

Case Description: 54 year old male presented to ED with sudden onset of lower abdominal pain without remarkable past medical history. A small urinary tract stone with hydronephrosis was identified. Incidentally on CT an area of mural thickening of a short segment of small bowel in the left lower quadrant was noted. Mild asymptomatic anemia was found, and patient was recommended outpatient endoscopic follow-up with analgesics for the renal calculi.

The patient was lost to follow up due to insurance reasons and returned to our hospital after three months with recurrent and severe anemia requiring blood transfusion and intravenous iron treatment. He denied any episodes of melena, hematochezia, chest pain, nausea and vomiting. The patient only complained of the mild exertional SOB, but was compensating by decreasing activity at home. Clinical examination revealed marked conjunctival pallor. No masses were palpated on rectal or abdominal examination. On admission a microcytic anemia with hemoglobin of 4.3 g/dL was noted. CT was performed showing segmental circumferencial thickening of a loop of ileum without perienteric stranding and lymphadenopathies. Remainder of the large and small bowel including terminal ileum was identified normal. The patient received a transfusion prior to upper and lower endoscopy.

Esophagogastroduodenoscopy was normal except mild gastritis. Colonsocopy didn’t reveal active bleeding or abnormalities in the colon. No bleeding was noted in the terminal ileum. Subsequently, he underwent technetium labeled red blood cell scan and no focus of active bleeding identified.

Given the CT findings and endoscopic workup, the patient underwent diagnostic laparoscopy and intraoperatively an 8 cm section of the mid-ileum was found distended distinctly from the surrounding bowel and it was resected with the feeding mesentery with a 5 cm margin. Histologic examination showed multiple endothelium lined cystic spaces and associated smooth muscle fibers consistent with a lymphangiomatous lesion.

Discussion: Lymphangiomas in the jejunum or ileum are extremely rare and surgery can be necessary when bleeding is not controlled by gastroenteroscopy. To avoid recurrence, laparoscopic segmental bowel resection is an optimal approach.


Weekday or Weekend Hospital Admission: Does it Matter for Acute Care Surgery?

Ibrahim Albabtain1, Roaa Alsuhaibani 1, Sami Almalki1, Nada Alhassan2, Hassan Arishi1, Hatim Alsulaim1; 1King Abdulaziz Medical City, 2King Saud bin Abdulaziz University for Health Sciences

Introduction: During weekends, hospitals usually reduce their staffing levels and services. This might result in decreased quality of healthcare or so-called the weekend effect. In this study, we aimed to determine the impact weekends on two common emergency general surgeries and their outcomes, in terms of day of operation and admission.

Methods and Procedures: This retrospective cohort study was conducted at a tertiary care hospital between January and December 2016. Surgical procedures included were cholecystectomy and appendectomy. Patients’ demographic, co-morbidities, admission date, surgery date, complications, readmission and follow-up details were collected from the electronic medical records. Post-operative outcomes associated with weekend admission were identified by multivariable analysis using univariable and multivariable logistic regression models controlling for potential confounders.

Results: A total of 539 patients were included. Median age for weekday admissions was 31 years (IQR: 22, 45), and 32 years (IQR: 23, 49.75) for weekend admissions. The majority of patients were admitted during weekdays (n = 391). No significant difference was found in the type of surgery performed between weekday and weekend admissions (p value 0.384). Surgeries tend to be delayed by a median of one day for weekend admissions compared to weekdays with similar overall length of stay for both groups. Weekend admissions were associated with higher complication rates compared with weekday admissions (12.2% vs. 6.1%). Regarding the day of surgery, 444 surgeries were performed during weekdays while 86 surgeries were performed during weekends. Patients who were operated on weekends were younger in age compared with weekdays (32 vs. 30 years old, p-value 0.019). The percentage of female patients undergoing surgery during weekends was lower compared with weekdays (40.7% vs. 53.8%). Both groups had similar complication rates (7.7 in weekdays vs. 9.3% in weekends, p-value .605). During weekends, appendectomies were performed more (77.9% vs. 45.9%), and less cholecystectomies were performed (22.1% vs. 54.1%, p-value 0.000).

Conclusions: Patients admitted on weekends tended to have their surgeries delayed by one day, with more complication rates. Patient operated on over weekends were younger and less likely to be females. Appendectomy was the most common performed surgery over the weekend.


Massive Splenic Infarction from Hypoperfusion

Nancy Panko, MD, Seeyuen Lee, MD, Melissa Boyle, MD, Phillip Leggett, MD; Houston Northwest Medical Center

Introduction: Massive splenic infarction (MSI) due to hypoperfusion is rare, with only one source documenting MSI from hypoperfusion in a patient with septic shock. We report a case of MSI managed with laparoscopic splenectomy three weeks after an exploratory laparotomy performed for control of a bleeding duodenal ulcer.

Case: Patient is a 28 year old man who presented with rectal bleeding. He underwent imaging but then sustained cardiac arrest due to hypovolemia. He responded to resuscitation and vasopressors, and then surgery was consulted for evaluation. We attempted endoscopic management of a bleeding duodenal ulcer with arterial hemorrhage. The ulcer was injected and clipped without success. The patient was then taken emergently for exploratory laparotomy with duodenotomy and ligation of the gastroduodenal artery. A drain was left adjacent to the duodenotomy and feeding jejunostomy was placed. The patient was extubated after definitive abdominal closure on post-operative day two. He received over 30 units of blood products in the first 24 hours.

Post-operatively, the patient had shock liver, acute renal failure requiring hemodialysis, and VTE. He developed fever 10 days postoperatively, and work up was initiated with no significant source. CT of the abdomen and pelvis was performed (Figure 2). The spleen was noted be significantly enlarged without evidence of perfusion. No other abnormalities were noted.

The patient was counseled that splenic infarction was likely the source of his fever. He was initially asymptomatic, but then developed abdominal pain and anorexia. This did not improve with conservative measures and he agreed to surgery.

Patient underwent uneventful laparoscopic splenectomy on postoperative day 24. Pathology showed marked splenic necrosis.

He recovered uneventfully, and was seen in clinic with no additional complaints.

Discussion: MSI is a rare occurrence, with less than twenty documented cases. The majority of these cases occurred secondary to blood disorders or coagulopathies, malignancy, infection, and organ transplant. Only one other case has been reported linking MSI to hypoperfusion and shock. This was attributed to both hypoperfusion as a result of septic shock as well as hypercoaguability related to the inflammatory response.

Splenic preservation is preferred in most cases of splenic injury, to preserve immune function. Splenectomy is reserved for patients with refractory abdominal pain, hemorrhage, abscess, or pseudocyst. In our case, the patient had significant abdominal pain, and requested operative management after a trial of conservative therapy. We were able to perform his splenectomy laparoscopically, which further sped his recovery.


Laparoscopic Management of Large Ruptured Subcapsular Liver Hematoma After Laparoscopic Cholecystectomy

Justin D Sargent, DO, Steven P Shikiar, MD; Hackensack Meridian Health Palisades

Introduction: Laparoscopic cholecystectomy has become the standard of care for symptomatic biliary disease due to its minimally invasive nature and low complication rate. Here we present a rare complication of a large ruptured subcapsular liver hematoma and its successful management with laparoscopic control of the hepatic hemorrhage.

Case Report: An 18-year-old female presented with a 9 day history of epigastric and RUQ abdominal pain with daily episodes of emesis. Pain was initially colicky but became constant. Patient was initially evaluated at an outside hospital with abdominopelvic ultrasound, HIDA and EGD. U/S showed acute cholecystitis with gallstones, wall thickening, and pericholecystic fluid. HIDA showed normal filling with decreased ejection fraction. Endoscopy showed a grossly normal stomach and duodenum without signs of gastritis/ulcers. Patient refused cholecystectomy at that time but returned to our hospital and was taken to the operating room for diagnostic laparoscopy.

Intraoperatively her liver and bowel appeared normal. Her gallbladder was grossly distended. A cholecystectomy was performed in the standard fashion without difficulty. Hemostasis of the GB fossa was noted at the end of the case.

On POD#1 she had a vasovagal syncopal episode when standing. HGB dropped from 16 to 10 and a leukocytosis of 39 k was noted. Abdominal U/S was performed and showed significant simple RUQ fluid. Three hours later hemoglobin of 7.5 was noted. She remained HD stable. Tachycardia continued to worsen and she was taken to the OR for diagnostic laparoscopy.

Intraoperatively a large subcapsular liver hematoma over the superior surface of the right dome of the liver was noted with a free rupture of Glisson’s capsule at the anterior margin of the liver. 1.4 L of hemoperitoneum was evacuated. The liver and abdomen were thoroughly inspected and the majority of the liver capsule was intact. A stable clot was noted under the capsule and left in place. Several small areas of oozing were noted and the free edge of the capsule was packed with surgicel and floseal. No active bleeding was noted at the end of the case. Intraoperatively she received 3 u pRBC and FFP.

She had an uneventful post-operative course. After discharge she received a CT scan revealing no sequelae from her surgeries.

Discussion: Exploration of the postoperative patient displaying signs and symptoms of hemorrhage is always indicated. Minimally invasive methods to evaluate and control hemorrhage can be safely used in select cases with a low threshold to convert to open technique.


Case Series of Seventeen Patients with Acute Appendicitis in Pregnancy: Management Algorithm and Laparoscopic Approach

Georges Abizeid, Hager Aref, Obada Alhallak; International Medical Center

Introduction: Acute appendicitis (AA) is the most common general surgical problem encountered during pregnancy, affecting 1 in 500 to 1 in 2000 pregnancies. Emergency Department, General Surgery, and Obstetric physicians will face this challenging situation of abdominal pain in a pregnant woman suspected of AA especially in diagnosis, management, and surgical approach.

Objectives: First, to report our experience of operated pregnant patients for AA; Second, to propose an algorithm to facilitate the optimal management. Third, to suggest strongly, after analysis of the results of this series and review of literature that Laparoscopic appendectomy (LA) is considered as the “new standard of care”.

Methods: Between November 2013 and January 2018, seventeen patients diagnosed with AA, who underwent LA (N = 17) were included in this study. Data collection and details were reviewed retrospectively based on medical records.

Results: Retrospective analysis of 17 consecutive cases of suspected AA during pregnancy was carried out. (Nov. 2013 - January 2018). Patients were in their first (35%), second (53%) and third trimesters (12%). The average gestational age was 17.5 weeks [5-27]. All patients had preoperative Ultrasound with (54%) accuracy, non-conclusive in 7 cases. MRI done for six of these seven patients confirmed the diagnosis of AA in 5 patients (84%). All patients were operated laparoscopically, no conversion done. Negative appendectomy rate was (6%). Postoperative complications were (6%) with paralytic ileus treated conservatively. No obstetrical or fetal complications found. No differences were observed between trimesters in terms of clinical presentation and outcome except for operative technical modifications.

Conclusion: Acute appendicitis in pregnancy is a clinically challenging situation that often cannot be faced without the aid of radiological investigations. Ultrasound and Magnetic Resonance Imaging may help to avoid late diagnosis and contribute to decreasing the rate of negative appendectomy. Operating with no delay will reduce the appendicular perforation and the feto-maternal complications. Laparoscopic appendectomy in pregnancy is the standard of care, regardless of the trimester.


Multi-Modal Minimally Invasive Approach to Boerhaave’s Syndrome: A Case Report

Kalyan Gorantla, MD, MBA, Seeyuen Lee, MD, MPH; University of Texas at Houston/Houston Northwest Medical Center

Background: Boerhaave’s syndrome, or effort rupture of the esophagus, is a life-threatening emergency and fatal if left untreated. It is associated with high morbidity and mortality often due to a delay in diagnosis. Given the critical nature of the disease, prompt surgical management is recommended. The management traditionally involved controlling sepsis with laparotomy, thoracotomy, or both to repair the site of esophageal perforation and mediastinal debridement/drainage. Since esophageal perforations, and specifically Boerhaave’s syndrome, are uncommon, ideal management guidelines have not been standardized. The authors present a case where a multi-modal minimally invasive approach was used to address the problem of Boerhaave’s syndrome.

Methods: Initial experience of managing Boerhaave’s syndrome in a multidisciplinary manner using laparoscopic, thoracoscopic (VATS), and endoscopic techniques is reported.

Results: Emergent laparoscopic Nissen fundoplication with transabdominal drainage of mediastinum and feeding jejunostomy was utilized to initially treat a patient with Boerhaave’s syndrome. VATS was subsequently utilized to treat a left-sided pleural effusion and empyema. A persistent leak was then managed endoscopically with an esophageal stent. The patient recovered, the stent was removed, and the patient was discharged by hospital day 24. At 8 weeks follow-up, the patient developed symptoms of dysphagia due to an esophageal stricture. The patient underwent endoscopic balloon dilation of the stricture. At 3 month follow-up, the patient was tolerating a diet and gaining weight with no signs of dysphagia.

Conclusion: A multi-modal minimally invasive approach to treating Boerhaave’s syndrome is feasible. Using a combination of laparoscopic, thoracoscopic, and endoscopic approaches can potentially mitigate the morbidity and mortality of open esophageal surgery. Further studies need to be conducted to evaluate and potentially standardize approaches to treating Boerhaave’s syndrome incorporating minimally invasive techniques.


Intraoperative Findings and the Diagnosis of Complicated Appendicitis. It is not What You Think

Luis R Taveras, MD, Omar Harirah, BS, Dang-Huy Do, BA, Folarin M Adeyemi, BS, Maryanne L Pickett, MD, Holly B Cunningham, MD, Jonathan B Imran, MD, Tarik D Madni, MD, MBA, Meaghan M Colletti, John Kubasiak, MD, Michael W Cripps, MD, MSCS; University of Texas Southwestern

Introduction: The objective of this study is to evaluate the relationship between intraoperative (IO) findings and the diagnosis of complicated appendicitis (CA). Postoperative management of these patients is highly dependent on the operative findings. Furthermore, IO assessment is a strong prognostic predictor of clinical outcomes.

Methods: A multicenter cross-sectional study surveyed all surgeons performing emergent laparoscopic appendectomies from September 2017 to September 2018. The survey collected information regarding disease severity, case complexity, and IO findings. General demographics, preoperative parameters, operative details, and histopathological (HP) descriptions were collected for all cases. Descriptive statistics were compared using Chi square and t-test where appropriate. Significance was set at p < 0.05 with a two-tailed distribution. Predictors of a diagnosis of CA were evaluated using a multivariable regression model.

Results: Twelve surgeons completed surveys for 263 patients, of which 57.9% were male and median age was 33 years old (IQR 24.5-43). Respondents rated case difficulty, on a Likert-type scale, with a median score of 2 out of 5 (IQR 1-3). Conversion to open rate was 0.004%. The most common IO finding was hyperemia (45.63%). Median OR time was 49 (IQR 39-64.5) minutes. An IO diagnosis of CA was made in 12.55% of cases, while 4.56% were reported as complicated by HP. IO diagnosis has a sensitivity of 75% (CI 95% 50.9%, 91.34%), specificity of 81.59% (CI 95% 76.08%, 86.29%) and accuracy of 81.08% (CI 95% 75.77,85.66).

Cohorts were divided by HP diagnosis. Those with CA had higher creatinine (0.86 vs 0.77, p = 0.031), higher heart rates (96.76 vs 85.32, p = 0.007), increased rate of appendicolith on imaging (55.56% vs 31.14%, p = 0.034) and larger appendix diameter (millimeters) on imaging (14.11 vs 11.38, p < 0.001).

Operative findings predictive of IO diagnosis were abscess (33.312, 2.270-488.879, p = 0.011), necrotic appendiceal wall (OR 13.71, 95% CI 2.148-87.497, p = 0.006) and purulent fluid (OR 7.703, 1.902-31.204, p = 0.004). While the findings that correlated with a HP diagnosis were gross perforation (OR 14.381, 95% CI 3.232-63.992, p < 0.001) and areas of necrosis (OR 5.36, 95% CI 1.249-23.039, p = 0.02), neither presence of purulent fluid or abscess was predictive for HP diagnosis.

Conclusion: Intraoperative findings of abscess and purulent fluid have a significant weight in the IO diagnosis of CA but do not correlate with a HP diagnosis. These findings start to explain the dichotomy between IO and HP diagnosis.


The Impact of a Dedicated Emergency Surgery and Trauma Team on Appendicitis Outcomes

Sabrina Cheok Hx, Dr, Serene Goh Sn, Woan Wui Lim, Anil Rao Dinkar, Kok Yang Tan, Jerry Goo Tt; Department of General Surgery, Khoo Teck Puat Hospital

Introduction: The Emergency Surgery and Trauma (ESAT) is a consultant led service to streamline emergency and elective workloads. As appendicectomy is one of the commonest emergency surgeries performed, we aim to compare outcomes of patients with appendicitis in the ESAT model as compared to the traditional on-call model.

Methods: We conducted a retrospective review of patients admitted to KTPH between two 6-month time periods: May–October 2014 (6 months pre-ESAT) vs January–June 2018 (post-ESAT) Patient demographics, diagnoses, and operations were compared. Efficiency, clinical outcomes and hospital bill savings were evaluated.

Results: There were 179 patients in the pre-ESAT period and 167 patients in the post-ESAT period. Patient demographics and comorbidities were comparable: mean age was 38.6 ? 15.8, majority were males (63.9%) and mean Charlson’s comorbidity index was 0.08. In the post-ESAT period patients had longer duration of symptoms 2.0 ? 1.8 days vs 1.8 ? 1.6 days (p = 0.08). There were more perforated appendixes in the post-ESAT period 25.8% vs pre-ESAT period 20.1% (p = 0.221). Majority underwent laparoscopic appendicectomy 85% (pre-ESAT) vs 89.3%. More patients in pre-ESAT period had conversion to open or open appendicectomy (p = 0.05). The remainder had antibiotics or percutaneous drainage for appendiceal abscesses. There were lower surgical complications 7.8% vs 9.5% in post-ESAT period (p = 0.02), shorter length of stay 2.5 ? 2.0 days vs 2.7 ? 2.9 (p = 0.07) and higher supervision rates during surgery in the post-ESAT period(p = 0.01). The hospital bill sizes were comparable (p = 0.475).

Conclusion: The ESAT service has improved outcomes of patients with appendicitis without increased costs.


Does Peritoneal Irrigation Reduce Postoperative Intra-abdominal Abscess Rates After Laparoscopic Appendectomy?

Kevin Bain, DO 1, Derek Lim1, Andrew Lelchuk, DO2, Vadim Meytes, DO3; 1NYU Langone Hospital - Brooklyn, 2Nova Southeastern University College of Osteopathic Medicine, 3Vassar Brothers Medical Center

Introduction: Intra-abdominal abscess (IAA) after laparoscopic appendectomy (LA) is a major cause of morbidity, can prolong hospitalization, and can increase hospital costs. Risk factors include diabetes mellitus, obesity, age, and perforated appendicitis.

Case Report: 15 year old female with 3 days of right-sided abdominal pain. A CT scan demonstrated perforated appendicitis, and the patient was taken for diagnostic laparoscopy. About 500 milliliters of pus was evacuated from the peritoneal cavity. A perforated appendix was visualized and removed in the normal fashion. Irrigation with 3 L of normal saline (NS) was performed.

Postoperatively, the patient continued intravenous antibiotics. She persisted to have an uprising leukocytosis to 13.0 K/uL on postoperative day 5. Further imaging demonstrated multiple intra-abdominal abscesses. Interventional radiology performed transgluteal drainage, with placement of a pigtail catheter. The patient was discharged home on antibiotics, with the catheter in place.

Discussion: Postoperative IAA after LA remains a debated topic. Studies have shown as high as a 20% abscess formation rate status post appendectomy for perforated appendicitis. Debate still remains between irrigation versus suction alone. The theory behind irrigation is dilution of bacterial concentration. Others believe irrigation actually spreads contamination, and dilutes immune system mediators.

In 2008, Hussain et al. described a prospective study of 283 patients with acute appendicitis. Their technique to reduce postoperative IAA included irrigating all four quadrants of the peritoneal cavity with 3 L of NS. No patients developed postoperative IAA, and they concluded that copious irrigation and drainage significantly decreased the rate of postoperative IAA.

In 2015, Cho et al. performed a retrospective cohort study to examine risk factors for postoperative IAA after LA, and concluded the exact opposite. They analyzed 1,817 LA and the only difference was that “peritoneal irrigation was performed significantly more often in the IAA group than in the non-IAA group (p < 0.001).” They concluded that peritoneal irrigation increased the incidence of postoperative IAA.

More recently, in 2016 Snow et al. published the first prospective, randomized controlled trial (RCT) in adults comparing irrigation versus suction alone during LA. In 81 patients, they found “the rate of IAA was equivalent between groups treated with peritoneal irrigation and suction alone.” This conclusion coincides with the only other prospectively conducted RCT on this topic, which was conducted in children.

Conclusion: There remains to be limited high-quality prospective studies to compare peritoneal irrigation to suction alone for preventing IAA after LA.


Case Report: An Unusual Case of Acute Appendicitis - Cecal Endometriosis

Romina Deldar, MD1, Chaitanya Vadlamudi, MD 1, Gao L Chen, MD2; 1Georgetown University Hospital, 2Kaiser Permanente, Mid-Atlantic States

Introduction: Acute appendicitis can arise from many etiologies. We present a case of acute appendicitis that was radiographically suspicious for appendiceal mucocele. However, final pathology revealed luminal obstruction secondary to cecal endometriosis. Cecal endometriosis is exceedingly rare, and only a few case reports describe this as a cause of appendicitis.

Methods and Procedure: A healthy 33-year-old woman with no prior gynecologic history presented on day five of her menstrual cycle with 48-hours of right lower quadrant abdominal pain, nausea, emesis, and leukocytosis of 13,900/mm3. Computed tomography (CT) of the abdomen revealed a 10-centimeter, distended and fluid-filled appendix, suspicious for mucocele (Figure 1). As clinical and radiographic evidence was consistent with acute appendicitis, the patient was taken for laparoscopic appendectomy. Intraoperatively, the appendix was noted to be massively dilated and associated with a firm cecal mass just beyond the appendiceal base. These findings raised suspicion for appendiceal mucinous neoplasm, therefore the operation was converted to open. A partial cecectomy was performed in addition to appendectomy. The appendix, cecal base, and mesoappendix were removed en bloc with no spillage. No mucinous deposits or other abnormalities were identified. The patient tolerated the procedure well and was discharged home on post-operative day one.

Figure 1. CT axial view showing dilated fluid-filled appendix.

Results: Three independent pathologists reviewed the specimens and found no evidence of an appendiceal mucinous neoplasm. Fluid within the appendiceal lumen did not stain positive for mucin. The specimen was consistent with acute appendicitis without evidence of malignancy. Interestingly, the cecum at the appendiceal base was noted to contain endometrial glands with surrounding stromal tissue in the muscularis propria, consistent with endometriosis (Figure 2). During menses, increased inflammation and tissue edema of the endometrial tissue positioned at the appendiceal base may have led to luminal obstruction and subsequent acute appendicitis. The patient had no other symptoms of endometriosis.

Figure 2. Focus of endometriosis in the muscularis propria (MP) of the cecum. Endometrial gland (E) and surrounding stromal tissue (S). Hematoxylin and eosin stain, ×100.

Conclusion: Cystic dilatation of the appendix can result from luminal obstruction secondary to a wide spectrum of benign or neoplastic causes. Clinically suspicious appendiceal mucocele should be resected intact to prevent mucinous deposits from seeding the abdomen and causing pseudomyxoma peritonei. Pathologic examination can reveal an unexpected diagnosis. This case simultaneously highlights an unusual presentation of endometriosis and an extraordinarily rare etiology of acute appendicitis.


Case of Intussusception after Roux-en-Y gastric Bypass

Ahmed Abdelhady, MD, FACS, MRCSeng, MRCSglas, MSC, Mohamed Elkady, FRCS, Ire, Ghaleb Aboalsamh, MBBS, SBGS, MSC; National Guard Health Affairs Saudi Arabia

The patient was a 46 year-old female who presented to the emergency room with a sudden severe abdominal pain as well as nausea and vomiting that began the day before after a meal. She is 3 years post retrocolic RYGBP. On examination, the patient was well nourished, afebrile, and with normal vital signs. She was in moderate distress with pain out of proportion to the physical examination. Her abdomen was soft, and there were no signs of peritoneal irritation or distension. Laboratory data were unremarkable. Computed tomography scan revealed a long segment obstructive retrograde small bowel intussusception adjacent to the jejuno-jejunal anastamosis and associated with complete proximal small bowel obestruction. The patient was immediately taken to the operating room.


Is The Risk of Venous Thromboembolic Event (VTE) Higher In Emergency General Surgery? Results From The National Surgical Quality Improvement Program (NSQIP)

Samuel W Ross, MD, MPH 1, John C Kubasiak, MD2, Lindsey P Mossler, MD3, Luis R Taveras, MD2, Thomas H Shoultz, MD2, Herbert A Phelan, MD2, Michael W Cripps, MD21Carolinas Medical Center, 2University of Texas Southwestern Medical Center, 3University of Indiana School of Medicine

Introduction: Trauma patients have an increased risk of VTE partly due to increased inflammation, and, therefore, are recommended to have increased VTE chemoprophylaxis dosing. A similar inflammatory physiology occurs in the patients with Emergency General Surgery (EGS) operative pathology, however, it is not well studied if this process leads to an increased VTE risk in this population. We hypothesized that EGS cases have a higher risk of VTE than their elective counterparts.

Methods: The American College of Surgeons NSQIP database was queried from 2005-2016 for all open and laparoscopic cholecystectomies (OC and LC), ventral hernia repairs (OVHR and LVHR), and partial colectomies (OPC and LPC) to give a sample of commonly encountered EGS procedures that have elective counterparts. Elective surgeries were then compared to emergent ones using univariate statistics with VTE at 30 days being the primary outcome. A multivariate analysis controlling for age, gender, BMI, cancer, bleeding disorders, pregnancy, surgery type, and open status was then performed.

Results: There were 604,537 surgeries over 12 years: 285,847 cholecystectomies (12.7% OC vs. 87.3% LC); 158,500 VHR (79.8% OVHR vs. 20.2% LVHR); and 160,190 partial colectomies (61.3% OPC and 38.7% LPC). There were 4,607 (0.8%) patients with DVT and 2,648 (0.4%) with PE, and a total 6,624 (1.1%) patients with VTE. Patients with emergent surgery were more likely to be younger, male, lower BMI, and have higher white blood counts and lower albumin (p < 0.001 for all). Patient outcomes by emergent status are displayed in Table 1. When VTE risk was examined by open versus laparoscopic surgery, as expected, VTE risk increased with invasiveness (2.0 vs 0.3% for all; 2.3 vs. 0.3% for cholecystectomy, 1.0 vs. 0.4% for VHR, and 3.2 vs. 1.2% for partial colectomy; p < 0.001 for all). On multivariate analysis, emergent surgery was an independent predictor of VTE (OR 1.8; 95% CI 1.4-2.2), with almost twice the odds of VTE as elective surgery. As was open surgery (2.7, 2.0-3.5) with almost three times the risk of VTE when controlling for emergent status. Additionally, more extensive surgeries had higher VTE odds when compared to cholecystectomy; VHR (1.8, 1.4-2.4) and partial colectomy (3.1, 2.4-4.0).

Conclusion: Emergent surgery was an independent predictor of VTE when compared to their elective counterparts. Given this increased risk, higher dosing and earlier VTE chemoprophylaxis should be considered in emergent and more extensive operations, especially when performed open, to reduce the risk of potentially lethal VTE.


Peritoneal Adhesions Seen During Laparoscopic Appendicectomy Post Prior Pelvic Floor Surgery

Pravish Rai Sookha, MD, MS, PhD; Welkin hospital, Clinic Muller, Clinic du Nord

During the last 226 adult female appendicectomies, 55 were found to have underwent prior open pelvis floor surgeries. The most common surgeries included LSCS, ovarian cystectomy, salpingo-oophrectomy and endometriosis. Due to prior open surgery scars, all the surgeries were started with the Hasson’s method. Out of the 55 cases peritoneal adhesions affecting the surgery were seen in 28 cases, while in the rest either very minimal or no adhesions were seen. The pelvic surgeries were further divided in 2 classes – LSCS (20 cases) – The rest 35 cases. LSCS had 6 cases of adhesions of out 20 surgeries whereas in the other group 22 cases had adhesions out of 35 surgeries.

Results: In our cohort 51% of cases after open pelvic surgery presented with adhesions. All cases of laparoscopic appendicectomy were completed laparoscopically after careful dissection of adhesions.

Conclusions: Adhesions due to prior surgery are not a contraindication for laparoscopic surgery. Adhesions after pelvic surgeries are more common after emergency surgeries than after LSCS.


Laparoscopic Repair with ERAS Pathway for Perforated Duodenal Ulcer

Yoshihito Shinohara, MD; Teinekeijinkai Medical Center

Background: Several studies have shown that, when compared with a conventional perioperative care, Enhanced recovery after surgery (ERAS) pathway was associated with a reduction in the length of hospital stay and rates of complication. Whether such a program is a feasible and beneficial in the setting of emergency ulcer surgery remains unknown.

Methods: This single-center, retrospective case-series study. From January 2005 to April 2017, 98 patients with Perforated Duodenal Ulcer (PDU) underwent laparoscopic repair with simple closure with omentopexy or Graham patch repair. Patients who underwent open surgical repair or standard care were excluded. The Primary outcomes were the length of hospital stay (LOS), morbidity and mortality within 30 days after surgery. The secondary outcomes measured included various functional recovery parameter as individual components of the ERAS protocol. Data were collected retrospectively to assess the efficacy of the ERAS protocol and included all patients undergoing LR. All data analysis.

Results: A total of 110 patients were diagnosed with PDU during the study period. 98 patients were initially performed laparoscopic approach. 88 patients (90%) performed laparoscopic repair (LR). LR included laparoscopic simple suture repair with omentopexy (n = 73) and Graham omental patch (n = 15). 82 patients were adapted ERAS pathway. The reasons for non-adaptation to 6 patients (6%), the required vasopressor for intraoperative shock (n = 1), the required ventilator for respiratory failure (n = 1), elderly patient with large perforation (n = 1), delirium immediately after operation (n = 2), and ileus (n = 1). Median of LOS was 4 days (quartile range: 4 -5). There was no 30-d mortality and readmission. There was one case above grade3 of the Clavien-Dindo classification because of leakage with percutaneous drainage. There was no reoperation. Median of solid diet was 2 days (quartile range: 2 -2). The overall compliance of ERAS protocol was 61% (50 cases). The variances show in Table 4 which of the prolong of NPO (n = 15:NG tube n = 5, pain and abdominal distension n = 5, suspect of leakage n = 4), prolong of LOS (n = 13: delayed diet n = 4, SSI n = 1, patients hope n = 1, no known reasons n = 7), and delayed drain removing (n = 2: suspect of abscess n = 2).

Conclusions: In conclusion, ERAS pathways seem safe and feasible for patients undergoing LGPR for PDU. In addition, ERSA pathway with LGPR for PDU make it possible to improve the early oral intake and discharge. It may be possible to early return to society for patients and to reduce health care costs.


A Review of Management of Hernias Containing the Vermiform Appendix

Kevin Bain, DO 1, Nicholas Morin, DO1, Vadim Meytes, DO2, Michael Nicoara, DO1, Galina Glinik, MD1; 1NYU Langone Hospital - Brooklyn, 2Vassar Brothers Medical Center

Introduction: Hernias involving the appendix are unusual and are often found during surgical exploration. Only approximately 1% of all hernias contain a portion of the vermiform appendix. The rarity of these hernias makes for a difficult discussion on standard of management.

Case report: 33 year old male who presented to the ED with right lower quadrant abdominal pain for ten days, and a CT scan demonstrated acute perforated appendicitis.

During diagnostic laparoscopy, the appendix was visualized herniating through a previously undescribed orifice in the lateral right iliac fossa. The orifice was lateral to the femoral triangle, in the so called “triangle of pain,” which is a “V” shaped area bounded by the iliopubic tract, testicular vessels, and peritoneal fold.

Using laparoscopic technique, the appendix was reduced, and an endoscopic stapler was used to remove the appendix. The hernia was primarily repaired, and surgery was completed in the usual manner.

Discussion: The most commonly described hernia which contains the appendix is the Amyand hernia. This occurs when the appendix becomes trapped within an inguinal hernia sac. The incidence ranges from 0.19% to 1.7%. An Amyand hernia is three times more likely to be seen in childhood due to a persistently patent processus vaginalis.

The next most commonly described is De Garengeot’s hernia. This occurs when the appendix is trapped within a femoral hernia sac, and occurs in approximately 1% of all femoral hernia cases. It differs from the Amyand hernia in that it is more commonly found in females, and follows a bimodal age distribution.

The mechanism by which appendicitis develops within hernias is not fully understood, and is extremely rare with rates ranging from 0.07–0.13%. In these instances, perforation only occurs in approximately 0.1% of the cases. When perforation does occur, there is increased mortality due to the spread of severe peritoneal sepsis.

Therapeutic strategies for these hernias depend on the condition of the appendix. The Losanoff and Basson classification is a management strategy for dealing with Amyand hernias. The Rikki modification adds to this in dealing with incisional hernias. The general principle shared between the two is that for a non-inflamed appendix, the patient should have hernia repair without appendectomy. When an acutely inflamed appendix is encountered, appendectomy should be performed and the hernia should be primarily repaired. These principles should be applied to all hernias containing the appendix in order to avoid postoperative complications.


Does Time of Day Matter for Acute Cholecystectomy in an Acute Care Surgery Model?

Ilya Rakitin, MD, Cletus Stanton, MD, Michael Dix, BA, Nathan Ziegler, BA, Jerry Stassinopoulos, MD, MBA, Jeffery Johnson, MD, Nadia Obeid, MD, Nathan Schmoekel, DO; Henry Ford Hospital

Introduction: Prompt cholecystectomy for acute cholecystitis is well accepted; however, whether this warrants urgent nocturnal surgery remains a matter of debate. Differences in available resources, multitasking, and sleep hygiene may affect performance. This could impact conversion rates to open surgery, length of operation, hospital length of stay, and complications such as bile duct injury, blood loss, and major organ injury. Some evidence supports improved outcomes in patients who can avoid after-hour cholecystectomy. We aimed to determine if outcomes changed based on time of day for laparoscopic cholecystectomy. Our null hypothesis is that night time cholecystectomy is associated with worse outcomes.

Methods and Procedures: Retrospective analysis of 486 patients aged ≥ 18 years who underwent cholecystectomy in a large, urban level 1 tertiary care center with a longstanding acute care surgery model. Demographics, procedural information, time of day of surgery, and postoperative outcomes were collected and stratified over a 4-year period from 2013-2017. Sixty five percent of the patients were female with an average age of 49.6 years and an average BMI of 32.7 kg/m2. A total of 230 (47%) patients underwent laparoscopic cholecystectomy for acute cholecystitis. Almost half (45%) underwent nighttime operation defined as procedure start time between the hours of 19:00 to 07:00.

Results: Analysis of the 230 patients with acute cholecystitis revealed an overall conversion rate to open of 14% (n = 32), bile leak (duct of Luschka or cystic) 3.5% (n = 8), 30-day readmission rate of 7.4% (n = 17), and length of stay of 3.9 days. Subgroup analysis of patients having nighttime cholecystectomy for cholecystitis (N = 103) revealed 6.1% conversion to open, 0.9% (n = 2) bile leak, 2.6% (n = 6) 30-day readmission rate, and 3.43 days length of stay. Other outcomes including mortality, cardiac events, pneumonia, stroke, PE, blood loss requiring blood transfusion were not statistically significant. One patient had a common bile duct injury in the daytime group that required conversion to open and hepaticojejunostomy.

Conclusions: Despite prior evidence that favors delaying cholecystectomy until daytime to avoid complications, our study did not support this. We found no difference in outcomes between daytime and nighttime cholecystectomy and conclude that cholecystectomy can safely be performed during any time of the day with similar complication rates. This may reflect the volume of experience in after-hours acute care surgery at this regional referral center.


Is There a “weekend effect” in Patients with Necrotizing Fasciitis: A Nationwide Analysis

Heather Peluso, DO 1, Wesley B Jones, MD1, Marwan S Abougergi, MD2; 1Greenville Health System, 2Catalyst Medical Consulting, LLC

Introduction: We sought to determine the impact of day of admission on treatment outcomes and resource utilization among patients with necrotizing fasciitis in the United States.

Methods: This is a retrospective cohort study using the 2014 National Inpatient Sample. Discharges were included if they had a principal diagnosis of necrotizing fasciitis. Patients < 18 years and non-urgent admissions were excluded. The primary outcome was inpatient mortality. Secondary outcomes were morbidity (sepsis and prolonged mechanical ventilation (PMV)), treatment metrics (time to surgery) and resource utilization (length of stay (LOS) and total hospitalization costs and charges). The following confounders were adjusted for using multivariate regression analysis: patient’s sex, age, race, Charlson comorbidity index, median income in patient’s zip code, hospital urban location, region, teaching status and bedsize.

Results: 3,590 patients were included in the study, 24% of whom were admitted on weekends. The mean age was 53 (52 - 54) years and 42% were Female. Weekend admission was not a predictor of mortality (adjusted odds ratio (aOR):1.29 (0.38-4.33), p = 0.68). Rates of septic shock (aOR: 1.03 (0.51-2.08), p = 0.93) and PMV (aOR: 0.87, (0.39-1.95), p = 0.74) were similar for both groups. Time to surgery (adjusted mean difference (amDiff):1.15 (0.77-1.71) days, p = 0.50) was similar for patients admitted on weekdays and weekends. Furthermore, LOS (amDiff:-1.77 (-4.04-0.50) days, p = 0.13), total hospitalization costs ($-4,788 ($-11,833-$2,256), p = 0.18), and charges (amDiff:$-15,276 ($-44,906-$14,353), p = 0.31) were also similar for both groups.

Conclusion: In-hospital mortality, morbidity, treatment metrics, and resource utilization were not different between patients admitted on weekends and on weekdays. Therefore, day of admission does not affect treatment outcomes or resource utilization among patients with necrotizing fasciitis.

Table 1: Primary and Secondary Outcomes.

Adjusted Odds ratio (95% confidence interval)

P value

In-hospital mortality

1.29 (0.38-4.33)




Septic Shock

1.03 (0.51-2.08)



0.87 (0.39-1.95)



Adjusted Mean Difference *

(95% confidence interval)


Treatment metrics


Time from admission to surgery

1.15 (0.77-1.71) days


Resource Utilization



-1.77 (-4.04-0.50) days


Total costs

$-4,788 ($-11,833-$2,256)


Total charges

$-15,276 ($-44,906-$14,353)



Small Bowel Obstruction and Perforation from Ingested Fish Bone Treated with Laparoscopic Bowel Resection

Justin D Sargent, DO, Steven P Shikiar, MD, John Davis, MD; Hackensack Meridian Health Palisades

Introduction: There is a wide range of variability in presentation for patients whom ingest foreign bodies (IFB). Most commonly patients are asymptomatic as the foreign body passes through the gastrointestinal tract without any complications. Patients may also present with obstruction, hemorrhage or perforation and subsequent sepsis of any part of the alimentary tract from esophagus to anus. When operative intervention is required traditionally exploratory laparotomy is performed. Here we will present a case of perforating and obstructing IFB treated successfully with laparoscopic bowel resection with intracorporeal anastomosis.

Case Description: A 67 year-old male, without previous abdominal complaints, presented to the ER with acute onset severe 10/10 sharp, constant, diffuse abdominal pain with associated nausea that began a few hours prior to arrival. Patient had never had any similar symtpoms. No past abdominal surgeries. Palpation of the abdomen showed diffuse tenderness with rebound tenderness in the lower abdomen. Workup was significant for a leukocytosis of 18,300 and CT imaging showing a focal area of small bowel perforation in the RLQ associated with a linear, radiopaque object in the lumen of the bowel at this level with associated bowel obstruction proximally. Further questioning revealed patient had eaten fish 2 days prior without any recollection of swallowing any bones. NG tube was placed and the patient was placed on empirical IV antibiotics and taken to the operating room.

Diagnostic laparoscopy was performed. A loop of small bowel was identified with a small perforation and associated induration of adjacent mesentery. A thin linear object was identified to be protruding from the lumen. Two healthy areas of adjacent bowel were identified. The mesentery to the bowel was divided. The proximal and distal areas of resection were divided with an endo GIA stapler. An intracorporeal bowel anastomosis was performed with the common channel created with an endo GIA stapler. The common enterotomy was closed with 3-0 vicryl in a running fashion. The specimen was removed in through a Pfannenstiel incision. The specimen was then opened on the back table and visualization of the bowel reveled a small linear fish bone with associated ulceration of the mucosa.

Post-operatively the patient had return of bowel function on POD#2, diet was advanced discharged on POD#3.

Conclusion: Laparoscopic bowel resection with intracorporeal anastomosis can be a viable option in patients requiring small bowel resection for perforating ingested foreign bodies.


Appendiceal Intussusception due to a Mucinous Neoplasm: a Crossroads of Two Rare Conditions

Alyssa Mowrer, MD, Clayton Theleman, MD, Thomas Rossi, MD, FACS; University of Illinois College of Medicine at Peoria

Introduction: Neoplasms of the appendix occur in less than 1% of all appendectomy specimens. Mucoceles of the appendix are mucin filled cystic lesions that are classified as either benign, a cystadenoma, or malignant, a cystadenocarcinoma. Rupture of mucoceles of the appendix is associated with peritoneal tumor implantation and mucinous ascites; a condition known as pseudomyxoma peritonei that carries a median 10-year survival rate of only 63%. Although the medical approach for mucinous neoplasms has been somewhat controversial, the standard of care remains prompt surgical resection.

Case Description: A 49-year-old female presented with 3 days of periumbilical abdominal pain. She described nausea with emesis, decreased bowel function, and an acute weight loss of 10 lb since onset of symptoms. A CT scan demonstrated appendiceal intussusception.

Figure 1Dilated, fluid filled, blind ending structure measuring 4 cm in diameter consistent with the appendix.

The patient was then taken to the operating room for resection. Due to the high clinical suspicion for an appendiceal tumor and significant risk of pseudomyxoma peritonei with rupture of an appendiceal mucocele, an open approach to a right hemicolectomy was planned. A firm mass palpated within the cecum at the base of the appendix was found to be inspissated mucin from the tumor. The specimen was removed intact.

Figure 2Surgical specimen including appendix and right colon with intussusception of appendiceal base into cecum.

Final pathology was consistent with a low grade appendiceal mucinous neoplasm that extended through the muscularis propria and into peri-appendicular tissue.

Figure 3 : Tumor with mild cytologic atypia. Cellular mucin goblets extruding into appendiceal lumen. Histologic grade 1 (well differentiated) and stage T3N0M0.

Discussion: This case of a suspected mucocele of the appendix was complicated by the presentation of appendiceal intussusception. With a devastating possible complication of rupture of the appendiceal mucocele seeding the peritoneum and progressing to pseudomyxoma peritonei, we elected to perform an open approach. Although there have been case reports discussing endoscopic reduction of an appendiceal intussusception, this patient presented with partial obstructive symptoms which contributed to the decision for first line intervention with operative management.

At this point, there is limited information in the literature involving the extremely rare combination of an appendiceal mucocele with the clinical presentation of an obstruction at an intussuscepted appendix. We hope to contribute to the growing body of literature to provide the general surgeon with recommended guidelines when presented with this unusual clinical scenario.


Gastrointestinal Stromal Tumor of the Appendix with associated Mucocele Mimicking Acute Perforated Appendicitis Treated with Laparoscopic Appendectomy

Elizabeth A Verrico, DO 1, Justin Sargent, DO1, Lindsay Tse, DO2, German Costa, MD1, Steven Shikiar, MD1; 1Hackensack Meridian Health Palisades Medical Center, 2Houston Methodist Hospital

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of the gastrointestinal tract and most often present in the stomach and small bowel although they may also present in the large bowel or esophagus. GIST of the vermiform appendix, however, is extremely rare, and represents < 1% of all GISTs.

This is a case of a 54-year-old male who presented with acute right lower quadrant abdominal pain with associated nausea. His medical history was only significant for hypertension and his surgical history included a laparoscopic right inguinal hernia repair. On physical exam he was tender in the right lower quadrant and suprapubic region with mild localized guarding without generalized peritoneal signs. Laboratory results were only significant for a mildly elevated white blood cell count. CT was performed and demonstrated an inflamed appendix with periappendiceal inflammatory change and a 2.3 × 4 cm rim enhancing fluid collection consistent with perforated appendicitis. The patient was given a course of intravenous antibiotics and taken to the operating room for laparoscopic appendectomy. Significant inflammation was noted in the right lower quadrant with mild peri-appendiceal adhesions and fluid. Successful laparoscopic appendiceal resection was completed. Post-operative course was unremarkable. Pathology revealed focal spindle cell proliferation at the distal portion of the appendix positive for CD 117 and CD 34, consistent with GIST, and focal mild luminal distention with luminal mucoid material and extravasation into the wall/periappendiceal tissue consistent with mucocele.

GIST of the vermiform appendix is infrequently reported in the literature with varying presentations from incidental diagnosis during surgery for another pathology or at autopsy, to signs and symptoms similar to acute appendicitis. Due to the variability of presentation and the uncommon pathological finding of GIST of the appendix, it is very difficult to diagnose in the preoperative period. Although rare, obstruction of the appendiceal lumen can lead to secondary inflammation and thus acute appendicitis-like symptoms. Therefore, appendiceal GIST should be considered in patients presenting with acute right lower quadrant abdominal pain, especially if imaging findings are concerning for possible mass of the appendix. Appendectomy should be performed in order to obtain appropriate pathological examination including immunohistochemical staining and evaluation of malignant potential so that treatment can be tailored on an individual basis.


Laparoscopic Treatment of Perforated Stump Appendicitis – A Case Report and Review of the Literature

Arthur Berg, Elizabeth Verrico, Jenna Gillen, Steven Shikiar, General Surgeon, John Davis, Program Director; Hackensack Meridian Health Center

Introduction: Stump appendicitis is a rare post-operative complication, with an incidence reported in the literature around 1 in 50,000 cases. It poses a diagnostic challenge and can mimic benign non-surgical causes of abdominal pain. Our patient presented with perforated stump appendicitis seen on CT imaging which was treated laparoscopically. A significant majority of cases in the literature have completion appendectomies performed in the open fashion. We discuss our successful laparoscopic approach as well as review management and risk factors of stump appendicitis in the literature.

Case Report: Our patient is a 22-year-old female with past medical history of Laparoscopic Appendectomy in the year prior presenting with sharp right lower quadrant abdominal pain. Of note, she had two readmissions for stump appendicitis in a span of 6 months since her appendectomy however elected for non-operative management. She was found to have perforated stump appendicitis on CT and intra-operatively was found to have purulent peritonitis. Partial cecectomy was performed including the segment of stump appendix. She did well post-operatively and was discharged on POD 3.

Discussion: Stump appendicitis is a rare post-operative complication with an incidence reported in the literature around 1 in 50,000 cases. The incidience of stump appendicitis is rising likely secondary to increased used of laparoscopy and the lack of tactile sensation while feeling for an appendiceal stump. Other risk factors include anatomical variations, presence of faecolith, and stump length greater than 5 mm. Aside from stump appendicitis, another danger of a long residual stump is the risk of harboring a small bowel cancer or carcinoid. The possibility of a duplicated appendix must be ruled out as well.

A large majority of cases in the literature have completion appendectomies performed in the open fashion. In our case, laparoscopy allowed us to have a global inspection of the abdomen while avoiding the need for a laparotomy incision or ileocolic resection, however there are no long-term studies on the outcomes between laparoscopic and open approaches.

Conclusion: Stump appendicitis is a rare post-operative complication of laparoscopic appendectomy. Given that it can mimic non-surgical causes of abdominal pain and its incidence is on the rise, a high index of suspicion is needed by clinicians to make an accurate diagnosis. The surgical management of perforated stump appendicitis is underreported in the literature and typically performed in an open fashion. We report a successful case of laparoscopic completion appendectomy of perforated stump appendicitis.


The Strengths and Limitations of Image-Based Anatomic Severity for Acute Appendicitis in the Japanese Healthcare System

Masakazu Fujii 1, Yusuke Watanabe, MD2, Chisato Ichimaru, MD1, Shintaro Takeuchi, MD1, Kiyotaka Imamura, MD1, Kentaro Katou, MD1, Yoshihiro Kinoshita, MD1, Minoru Takada, MD1, Yoshiyasu Anbo, MD1, Fumitaka Nakamura, MD11Department of Surgery, Teine Keijinkai Medical Center, 2Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine

Introduction: Validity evidence of the American Association for the Surgery of Trauma (AAST) grading system for appendicitis has been reported in the US and South America. We evaluated whether the preoperative AAST severity scores correlate with outcomes of appendicitis in the Japanese healthcare system and correspond with intraoperative findings in order to forecast case difficulties.

Methods and Procedures: Patients (≥ 18 years) with a preoperative diagnosis of appendicitis during 2013-2017 in a major teaching hospital were reviewed. The image-based AAST (iAAST) grades were assigned based on CT findings (range 1-5, grade ≥ 3 were defined as perforated appendicitis). Demographics, operative findings, and procedure types were collected. Outcomes including 30-day mortality, complications based on Clavien-Dindo categories, length of stay, and institutional costs were reviewed. Descriptive and univariate analyses were performed to compare iAAST grades with operative findings and clinical outcomes. The correlation of iAAST with intraoperative AAST grades was calculated using a kappa statistic. Malignant cases were excluded from data analysis.

Results: A total of 406 consecutivepatients with a median [IQR] age of 45 [32-63] (range 18-92) were analyzed (46% female). The iAAST grade is as follows: Grade I (115, 28%), Grade ? (46, 11%),Grade ?(144, 36%),Grade ? (58, 14%),and Grade ? (43, 11%). Management included appendectomy (n = 295, 76%), interval appendectomy (n = 36, 9.0%), and conservative management with antibiotics(n = 63, 15%). Operative management consisted of laparoscopic appendectomy (LA; n = 319, 93%), LA with partial cecectomy (n = 13, 3.8%), laparoscopic ileocecal resection(n = 3, 0.9%), and open surgery (n = 8, 2.3%).Among all patients, increased iAAST grade correlated with length of stay (rs = 0.44, p < 0.01) and institutional cost (rs = 0.30, p < 0.01) regardless of management pathways. Of 295 patients with initial operative management performed by surgeons at varying levels of experience [24 surgical trainees (72%), 8 attending surgeons (28%)], the iAAST grade associated with operative time (rs = 0.33, p < 0.01) but didn’t correlate with procedure types. No 30-day mortality was observed, and overall complication rate was 10% (Clavien-Dindo ≥ 2). From operative findings, 29% of the patients with iAAST grade ≤ 2 (n = 121) were diagnosed with perforated appendicitis, and 48% with iAAST grade 3-5(n = 174) were diagnosed with non-perforated appendicitis (kappa coefficient = 0.22, p < 0.01). Perforated appendicitis significantly increased operation time (65[50-85] vs. 102[72-127], p < 0.01) and complication rate (p < 0.01), regardless of level experience.

Conclusions: Although the iAAST grade predicts clinical outcomes in a Japanese population, the preoperative grading has some limitations to forecast intraoperative findings. Better estimations of intraoperative findings may help predict case difficulty to optimize the efficacy of surgical care in teaching hospitals.


Sarcopenia Predicts Postoperative Mortality in Emergency Abdominal Surgery. The Effect is More Significant in Emergency Surgery Compared to Elective Surgery: Meta-analysis and Comparative Cohort Study of Literature

Sheik Rehman, Mr, Shahab Hajibandeh, Mr; Royal Bolton Hospital

Objectives: To investigate the effect of sarcopenia on postoperative mortality in patients undergoing emergency abdominal surgery and to compare postoperative mortality in patients with sarcopenia undergoing emergency abdominal surgery with those undergoing elective abdominal surgery.

Methods: A search of electronic information sources was conducted to identify all observational studies comparing sarcopenia with no sarcopenia in a) emergency abdominal surgery and b) elective abdominal surgery. We also identified the available cohort of patients in the literature with sarcopenia undergoing abdominal surgery and divided the entire cohort into two groups based on exposure to emergency surgery or elective surgery. The primary outcome measure of this study was postoperative 30-day mortality.

Results: Overall, 4 studies, enrolling a total of 734 patients, were eligible for the comparison in emergency setting and 16 studies, enrolling a total of 4590 patients, were eligible for the comparison in elective setting. Sarcopenia is associated with significantly higher risk of 30-day mortality (RR: 2.15, P < 0.0001), 1-year mortality (RR: 1.97, P < 0.0001), total complications (RR: 2.07, P = 0.0008), and need for ICU admission (RR: 1.38, P = 0.003) and significantly longer length of ICU stay (MD: 2.26, P = 0.006) and length of hospital stay (MD: 2.46, P < 0.00001) compared to no sarcopenia in patients undergoing emergency abdominal surgeries. Sarcopenia was also associated with significantly higher risk of 30-day mortality in patients undergoing elective abdominal surgery (RR: 2.15, P = 0.002). Emergency abdominal surgery in patients with sarcopenia was associated with significantly higher risk of 30-day mortality compared to elective surgery (OR: 12.00, P < 0.00001).

Conclusions: Sarcopenia is an independent predictor of postoperative mortality in emergency abdominal surgery.


Conversion from Laparoscopy to Laparotomy in Patients Undergoing Surgery for Small Bowel Obstruction: Does Prior History of SBO or Previous Abdominal Surgery Matter?

Remealle A How, MD 1, Valerie G Sams, MD1, Christopher Corkins, MD1, John C Graybill, MD1, James Aden1, Martin D Zielinski, MD2, Daniel C Cullinane, MD3, Kenji Inaba, MD4, Daniel D Yeh, MD5, Salina Wydo, MD6, David S Turay, MD7, Andrea Pakula, MD, MPH8, Therese M Duane, MD, MPH9, Jill Watras, MD10, Kenneth A Widom, MD11, John Cull, MD12, Carlos J Rodriguez, DO, MBA13, Eric A Toschlog, MD14, Mohamed D Ray-Zack, MD2, Matthew C Hernandez, MD2, Asad Choudhry, MD2, Richard Lesperance, MD11San Antonio Uniformed Services Health Education Consortium (SAMMC), 2Mayo Clinic, 3Marshfield Clinic, 4University of Southern California, 5University of Miami, 6Cooper University Hospital, 7Loma Linda University, 8Kern Medical Center, 9John Peter Smith Hospital, 10Inova Fairfax Hospital, 11Geisinger Medical Center, 12Greenville Memorial Hospital, 13Walter Reed National Military Medical Center, 14East Carolina University

Introduction: Laparoscopic adhesiolysis can be used for small bowel obstruction (SBO); however, conversion to laparotomy is frequent. In this study, we aimed to determine whether patient factors such as prior SBO or abdominal surgery were associated with an increased likelihood of conversion from laparoscopy (LS) to laparotomy (LT) in patients with SBO.

Methods and Procedures: We performed a post hoc analysis of the EAST SBO database and included patients who initially underwent a laparoscopic approach. Patient history, admission physiology, laboratory data, and operative details were reviewed and compared between patients whose operations remained LS and those whose operations converted to LT. Descriptive statistics were calculated, and comparisons between groups were performed using Chi squared test, Fisher’s exact test, and t test.

Results: Of the SBO patients (n = 1322), 464 patients required surgery (35%). LS was initially attempted in 100 cases (21%). Of those, 56% required LT. Between groups, there were no differences in admission physiology or laboratory values. The rates of prior SBO admission or abdominal surgery were not significantly different between groups (p-values > 0.05; Fig. 1). More LT patients required small bowel resections (59% vs. 14%, p < 0.001), anastomoses (54% vs. 14%, p < 0.001), and had operative findings of perforation (9% vs. 0%, p = 0.014) compared to LS patients. There were more nontherapeutic explorations in the LS group (p-value = 0.04; Fig. 2).

Conclusion: More than half of patients undergoing laparoscopy for SBO require conversion to laparotomy. No pre-operative patient factors, including prior hospitalization for SBO or previous abdominal surgery, were predictive of increased likelihood of conversion. Approach to a successful therapeutic laparoscopic intervention for small bowel adhesiolysis may not depend on the patient’s pre-operative history but more on intraoperative findings.


‘Rare Case of Mesentrico Axial Gastric Volvulus - A Series of Three Cases’

Sumita Jain, Professor; SMS Hospital

Gastric Volvulus was first described in 1896 by Berti. It is a rotation of stomach around a fixed axis which is greater than 180 degrees. The incidence if this in males and females are equal. It is mainly observed in infants and young adults and rarely seen in the elderly (> 50 yrs). A dreaded complication of gastric volvulus is gastric strangulation (observed in 28% cases). It’s classification is proposed by Singleton as (i) Organo-axial type (59%), (ii) Mesentero-axial type (29%) and (iii) Mixed (12%).

We have experience of treating three cases of ‘mesentrico axial gastric volvulus’. All patients presented in acute stage having upper abdominal pain, distention and recurrent vomiting. All patients underwent upper GI endoscopy and barium meal to confirm the diagnosis. These were managed through laproscopic surgery. All our patients had uneventful surgeries and are doing well in follow-up.

Conclusion: From our experience with this rare presentation of mesentrico axial gastric volvulus, we conclude that this disease can be managed by minimal invasive surgery with no morbidity and mortality. The component of surgery should include reduction of volvulus, excision of hernial sac, repair of diaphragmatic defect and anti reflux procedure (if required), and gastrostomy tube placement. The excision of hernial sac and gastrostomy tube placement prevents recurrence and further complications. Hence, our procedure is superior to other procedures like endoscopic reduction and gastrostomy or alpha-loop or J-type technique. There are many other variations of gastropexy available like tanner’s slide, oozler’s operation, gastrojejunostomy with gastro-colic discontinuation, but our experience has shown that a simple pexy by doing 2 point fixation - suturing the fundus to the diaphragm and gastorstomy in the distal stomach helps to prevent recurrence.


The Presence of Air Fluid Levels in the Mesenteric Veins as an Indicator of Early Bowel Ischemia

Vinay Bajaj, MD, Anthony Dippolito, MD; Easton Hospital

Our patient is a 67 year old male with significant history of insulin dependent diabetes, end stage renal disease on hemodialysis, cerebrovascular accident, and ischemic cardiomyopathy with EF 25% who was initially admitted for worsening dyspnea on exertion. He was found to be in flash pulmonary edema secondary to cardiogenic shock, and was being treated for the same. During his recovery patient started complaining of new onset 10/10 abdominal pain after his morning dialysis session, and was sent for a CT scan of his abdomen. On examining the patient he complained of no tenderness to palpation, no rebound or guarding, but returned to fetal position as soon as the exam was completed. Lab findings revealed a type II MI, with Troponin level of 1.66 and a lactic acidosis of 2.9. CT showed massive portovenous gas (PVG) with an impressive air fluid level in the mesenteric veins as shown below. At this point the patient was rushed to the operating room for an exploratory laparotomy that showed patchy dusky jejunal loop with a palpable and dopplerable superior mesenteric artery. At this point a decision to place an abthera vac was made with plans for a second look surgery within 24-48 h.

Discussion: The presence of PVG on radiologic testing is usually considered a sign of impending doom. Factors that can cause this sign historically include, most commonly, bowel necrosis, ulcerative colitis intra-abdominal sepsis, small bowel obstruction, gastric ulcers, chronic obstructive pulmonary disease and even chronic steroid use in adults. The mortality rates vary from 56-90% based on the underlying etiology. Bowel ischemia, especially in adults, is especially morbid with rates from 75-90% cited in literature. The extent of bowel ischemia in the bowel wall is divided into three stages: Stage I: reversible ischemic enteritis limited to the mucosa; Stage II: necrosis of the mucosal and submucosal tissues, which may lead to fibrotic strictures; Stage III: the entire wall is affected by ischemia. PVG when associated with ischemia is usually related to Stage III and carries the highest mortality. Although CT scans are neither sensitive nor specific for the detection of bowel ischemia, the presence of PVG should raise concerns. Detection of air fluid levels in the pre-portal venous system as seen here could be an early indicator of the same, requiring emergent intervention to operate and concurrently to attempt to reverse the underlying etiology.


Posterior Gastric Perforation with Laparoscopic Omental Patch Repair

Derek Lim, DO 1, Shinban Liu, DO1, Nicholas Morin, DO1, Vadim Meytes, DO21NYU Langone Medical Center - Brooklyn, 2Vassar Brothers Medical Center

Case Presentation: A 64-year-old female with a past medical history of chronic back pain with daily NSAID use had complaints of 5 days of abdominal pain, malaise, nausea, and vomiting. She was tachycardic in the emergency room with generalized peritonitis on physical exam. A CT scan of the abdomen demonstrated extraluminal air and oral contrast extravasation in the lesser sac, suggestive of a gastric perforation.

A diagnostic laparoscopy was performed and upon initial inspection, the lesser omental sac was noted to be full of succus and air. The greater curvature was dissected and a 3 cm pre-pyloric perforated ulcer was identified on the posterior surface of the stomach. An omental patch was secured with seromuscular 2-0 silk sutures across the ulcer. An esophagogastroduodenoscopy visualized the repaired non-bleeding ulcer and a post-pyloric NGT was placed intraoperative. The remainder of her hospital course was uncomplicated and her diet was advanced after a negative gastrograffin study.

Discussion: Posterior gastric ulcer perforations are an uncommon surgical emergency. Less than 1% of peptic ulcer perforations occur in the posterior stomach. Symptoms vary depending on the location of the perforation. Posterior pre-pyloric perforation causes leakage of stomach contents within the lesser sac. Generalized peritonitis occurs with contamination through the Foramen of Winslow into the peritoneal cavity. Posterior post-pyloric perforation contaminates the retroperitoneal space and may present as back pain or retroperitoneal abscess formation. CT imaging is the modality of choice to identify the location and extent of the perforation. Gastric perforations may be repaired with an omental patch, wedge resection, or gastric reconstruction depending on the size of the perforation. In rare instances, perforations may be contained on imaging and can be managed nonoperatively through careful observation, gastric decompression, bowel rest, and empiric antibiotics. However, extreme vigilance with a low threshold for operation is warranted with conservative management.

Conclusion: posterior gastric ulcer perforations are rare and insidious, requiring prompt diagnosis and treatment. The clinical presentation may be atypical and a CT scan is the gold standard for diagnosis. Laparoscopic and open approaches are both acceptable methods of repair depending on operator skill and clinical status of the patient.


Clinical Course of Patients Presenting to the Emergency Department with Small Bowel Obstruction

Maria S Altieri, MD1Lisa A Bevilacqua, MD 2, Jie Yang, PhD1, Chencan Zhu, MS1, Konstantinos Spaniolas, MD1, Mark Talamini, MD, FACS, MBA1, Aurora D Pryor, MD, FACS11Stony Brook University School of Medicine, 2Thomas Jefferson University Hospitals

Introduction: Small Bowel Obstruction (SBO) is a common pathology requiring surgical workup and treatment; it is also often a consequence of prior abdominal surgery. Admissions for SBO and abdominopelvic adhesions have been estimated as high as 350,000 per year in the US alone. However, little is known regarding the anticipated clinical course of patients presenting to an emergency department (ED) with SBO. This includes rates of admission, need for surgery, or transfer to a tertiary care facility. This study aims to identify all patients who presented to the ED in New York State with SBO and follow their clinical course, with a focus on predictors of transfer.

Methods and Procedures: The New York SPARCS administrative database was used to identify all patients who presented to an ED with the diagnosis of SBO between 2012-2014. Patients were followed to identify discharges from the ED, admissions, operations, and transfers. To evaluate predictors of transfer, Chi square tests with exact p-values based on Monte Carlo simulation were utilized to examine the marginal association between categorical variables and transfers. Factors that were significantly associated with transfer (p < 0.05) were further evaluated as possible risk factors for transfer in a multivariable logistic regression model.

Results: Between 2012-2014, there were 43,567 ED visits for SBO from 35,646 patients. Figure 1 shows the percentage discharged, admitted, transferred, and deceased. Of those requiring surgery, 94.2% underwent an operation at the initial presenting institution while 5.8% had surgery after transfer. The mean time-to-surgery was 0.7 days (SD = 0.83) and 2.47 days (SD = 4.82) at presenting and transfer institutions, respectively. Independent predictors for transfer included age over 18-29 (p = 0.03), white non-Hispanic race/ethnicity (p < 0.0001), and location in Western NY (p < 0.0001). There was no effect of insurance status on transfer (p = 0.38). Interestingly, presence of any comorbidity resulted in a lower likelihood of transfer while any complication during initial visit significantly increased the likelihood of transfer.

Conclusions: To our knowledge, this is the first study that examines what happens to patients presenting with SBO in the ED using a large state-wide database. We found an in-hospital mortality rate of 1.9%, a surgery rate of 17.6% during initial visit, and a transfer rate of 4.5%. Further research is needed to determine demographic and clinical predictors of these outcomes.


The Incidence and Risk Factors OF Venous Thromboembolism After Operative Management of Patients with Complicated Diverticulitis

Mustafa Al-Jubouri, MD, MRCSI, Mohanad Baldawi, MD, Mustafa Baldawi, MD, Munier Nazzal, MD, FACS, Francis Burnicardi, MD, FACS; University of Toledo

Introduction: The prevalence of colonic diverticular disease increases with age and reaches over 70% in octogenarians. Dietary modification and the use of antibiotics are the main form of management of uncomplicated acute diverticulitis. But for complicated cases, surgical intervention is required.

Major surgery is a significant risk factor for venous thromboembolism. The incidence and risk factors of venous thromboembolism in patients undergoing colonic surgery for complicated diverticulitis has not been studied.

This study aims to determine the risk factors and the incidence of postoperative venous thromboembolism (VTE) within a 30 day postoperative period, in patients with complicated diverticulitis requiring surgical intervention.

Methods: Retrospective review from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). All patients who underwent colonic resection for complicated acute diverticulitis from the years 2012-2016 were included in our analysis.

Data regarding patient demographics, comorbidities, type of operative intervention and occurrence of postoperative VTE was recorded.

Results: A total of 47,890 patients underwent colorectal resection for complicated acute diverticulitis during the years 2012-2016. The incidence of VTE was 1.6% (n = 774) within 30 days postoperatively.

Univariate analysis showed an increased risk of VTE with increasing age, African-American race, diabetes mellitus, congestive heart failure, COPD, hypertension, chronic steroid use, emergent surgery, open surgery, preoperative sepsis, preoperative blood transfusion, impaired renal function, and intraoperative blood transfusion. Multivariate analysis identified 9 independent predictors of postoperative VTE: age > 70 years, chronic steroid use, emergent surgery, open surgery, preoperative PRBC transfusion, preoperative sepsis, BUN > 20 mg/dl, hematocrit < 36 and intraoperative blood transfusion.

Conclusion: Multiple risk factors are associated with higher risk VTE among patients with complicated acute diverticulitis undergoing colorectal resection. Awareness of these factors can help the colorectal or general surgeons predict patients at high risk of developing VTE and therefore, modify and be more vigilant in their prophylaxis measures.


Laparoscopic Management of Small Bowel Obstruction

Prof Subhash Khanna, MS, FICS, FIAGES, FALS; Swagat Super Speciality Surgical Institute

Background: Acute abdomen is one of the commonest presenting symptom to an emergency physician and surgeon In the day to day clinical practice.

Acute abdominal may be caused by various causes but small bowel obstruction is one of the common causes of those patients particularly having history of previous surgery

Although considered a relative contraindication diagnostic laparoscopy is increasingly being used in small bowel obstruction not only for diagnosis but also as a therapeutic tool.

We had been using diagnostic laparoscopy in all our cases of bowel obstruction presenting to us particularly those patients who did not have massive distension and who were not in shock.

With growing experience small bowel obstruction is no more a contraindication to diagnostic laparoscopy rather most of these cases can be better managed with laparoscopy compared to convention surgery.

Methods: We searched medical records of medical records of all patients of acute abdomen undergoing diagnostic laparoscopy in our both centers during the period from august 2000 to june 2018 and reviewed the medical records of all the patients were reviewed to obtain data on feasibility, intra operative findings and also the total number of cases who needed a small incision for segmental resection or enterotomy.

We shall be presenting our data of all cases of bowel obstruction presenting to us and shall also share the technique of release of obstruction with video clippings of internal hernias, band obstruction, obstruction due to Meckel’s and many such rare conditions including trichobezoar.

Conclusion: Diagnostic laparoscopy should always remain a preferred option in patients presenting with small bowel obstruction particularly those without massive abdominal distension as many of these patients can be better managed by laparoscopy much better way compared to unnecessary laparotomy causing morbidity. We shall present our series and some of the rare cases presented to us and who underwent therapeutic laparoscopic management successfully.


The Surgical Management of Ingested Sharp Foreign Objects in the Small Bowel (Adults): A Case Series and Review of the Literature

Nicholas Morin, DO, Shinban Liu, DO, Erika King, George Ferzli, MD; NYU langone Brooklyn

Introduction: The surgical management of arrested sharp foreign bodies (FB) in the small bowel is often managed with a concurrent approach that balances endoscopy, laparoscopy, and laparotomy for their removal. Controversy exists as to the timing of surgical intervention and the management of asymptomatic patients. Here we discuss the management and present a case series with a review of the current literature.

Cases Series: Patient one underwent endoscopic retrieval of a wire bristle embedded in the duodenum. Patient two underwent diagnostic laparoscopy converted to open small bowel resection of chronically retained FB after it eroded through the bowel wall of the mid jejunum. Patient three underwent laparoscopic removal via enterotomy and primary repair of a chicken bone embedded in the terminal ileum.

Discussion: Any arrested sharp foreign body should be surgically removed in a timely fashion. The literature shows that longer delays to the operating room, and asymptomatic patients with retained small FBs, increases the risk of significant morbidity; such as migration of the FB through the bowel wall, enterocolic fistula, aortic - duodenal fistula, and frank acute perforation. Any known or suspected ingestion of a sharp FB should be staged with imaging if it is detectable. If progression fails, then surgery is indicated. If it has arrested in the stomach or duodenum endoscopic retrieval is appropriate. A skilled endoscopist can attempt balloon endoscopy for proximal jejunal FB retrieval, but retrieval should not be delayed. Laparoscopic retrieval is preferable when endoscopic attempts have failed. This can be performed via an enterotomy and primary repair for small FBs or laparoscopic small bowel resection with primary anastomosis. If there is frank perforation (or a skilled laparoscopic surgeon is not available) then a laparotomy and washout with resection of affected segment may be indicated.

Conclusion: Retrieval after ingestion of a sharp FB should be performed in a timely manner. A review of the literature shows that chronically retained FBs, and traditional long delays to monitor for transit of the FB increase morbidity and mortality.


Laparoscopic Spleen Preserving Distal Pancreatectomy for Grade IV Pancreatic Injury

Srikanth Gadiyaram, Dr, Gaurav Singh, Dr, Yashas H Ramegowda, Dr; Sahasra Hospitals, Center of Excellence for Gastroenterology

Background: Laparoscopic distal pancreatectomy with spleen preservation is one of the standardized procedures in selected cases with distal pancreatic tumors but is technically demanding in the setting of pancreatic trauma when distal pancreatic resection is required. We herein present a video with operative steps

Case Report: A 15 year old girl presented 24 h after trauma to upper abdomen while playing Kabaddi. She was hemodynamically stable and and had guarding and tenderness in her upper abdomen. MDCT of the abdomen revealed minimal hemoperitoneum, no pneumoperitoneum and transected pancreas opposite the vertebral body (grade IV pancreatic injury). She was resuscitated and taken up for emergency laparoscopic exploration. At laparoscopy there was 500 ml of blood in the peritoneal cavity. Lesser sac was opened by dividing gastrocolic omentum with harmonic shears. A large hematoma was seen occupying the space between the transected head and body of the pancreas with extension of the hematoma into the mesocolon and mesentery. There was no obvious duodenal injury. A laparoscopic spleen preserving distal Pancreatectomy was performed in the following steps.

Step 1 - Division of gastrocolic omentum and placement of a gastric traction suture to provide wide exposure of lesser sac.

Step 2 - Evacuation of the hematoma by gentle suctioning.

Step 3 - Careful dissection behind the transected body of pancreas to identify the splenoportal venous confluence.

Step 4 - Progressive division of branches of the splenic vein and artery to the body and tail of pancreas using harmonic shears.

Step 5 - Bagging the specimen and extraction through the 12 mm port site in an endobag.

Step 6 - Fibrin glue injection at the proximal transected surface and drain placement. The operative procedure took 2 h and 45 min.Her post operative period was uneventful. The abdomen drain was removed on the 4th POD. She was discharged on a normal diet on postoperative day 7.

Conclusion: Laparoscopic distal panreatectomy with spleen preservation is feasible and safe in an emergent situation in a hemodynamically stable patient


Systemic Review on Surgical Management of Colonic Injuries in Trauma: To Divert or to Anastomose?

Man Hon Tang, Daniel Lee; Khoo Teck Puat Hospital

Introduction: There has been more evidence to support the role of primary repair or anastomosis for colonic injuries in trauma. However, there are no randomized trials especially on blunt trauma or in cases of damage control (DC) setting.

Aims: To perform a systemic review of studies comparing outcomes of fecal diversion (FD) versus primary repair/anastomoses (PR/A) in traumatic colonic injuries.

Methods: A systematic review was performed as per PRISMA guidelines utilizing three electronic databases: Pubmed, EMBASE, and Cochrane Library resources. Primary and secondary outcomes are overall mortality and anastomotic leak rates respectively.

Results: There were 13 studies identified, including 10 retrospective, 2 prospective cohort and 1 randomised studies. Data from 1890 patients were abstracted including need for damage control surgery, surgical interventions, mortalities and complications. Overall, 71.3% of the patients underwent a PR/A, with a lesser proportion (64.5%) being performed in the DC group. The overall mortality is 3.59% (2.89% in PR/A vs 5.30% in FD). The overall anastomotic leak rate is 5.64%, and it is significantly higher in the DC group (16.7%). Most papers identified significant blood transfusion, severe abdominal contamination and physiological instability as risk factors for poor outcomes.

Conclusion: It is safe to perform PR/A in stable patients with traumatic colonic injuries. FD should be recommend in unstable patients especially in a DC setting or in those at higher risk for complications.


CT Scan Measurement of Gastric Volumes Pre and Post Laparoscopic Sleeve Gastrectomy. Does the Resected Volume Correlates to Weight Loss Results?

Fernandez Ananin Sonia, PhD, Rodriguez-Otero Carlos, Balague Ponz Carmen, Gonzalo Prats Berta, Pernas Canadell Juan Carlos, Garay Solá Meritxell, Targarona Soler Eduardo; Hospital de la Santa Creu i Sant Pau

Laparoscopic sleeve gastrectomy (LSG) has enormously grown in popularity as a stand-alone procedure for the treatment of morbid obesity. The aim of this study was to assess if the resected and the remnant gastric volumes (measured by multi-detector CT scans) were predictors for effectiveness of weight loss at 1 year after surgery.

Materials and methods: Sixty-four patients with BMI > 40 kg/m2 or > 35 kg/m2 and medical comorbidities underwent LSG between January 2012 and October 2016 included into a RCT (NCT02144545) study comparing different bougie sizes (33 Fr vs 42 Fr). Multi-slice CT scans were performed preoperatively, 2 months, and 1 year after surgery in those patients, to evaluate the gastric volume with a dedicated examination protocol. Parameters were compared to percentage of excess weight loss (%EWL) at 1 year.

Results: Females accounted for 68.7% of patients. Mean age was 50.2 years. Mean preoperative BMI was 44.5 kg/m2, and mean preoperative gastric volume measured by CT volumetry was 686.8 ml. %EWL at 1 year was 60.1 ± 19.3%. Mean remnant gastric volume was 103.5 ml at 2 months and 178.5 ml at 1 year, this increase was statistically significant (p < 0.001). No differences were found between the gastric volume increase after surgery (2 months volumen/1 year months volume months) with weight loss results at 1 year (r = 0.016, p = 0.92).

No significant differences were found in %EWL (61% vs 59%) with the different bougie sizes (p = 0.327). A significant correlation was found between the percentage of resected stomach (preoperative volume/2 months volume) and %EWL (r = 0.322, p = 0.043). We also found a correlation between the resected volume (preoperative volume/2 months volume) with weight loss results at 1 year (r = 0.384, p = 0.014).

Conclusion: LSG is an effective treatment for inducing weight loss, and it seems that the bougie size should be tailored in each patient to resect a suitable gastric volume. Gastric dilatation does not seem to have an impact in short-term results.


Pyloroplasty as a Rescue Procedure for Morbidly Obese Patients with Refractory Gastroparesis after Sleeve Gastrectomy

Keneth Hall, MD, FACS, FASMBS, Raelina S Howell, MD, Harika Boinpally, MD, Patricia Cherasard, PAC, Patrizio Petrone, MD, Collin E Brathwaite, MD, FACS, FASMBS; NYU Winthrop Hospital

Introduction: Patients with morbid obesity and gastroparesis can be treated with sleeve gastrectomy (SG), which has been shown to increase gastric emptying, decrease transit time, and increase glucagon-like peptide levels. Historically, in the setting of refractory gastroparesis following SG, conversion to Roux-en-Y gastric bypass (RNY) was used as a salvage procedure. However, there are limited surgical options for patients with refractory gastroparesis who are poor RNY candidates (i.e. high risk for anastomotic breakdown such as in Crohn’s disease, high-dose steroids, immunosuppressed) or who are unwilling to undergo RNY. This case series describes the unique surgical management technique of rescue pyloroplasty with sleeve gastrectomy (SG) for patients with morbid obesity (body mass index [BMI] ≥ 35 kg/m2) and refractory gastroparesis.

Methods: A retrospective chart review was performed for patients with morbid obesity and gastroparesis who underwent SG and simultaneous or subsequent pyloroplasty by a single surgeon at a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence from August 2016 through July 2018. Patient workup, surgical techniques, and outcomes were assessed.

Results: Three patients underwent SG and simultaneous pyloroplasty (n = 2) or subsequent pyloroplasty (n = 1) and were included in this case series. The first patient was a 70-year-old female with a BMI of 36 who had undergone placement and removal of two prior adjustable gastric bands. She underwent laparoscopic SG, but complained of bloating and dysphagia during postoperative visits and was found to have gastroparesis on a gastric emptying study. She then underwent robotic revision SG and pyloroplasty with subsequent symptom resolution. The second patient was a 46-year-old male with diabetic gastroparesis (hemoglobin A1c 6.8) and a BMI of 40 who was offered RNY, but elected for SG with pyloroplasty and also had postoperative resolution of symptoms. The third case was a 34-year-old female with a BMI 37.8 and idiopathic, refractory gastroparesis who underwent laparoscopic SG and pyloroplasty. She was readmitted on postoperative day seven for liquid intolerance that resolved with conservative, non-operative management and she was discharged home the same day with continued symptom resolution during subsequent follow-up.

Conclusion: We have demonstrated good results with the use of rescue pyloroplasty following SG in patients with morbid obesity and refractory gastroparesis. In patients with gastroparesis who have already undergone sleeve gastrectomy, surgeons should consider pyloroplasty as a salvage maneuver prior to conversion to RNY, keeping in mind that conversion is still an option if symptoms persist.


LSG: One Minute to Fire is Better than 20 Secs?

Mirto Foletto, MD, Pasquale Auricchio, MD, Mostafa Altowerqi, MD, Alice Albanese, MD; University of Padua

Introduction: Laparoscopic Sleeve Gastrectomy (LSG) is one of the most popular bariatric procedure, with good outcomes in terms of weight loss and comorbidities resolution in the mid- and long-term.

Staple line bleeding is one of the major related complications, occurring in 1- 4% of cases. Adequate tissue compression is considered of utmost importance to create a good staple line

Objectives: To evaluate the impact of the time of stapler closure before firing on staple line bleeding.

Methods: From January to August 2018, 116 patients (mean age 43 years old, F 69, M 47, mean BMI 40 kg/m2) underwent LSG at our Institution. In 57 patients stapler was kept closed for 60 s (group 1) before firing, while in the remaining 59 the time of compression was 20 s (group 2). Mean operative time, Haemoglobin loss (DHb) and drainage output (ml) in 1st and 2nd post-operative day (POD) were collected and compared. P < 0,005 was considered significative.

Results: DHb (pre-op vs POD1) resulted higher in group 1 (10.9 ± 0.07 vs 8.01 ± 0.7; P = 0,0001). The same was observed for drainage output in POD 1 and 2 (81.3 ± 48.37 vs. 57.5 ± 9.37, p = 0.003; 70.9 ± 51.7 vs 67.88 ± 9.38 ml, p = 0.001).

Mean operative time was shorter in group 1 (63.2 ± 13.9 min vs 68.7 ± 9.3 min, p = 0.001).

Conclusions: According to our experience, the longer time of tissue compression before stapler firing reduce intra-operative staple line bleeding during and mean operative time, but doesn’t affect Hb changes in the early post-operative period (POD1 and 2).


Rates of Reoperation and Intervention Within 30 Days of Bariatric Surgery

Farah Ladak, MD, MPH, Jerry Dang, MD, PhDc, Noah Switzer, MD, MPH, FRCSC, Valentin Mocanu, MD, Daniel W Birch, MSc, MD, FRCSC, FACS, Shazeer Karmali, MD, MPH, FRCSC, FACS; University of Alberta

Introduction: The objective of this study was to identify early complications that result in intervention or reoperation following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYBG), the timeframe within which to expect them, and factors that influence the likelihood of intervention and reoperation. Complications arising from RYGB and SG are not insignificant and can necessitate additional invasive interventions or reoperation. This study provides a granular assessment of the morbidity associated with these procedures.

Methods and Procedures: Data for this study were obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program’s participant use files for 2015 and 2016. Statistical analysis was performed using STATA 15 (StataCorp, College Station, TX). Between group differences were assessed via univariate analysis where chi2 was used for categoric data and independent t-test was used for continuous data. Predictors for reoperation and intervention were identified using multivariable logistic regression analysis. A combination of forward and purposeful selection was used in the creation of the final model. A goodness of fit test was conducted to estimate the predictive utility of the model.

Results: In 2015 and 2016, 243,747 underwent RYGB or SG, of which 3,014 had a reoperation and 1,536 had an intervention. Complications occurred in 5.48% of RYGB patients and 2.28% of SG patients, the most common of which was bleeding. Anastomotic/staple line leaks were rare, affecting only 0.08% and 0.16% of SG and RYGB patients, respectively. SG was associated with far fewer interventions (0.85% vs. 2.2%). and re-operations than RYGB (0.67% vs. 2.5%) and was associated with a lower risk of re-intervention and re-operation (OR: 0.45, p < 0.001). Renal insufficiency, including dialysis dependency, was an important predictor of reoperations among bariatric surgery patients. This was also true of interventions however, history of pulmonary embolism and use of therapeutic anticoagulation were marginally stronger predictors.

Conclusions: This study provides a representative assessment of perioperative morbidity in two of the most commonly performed bariatric procedures: SG and RYGB. Complications were predominantly bleeding and soft tissue infections with a very low incidence of anastomotic or staple line leaks. Reoperation and intervention were relatively infrequent but more common among RYGB patients, corroborating what has been observed in smaller studies. These findings, in conjunction with new efficacy data demonstrating comparable long-term weight loss between RYGB and SG, provide further support for the safety, effectiveness and cost efficiency of SG.


Does Bougie Size and Distance from the Pylorus affect Rates of Dehydration Following Laparoscopic Sleeve Gastrectomy?: An MBSAQIP Analysis

Ivy N Haskins, MD, Ada Graham, MD, Sheena W Chen, MD, Andrew D Sparks, MS, Paul P Lin, MD, FACS, Hope T Jackson, MD, Khashayar Vaziri, MD, FACS; George Washington University

Introduction: Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure in the United States. Despite its prevalence, there are many technical factors related to this procedure that are not standardized. Specifically, the size of the bougie used and the distance from the pylorus used to create the gastric sleeve varies both by surgeon and across institutions. The purpose of this study was to determine if there was an association between either bougie size or distance from the pylorus on the rate of dehydration following laparoscopic SG.

Methods: All patients undergoing first-time, elective laparoscopic SGs from 2015-2016 were identified within the American College of Surgeons Metabolic and Bariatric Surgery Quality Program (ACS-MBSAQIP) database. The association of bougie size and distance from the pylorus on the rate of dehydration following laparoscopic SG within the first 30-days postoperatively was investigated using multivariate logistic regression analysis.

Results: A total of 170,751 patients met inclusion criteria. The most commonly used bougie size was 36 French (Fr) and the most common distance from the pylorus was 5 cm (cm). The patients were divided into four different groups based on bougie size and distance from the pylorus. Group 1 included bougie size < 36Fr and pylorus distance < 4 cm, Group 2 included bougie size > 36Fr and pylorus distance < 4 cm, Group 3 included bougie size > 36Fr and pylorus distance > 4 cm, and Group 4 included bougie size < 36Fr and pylorus distance > 4 cm. Patients in Group 4 were significantly less likely than patients in Group 1 to be treated for dehydration within the first 30 days postoperatively (p = 0.04). There were no other statistically significant differences between the four groups.

Conclusion: Distance from the pylorus, but not bougie size, is significantly associated with dehydration requiring treatment following laparoscopic SG. Specifically, a longer distance from the pylorus is significantly associated with a decreased risk of being treated for dehydration within the first 30-days following laparoscopic SG (OR: 0.82, CI: 0.67-0.99, p = 0.04). Consideration should be made for standardizing distance from the pylorus during laparoscopic SG.


The Impact of Severe Obesity on Electrolyte Imbalance and its Potential Effects on the Sodium/Potassium-ATPase Pump Regulation

Cristian Milla Matute, MD, Maria C Fonseca, MD, Carlos Rivera, MD, David Romero Funes, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul Rosenthal; Cleveland Clinic Florida

Introduction: Sodium/Potassium-ATPase (Na +/K + -ATPase) is a membrane protein responsible for the active transport of sodium and potassium ions across the plasma membranes on eukaryotes. Recent studies have shown that obesity, among other complications, induces an aberrant activity of Na+/K+ -ATPase, causing extracellular and intracellular ions imbalance. Hyperinsulinemia, leptin resistance, and hyperandrogenism are factors that play a key role in Na+/K+ -ATPase expression and regulation. The aim of this study is to analyze our bariatric patient population with electrolyte disturbances before and after surgery.

Methods: After IRB approval, we retrospectively reviewed the electronic records of all patients that underwent bariatric surgery at Cleveland Clinic Florida between the years 2003 and 2017. Inclusion criteria were BMI > 35, serum sodium and potassium measurements pre-operatively and post-operatively at 3 months follow up. Patients with comorbidities under pharmacological treatment and/or hormonal replacement therapy were excluded from this study. SPSS software was used to apply a t-test for means.

Results: From a total of 5,373 patients reviewed, 22.5% (n = 1,558) patients met the inclusion criteria. This patient population was predominantly female 77.8% (N: 1,212), the most prevalent procedure was RNYGB 61% (N: 950), the mean age was 54y ± 13. The mean BMI was 44 ± 8 kg/m2 at the time of the procedure and 32 ± 9 kg/m2 at 3 months follow up. We identified 37% (n = 589) of patients with serum electrolyte imbalance preoperatively versus 3.1% (n = 47) postoperatively at three months follow up. Before surgery 18% (n = 106) patients had hypokalemia, 17.6 (n = 104) hyperkalemia, 56.8% (n = 335) patients had hyponatremia and 6.6% (n = 39) had hypernatremia. At 3 months follow up after surgery a total of 21.2% (n = 10) had hypokalemia, 34% (n = 16) hyperkalemia, 17% (n = 8) patients had hyponatremia and 27.6% (n = 13) had hypernatremia.

Conclusions: Electrolytes disturbances are just one of the multiple manifestations of Na +/K + -ATPase pump impaired activity in patients with severe obesity. The prevalence of obese electrolytes disturbance is higher than in the general population. Rapid weight loss after bariatric interventions showed a significant improvement of serum electrolytes levels. However multiple factors might be related to these changes. Further studies with the inclusion of more variables should be performed in order to better understand these findings.


Bleeding Dieulafoy Ulcer After Gastric Sleeve: A Case Report and Examination of the Need for Preoperative Esophagogastroduodenoscopy Before Bariatric Surgery

Michael Nicoara, DO, Nicholas Morin, DO, Shinban Liu, DO, Corneliu Vulpe, MD, George Ferzli, MD; NYU Langone Brooklyn

Introduction: There is still controversy regarding whether or not a preoperative esophagogastroduodenoscopy (EGD) should be done before bariatric surgery; does it change surgical course, and does it prevent postoperative complications? Here we present a relevant case and review the current literature relating to preoperative EGDs in bariatric surgery.

Case Presentation: A 51 year female presents for preoperative workup prior to undergoing a restrictive bariatric procedure. A standard institutional preoperative workup was performed without an EGD. Patient returned postoperative day number two with hematemesis. Emergent EGD showed clotted blood in the stomach and a Dieulafoy ulcer that was successfully clipped by the endoscopist.

Methods: A literature review was performed using Pubmed. Search term “EGD bariatric surgery” was used.

Results: PubMed search returned 50 papers, and 13 were selected for review due to their relevance; 4 against EGD, 5 in favor of EGD, and 4 in favor if patient has reflux symptoms.

Discussion: A Dieulafoy ulcer is rare, accounting for 1-2% of upper gastrointestinal bleeding presentations. Our patient presented with classic findings of this lesion: larger diameter vessel on the lesser curve of the stomach, about 6 cm from the gastroesophageal junction, with vessel protruding through a mucosal defect with active arterial bleeding. It is uncertain if a preoperative EGD would have located this lesions and/or provided a means for intervention before presentation. Our literature review on the subject shows that preoperative EGD rarely changes surgical management. They do change medical management in a significant number of cases. With the majority of papers in favor of preoperative EGD (albeit 4 only if patient has symptoms of GERD) there is evidence in favor of performing a preoperative EGD before bariatric surgery.

Conclusion: The current literature is equivocal regarding a preoperative EGD as it rarely changes the surgical management, but often changes the medical management. Even though the yield is small, we recommend preoperative EGD before bariatric procedures for medical optimization; in order to avoid the potentially devastating consequences associated with a missed lesions such as the one presented.


Gastric Pseudocyst associated with a prolapsed Laparoscopic Adjustable Gastric Band

Tianming Liu, MD 1, Ziyad Nasrawi, MD1, George John, MS2, Darren Kong, BS2, Piotr Gorecki, MD, FACS11New York Presbetyrian Brooklyn Methodist Hospital, 2Rowan School of Osteopathic Medicine

Introduction: Due to long term failures and complications, the number of laparoscopic adjustable gastric bands (LAGB) being performed in the United States each year is decreasing. We report a case of the prolapsed (slipped) gastric band associated with perigastric pseudocyst and discuss the pathophysiology.

Case report: A 42-year-old woman with a history of morbidobesity and LAGB placed 8 years ago presented emergently with abdominal pain, dehydration, vomiting and severe gastroesophageal reflux (GERD). Emergent plain radiogram revealed prolapsed LAGB. Postoperatively the patient experienced an excellent weight reduction with 94% Excess Weight Loss and a BMI of 23.5 kg/m2. At emergent laparoscopy, a 6 cm cystic mass was found in association with the prolapsed LAGB. The perigastric cyst was dissected and excised. Intraoperative endoscopy did not reveal communication to the gastric lumen. The LAGB was explanted without evidence of gastric erosion. Pathologic evaluation revealed a smooth thin walled pseudocyst with inflammatory and mesothelial cells. The patient recovered well and was discharged the following day.

Discussion: Perigastric pseudocyst associated with LAGB has been reported in the literature. It’s pathogenesis may be connected to foreign body reaction. We propose collagen and granulomatous tissue deposits around the LAGB and the gastro-gastric plication area contributed to this rare entity. The fibrotic tissue blocks lymphatic channels which may result in an accumulation of lymphatic fluid. This condition may be revealed during emergent exploration or during the preoperative advanced imaging such as the CT imaging. Pathological findings consistent with fibrotic and inflammatory tissue confirm the diagnosis and rules out malignancy and true gastric cyst. Lack of epithelial lining confirms the diagnosis of pseudocyst.

Conclusion: Pseudocysts may form as a mechanism of foreign body reaction. Slipped LAGB could be a contributing factor as in this case. Intraoperative photographs and endoscopic images will be presented. Additional observational studies and reports are needed to further understand the pathophysiology of this entity and to determine the causal association with a band and particularly a prolapsed LAGB.

Figure 1: B marks the normal location and position of the LAGB. * marks the flow of contrast which is normal through the GE junction and stomach.
Figure 2: B, marks the slipped lap band. * marks dilation of the of the proximal stomach and esophagus.
Figure 3: 6 cm cystic mass associated with gastric band.
Figure 4: Gastric psuedocyst wall, consistent with fibrous cyst wall, focal mild hemorrhage, and organizing chronic inflammation/fibrosis.


Use of Laparoscopic Witzel Gastrostomy without Gastropexy in Bariatric and General Surgery

Joshua Davies, MD, Luise Pernar, MD, Brian Carmine, MD, Donald Hess, MD, Cullen Carter, MD; Boston Medical Center

Introduction: Gastrostomy placement is the preferred means of long term enteral feeding for patients who cannot eat by mouth. During laparoscopic gastrostomy, it is standard to perform gastropexy, apposing visceral and parietal peritoneum. However, in some settings, such as the presence of an antecolic roux limb from prior gastric bypass, gastropexy is not possible. This study reports a series of cases where gastrostomy was performed via a witzeled approach without gastropexy.

Methods and Procedures: A retrospective chart review was performed of all patients at a tertiary academic medical center who underwent witzeled gastrostomy without gastropexy over a three year period. In each case, an 18 French feeding tube was brought through the abdominal wall and placed into the fundus of the stomach and secured with a pursestring suture. A 5 cm serosalized witzel tunnel was created around the tube using running silk suture. No gastropexy was performed, and no drain was placed in any case.

Results: Between September 1, 2015 and August 1, 2018, 6 patients underwent 7 witzeled gastrostomy procedures. The patients ranged in age from 39 to 86. In three cases, patients had undergone prior major upper abdominal surgery where adhesive disease prevented gastropexy. In the other four cases, the patients had undergone prior gastric bypass with antecolic antegastric position of the roux limb. Indications for procedure were dysphagia in two cases, critical illness in one, chronic nausea and malnutrition after gastric bypass in three cases, and perforated marginal ulcer in one case. No patient suffered leakage of gastric contents into the peritoneum, and there were no postoperative complications or mortality related to the gastrostomy procedure.

Conclusion: In cases where enteral access is necessary, and where the stomach cannot reach the anterior abdominal wall for gastropexy due to prior surgeries, a witzeled gastrostomy without gastropexy is a safe option, and in this small series resulted in no morbidity or mortality.


Impact of Sleeve Gastrectomy on Gastric Emptying Scintigraphy and Weight Loss in an Ethnically Diverse Bariatric Patient Cohort

Matthew Knouse, MD 1, Perry Orthey, BS1, Henry Parkman, MD2, Michael A Edwards, MD, FACS, FASMBS21Temple University Hospital, 2lewis Katz School of Medicine at Temple University

Background: Sleeve gastrectomy (SG) is the most common bariatric operation performed. Its impact on gastric emptying remains controversial. In this study, we evaluated the impact of SG on gastric emptying scintigraphy (GES) and weight loss.

Methods: We performed a retrospective analysis of SG patients who had both a preoperative and postoperative GES between 2012 and 2017. Postoperative gastric retention (GR) and weight loss (TBWL) were compared among ethnic groups. All analysis was performed with IBM SPSS Statistics 24. A p value < 0.05 was considered significant.

Results: Of 435 SG cases, 17 patients with a preoperative and postoperative GES were analyzed. Retention was higher in white patients (p = 0.014). Preoperatively, 35.3% (2-hr GES) and 29.4% (4-hr GES) had gastroparesis (GP). Gastroparesis decreased after SG on both 2-hr (42.4% vs 11.1%, p < 0.0001) and 4-hr (8.9% vs 2.2%, p = 0.01) GES. TBWL was less in Hispanics at 12 (p = 0.036) and 18 (p = 0.058) months. All patients had normal postoperative GES at 2-hr and 4-hr scintigraphy. No correlation could be made between postoperative gastroparesis and TBWL. On average, SG was initiated 4.93 cm proximal the the pylorus. There was no correlation between TBWL and distance from the pylorus.

Conclusion: SG significantly improves gastric retention in this ethnically diverse patient cohort with severe obesity. There was no significant difference in postoperative gastric retention and weight loss among ethnic groups. Further research and a larger sample size are needed to further validate these findings and better understand the impact of sleeve gastrectomy on gastric emptying scintigraphy and postoperative weight loss in ethnically diverse patients with severe obesity.


Pre-existing Cardiac Disease is Associated with Increased Risk of Peri-Operative Mortality Among Patients Undergoing Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

Victoria M Gershuni, MD, MSGM, Michael W Foster, MD, Colleen M Tewksbury, PhD, MPH, RD, Eduardo Rame, MD, Kristoffel R Dumon, MD, Noel N Williams, MD; Hospital of the University of Pennsylvania

Introduction: Severe obesity and its related complications, including hyperlipidemia, hypertension, insulin resistance, and obstructive sleep apnea (OSA), confer increased risk of developing cardiac disease. Paradoxically, patients with overweight and obesity have lower cardiac-related mortality than their normal-weight, cardiovascular risk-adjusted counterparts, which suggests that obesity may exert a slightly protective effect in this population. It is unclear, however, whether cardiac disease portends worse surgical outcomes following bariatric surgery.

Methods: Using the MBSAQIP Participant Use Data File, a retrospective analysis of patients undergoing laparoscopic and laparoscopic-assisted Roux-en-Y Gastric Bypass (LRYGB) or sleeve gastrectomy (LSG) between 2016-2017 was performed. Patients were classified as having cardiac disease by history of prior myocardial infarction (MI), percutaneous coronary intervention (PCI), or cardiac surgery. Patients were assessed for 30-day mortality and incidence of peri-operative cardiac arrest/need for CPR.

Results: Of patients undergoing bariatric surgery (n = 325,653), 4,405 have history of MI, 7,097 have had PCI, and 3,774 have had prior cardiac surgery. Compared to the rest of the cohort, cardiac patients (3.5%) had a greater number of comorbidities as demonstrated by increased prevalence of hypertension (88.9% vs. 47.7%, p < 0.0001), hyperlipidemia (71.2% vs. 23.2%, p < 0.0001), diabetes (54.6% vs. 25.8%, p < 0.0001), and renal insufficiency (4.1% vs. 0.54%, p < 0.0001). Prior MI, PCI, and cardiac surgery were each associated with significantly increased risk of intra-operative cardiac arrest requiring CPR (RR: 5.65; 95% CI 3.1-10.4, RR 4.88, 95% CI: 2.9-8.3, RR: 7.26; 95% CI 4.0-13.1, respectively) and 30-day mortality (RR: 4.29; 95% CI 2.7-6.8, RR 3.85, 95% CI: 2.6-5.7, RR 4.46, 95% CI: 2.7-7.3, respectively).

Conclusion: Patients with significant pre-existing cardiac disease as indicated by prior cardiac intervention were at greatly increased risk for perioperative mortality, either at time of surgery or in the initial 30 days following the operation. Severe obesity is a known risk factor for cardiac disease suggesting benefit for bariatric surgery in this population; however, cardiac patients undergoing bariatric surgery may require additional preoperative treatment, perioperative interventions, and postoperative monitoring.


Does Resected Stomach Weight Predict Weight Loss after Laparoscopic Sleeve Gastrectomy?

Avian Chang, Sarang Kashyap, Manthan Makadia, Vinay Singhal; Easton Hospital

Background: Laparoscopic sleeve gastrectomy (LSG) has gain popularity as a standalone bariatric procedure and is being performed with increasing frequency. Limited data exists on predictors of post-operative weight loss. The aim of this study is to determine if resected stomach weight could predict post operative weight loss following a LSG.

Method: This is a retrospective review of patients who underwent a standard LSG for morbid obesity over a 40F bougie. Stomach weight was recorded and data was recorded for post-operative weight loss. Mean values were compared using t-tests and analysis of variance. Pearson’s coefficient was used for correlation.

Results: Patients are still being followed however 107 patients underwent a LSG during this time. Mean percent excess body weight loss (%EBWL) was 26.49 ± 14.75, 39.43 ± 15.74, 49.01 ± 20.05 and 52.40 ± 23.46% at 6 weeks, 3, 6 and 12 months respectively. Mean weight of stomach removed was 114.39 ± 48.85gm. No significant difference was seen between amount of stomach removed and mean  %EBWL. Positive correlation was seen between pre-operative weight and amount of stomach removed. Males had a larger stomach compared to females.

Conclusion: Mean %EBWL after LSG is significant although weight of stomach removed did not affect post-operative weight loss. Males and patients with a higher pre-operative weight had a larger amount of resected stomach.


Use of Transversus Abdominis Plane Block with Liposomal Bupivacaine in Patients Undergoing Bariatric Surgery: A Case–Control Study

Allison M Barrett, MD, FACS1, John A Afthinos, MD, FACS1, Christopher Funfgeld, PAC, MPAS1Vaughn E Nossaman, MD 2, Kevin K Kresofsky, MD21Long Island Jewish Forest Hills Hospital, 2Nassau University Medical Center

Introduction: The overuse of postoperative narcotics has gained attention due to the epidemic of opiate abuse in the United States. Multimodal postoperative pain management strategies can address this through the addition of non-opiate analgesia and are incorporated within enhanced recovery after surgery (ERAS) pathways. We hypothesize that the use of an intraoperative transversus abdominis plane (TAP) block with liposomal bupivacaine will decrease the use of narcotic pain medications in patients undergoing bariatric surgery.

Methods: This is a retrospective review of in-hospital pain medication use for patients who underwent bariatric surgery from 2016-2018 at a single institution. From 2016 - 2017 patients received injection of bupivacaine locally at incision sites. From 2017 - 2018, patients received a laparoscopic-guided TAP block with a mixture of 20 mL of liposomal bupivacaine, 30 mL of 0.5% bupivacaine, and 100 mL of normal saline at the beginning of the procedure. This was injected by the surgeon bilaterally at the level of the anterior axillary line, with extension into the subcostal space. Injections were performed with a 20G or 22G spinal needle and were placed with laparoscopic visualization. Postoperatively, all patients received standing intravenous ketorolac and acetaminophen, unless contraindicated. Patients were excluded from the study if they required a concomitant procedure, returned to the OR, had alterations in surgical technique, or were on narcotics or benzodiazepines preoperatively. In-hospital narcotic use was converted to morphine equivalent units, according to previously published equianalgesic tables.

Results: A total of 80 patients underwent bariatric surgery during the time period and 15 patients were excluded. TAP block was performed in 39 patients, compared to 24 who did not have a TAP block. Mean age was 41, and pre-operative BMI was not different between the groups. Intraoperative dosing of morphine equivalent units, acetaminophen, and ketorolac were also not statistically different between the groups. Use of narcotics on postoperative day 0 was significantly less for the TAP-block group (5.97 vs 10.14 mg morphine, p = 0.016). Pain scores in the PACU and up to 24 h postoperatively were not different, nor was the use of acetaminophen and ketorolac postoperatively or length of stay. There were no medication-related adverse events.

Conclusion: Performance of an intraoperative TAP block decreases the use of postoperative narcotic medication use, but does not affect length of stay. As a part of an ERAS protocol, a TAP block is a useful approach for minimizing postoperative opiate use.


The Preoperative Weight Loss Program and Predictive Marker of Postoperative Weight Loss in Sleeve Gastrectomy

Hideya Kashihara, Mitsuo Shimada, Kozo Yoshikawa, Jun Higashijima, Tomohiko Miyatani, Takuya Tokunaga, Masaaki Nishi, Chie Takasu; Department of surgery, Tokushima university

Background: Our department perform preoperative weight loss program for the purpose of decreasing the perioperative complication in sleeve gastrectomy (SG). The aim of this study is to show the surgical outcome of SG and predictive marker of postoperative weight loss.

Patients and Methods:

1. 13 obese patients who underwent SG were enrolled in the preoperative weight loss program (Duration; 37.2 days). Preoperative weight loss program contains calorie restriction (1200 kcal/day) and exercise by the nutrition support team.

2. The relationship between  % EWL in postoperative 1 year and preoperative neutrophil/lymphocyte ratio (NLR) was examined in the cases with less postoperative weight loss after SG.


1. The preoperative weight loss program showed decrease of body weight (-12.1 kg, -9.1%), visceral fat mass (230.9 → 192.9), improvement of transaminase and maintenance of skeletal muscle. There was no perioperative complication.  %EWL in 3, 6 months and 1 year were 46.3, 50.8 and 47.4%. In postoperation, SG improved NASH (AST/ALT, FIB4 index, liver to spleen ratio in CT value). Obesity related disease were improved (diabetes; 75%, hypertension; 64%, hyperlipidemia; 71%, SAS; 90%). NLR in postoperative 3 months showed decrease (2.68 → 1.86). So, immune function was improved.

2. There was negative relationship between preoperative NLR and  %EWL in postoperative 1 year (R2 = 0.52). Comparing preoperative NLR in %EWL < 50% and ?50% in postoperative 1 year, < 50% was 2.97 and ?50% was 2.01 (cut-off 2.25). Preoperative NLR predicts postoperative weight loss in SG.

Conclusion: Preoperative weight loss program is effective in SG. However, more strong preoperative intervention or bypass surgery may be needed in the cases with NLR?2.25.


Impact of smoking on elective bariatric surgery postoperative complications: analysis of the MBSAQIP database

Jingliang Yan, MD, PhD, Brandon Williams, MD, Matthew Spann, MD, Chetan Aher, MD, Wayne English, MD; Vanderbilt University Medical Center

Introduction: Bariatric surgery is an effective means of achieving weight loss and improvement of metabolic co-morbidities. Enhancing quality and safety profile is imperative as the number of bariatric procedures increases worldwide. Smoking has been associated with increased postoperative complications after many surgical procedures. We aim to study how preoperative smoking status affects postoperative outcomes in bariatric patients using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

Methods and Procedures: Patients in the MBSAQIP 2016 data registry undergoing elective bariatric procedures were identified and included. Odds ratio (OR) and 95% confidence interval (CI) of postoperative complications in recent smokers compared to non-smokers were calculated.

Results: A total of 184,749 patients undergoing elective bariatric surgery in 2016 were identified. Of these patients, 16,084 (8.6%) reported smoking cigarettes within 1 year prior to the bariatric operations. Length of stay was slightly longer in patients with a smoking history (1.8 vs 1.7 days). Several postoperative complication rates were increased with smoking. Unplanned re-intubation (OR = 1.70, CI 1.23-2.34), Clostridium difficile infection (OR = 1.64, CI 1.15-2.33), postoperative incisional hernia (OR = 1.62, CI 1.02-2.55), and 30-day mortality related to the operation (OR = 1.80, CI 1.02-3.18) were associated with an odds ratio of at least 1.5. In addition, intraoperative or postoperative transfusion requirement (OR = 1.20, CI 1.00-1.44), unplanned ICU admission (OR = 1.34, CI 1.12-1.58), 30-day reoperation (OR = 1.23, CI 1.08-1.39), 30-day readmission (OR = 1.16, CI 1.07-1.25), and need for intervention within 30 days (OR = 1.25, CI 1.10-1.40) were associated with an odds ratio of greater than 1.

Conclusion: Prior smoking history within a year of bariatric surgery is associated with an increase in multiple postoperative complications as well as mortality. Smoking cessation therefore may improve outcomes among bariatric patients.


Computational Tools for the Reliability Assessment and the Engineering Design of Procedures and Devices in Bariatric Surgery

Chiara Giulia Fontanella, PhD, Mirto Foletto, MD, C Salmaso, I Toniolo, Alice Albanese, MD, Pasquale Auricchio, MD, Lino Polese, Professor, Mostafa Altowerqi, MD, Emanuele Luigi Carniel, Professor; University of Padua

Background: Sleeve Gastrectomy (SG) is one of the most performed bariatric procedure worldwide. Unsatisfactory weight loss and de novo gastroesophageal reflux (GERD) are the major long-term concerns, which can be related to the gastric pouch conformation.

Aims: A novel approach is required to better assess SG in the long run. Rational criteria are advocated to provide engineering tools for the forecast of SG efficacy and the identification of the optimal post-surgical stomach configuration.

Methods: The methods of computational and experimental biomechanics allow investigating interactions between bolus and stomach tissues. As bolus interacts with stomach lining, stretching forces develop and their magnitudes increase with food intake. Such mechanical stimuli act on gastric receptors, initiating neural signals, which convey information to the brain. The brain responds by releasing neuro-transmitters that elicit the feeling of satiety, depending on intensity of stomach wall mechanical stimulation.

A computational model of the stomach was developed by means of histo-morphometric investigations and mechanical tests. Computational analyses were performed to evaluate stomach functionality in both pre- and post-surgical conformation, as the stomach pressure–volume behaviour and the mechanical stimulation of gastric receptors.

The stomach computational model was exploited to investigate an endoscopic approach to sleeve gastrectomy. Different clips conformations were investigated, as anchors, spiders, screws and spirals, considering both the endoscopic applicability and the capability to support intraluminal loads.

The results showed the potentiality of computational methods to investigate stomach functionality and to optimize procedures and techniques in bariatric surgery.

Biomechanical approach to stomach functionality. Schematic representation of stomach conformation and regions (a). Virtual solid models of stomach regions and layers with indication of local material directions (b). Model validation by the analysis of stomach inflation behavior: comparison of experimental data and model results (c). Results from computational analyses of stomach functionality: distribution of stretch components along circumferential and longitudinal directions within the muscular layer at 1200 ml inflated volume (a); average values of stretch components in fundus and corpus regions depending on inflated volume (b). Endoscopic approach to bariatric surgery: schematic representation of intraluminal fixation devices (f); clips design for endoscopic fixation, as anchor, spider, screw and spiral; analysis of interaction phenomena between clips and stomach tissues (h).


Can Bariatric Surgery Prevent the Development of Metabolic Syndrome?

Salman Alsabah, MBBS, MBA, FRCSC 1, Eliana Al Haddad2, Aliaa Al-Mutawa1, Mohammad Al-Mutawa1, Jonathon D Vaz11Kuwait University, 2Columbia University Medical Center

Introduction: Obesity has been directly correlated with the development of metabolic syndrome, a life-threatening disorder. With the constant rise of obesity in the world, this correlation has become of major significance.

Methods: A retrospective analysis of LSG patients’ medical records was performed between October 2008-2017 at a single institute in Kuwait. 1818 patients that have not been previously diagnosed as diabetic and/or dyslipidemic were included.

Results: Patients were followed-up for a 5-year period. Pre-operative weight and body mass index(BMI) were 123.8 kg and 46.1 kg/m2. The greatest weight loss was achieved at 1.5 years post-operatively, correlating to a %excess weight-loss(EWL) of 73.8% and change in BMI of 14.62 kg/m2. Pre-operatively, only 45.1% of the patients exhibited normal FBS levels. This number dropped significantly throughout the follow-up period, corresponding to a normal FBS level in 77.8% at 12 months post-op. Only 20% of the patients had normal HbA1c levels pre-operatively, and this number increased to a maximum of 50.4% at 1-year. When it came to looking at the effect of LSG on lipid status, it was seen that it had little effect on total cholesterol and LDL levels, while our patients demonstrated significantly favorable results on HDL, VLDL and TG numbers

Conclusion: Our study was able to prove substantial positive results with regards to metabolic syndrome post-LSG, with a significant improvement in the glycemic and lipid profile of patients from numbers that are considered dangerous, to those that are in the normal range post-operatively. This improvement is not just due to the weight loss associated with the surgery, but also due to the nature of this procedure.


Banded Versus Non-banded Roux-en-Y Gastric Bypass for Morbid Obesity: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Saeed Shoar, MD 1, Zhamak Khorgami2, Essa Aleassa, MD1, Stacy A Brethauer1, Ali Aminian11Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, 2Department of Surgery, University of Oklahoma, College of Medicine, Tulsa, OK

Introduction: Despite remarkable effects of bariatric surgery in achieving weight loss and improvement of obesity-related comorbidities, efforts still continue to improve the long-term outcomes of bariatric surgery. Banded Roux-en-Y gastric bypass (RYGB) has been continuously scrutinized in comparison to standard (non-banded) RYGB in terms of durability of benefits and band-related complications.

Methods: In an attempt to conduct a meta-analysis of high-quality studies comparing the banded versus non-banded RYGB, we systematically searched the PubMed/Medline and Cochrane Database until September 2018 for the published randomized controlled trials (RCTs) comparing these two procedures. Meta-analysis was performed to pool the data on excess weight loss, food tolerability (including the incidence of postoperative dysphagia and emesis), and postoperative complications.

Results: Three RCTs were eligible to be included into this meta-analysis comprising a total of 494 patients (247 in each group). Two RCTs provided 2-year postoperative data and one study reported 5-year data. Age ranged between 21 and 49.8 years and the initial BMI was between 42 and 64.8 kg/m2. Pooled results on the postoperative outcomes were compared between the two groups (Figure). Excess weight loss was significantly greater in the banded RYGB than in non-banded RYGB (mean difference 5.63, 95% confidence interval (CI) 3.26-8.00). Postoperative food intolerance, emesis, and dysphagia were more commonly seen after the banded RYGB (odds ratio 3.76, 95% CI 2.27-6.24). Nevertheless, major postoperative complications did not significantly differ between the two groups (Figure 1).

Conclusion: Findings of this meta-analysis of RCTs indicate that excess weight loss by banded RYGB would be only 5% greater than that of non-banded RYGB (about 1 point difference in BMI) at the expense of more food intolerance and postoperative vomiting; however, the frequency of postoperative complications is not significantly different. Larger RCTs with longer follow-up time would be necessary to delineate the safety and durability of banded RYGB.

Figure 1. Comparison of excess weight loss outcome (above), food intolerance (middle), and postoperative complications (below) between the banded and non-banded RYGB.


Weight Loss by Obesity Stage: Dual Intra-Gastric Balloon Outcomes

A. Dorsey, MD, S. Ahmed, MD, J. M Morton, MD, MPH, FACS, FASMBS; Stanford

Introduction: The Reshape ® intra-gastric balloon is a saline-filled dual chamber intra-gastric balloon approved by the FDA for weight loss in patients with BMI of 30-40 mg/kg2 who otherwise failed to lose weight with diet and exercise. The intra-gastric balloon promotes weight loss by reducing gastric capacity and enhancing satiety. The aim of this paper is to determine the weight loss attained at 3, 6, and 12 months with the intra-gastric balloon among BMI ranges.

Methods: At a single academic center, preoperative, 3 month, 6 month, and 12 month data were prospectively collected from individuals undergoing ReShape® Intra-gastric Balloon placement. Patients were categorized into BMI 30-34.9 (Stage 1), 35-39.9 (Stage 2), and > 40 (Stage 3). Data were analyzed with Student T tests, ANOVAs and Chi square tests.

Results: Forty six patients underwent placement and subsequent removal of the intra-gastric balloon from 2015 - 2018. Sixty five percent of patients were women. Mean age at placement was 48 yrs, mean weight and BMI at placement were 344 lbs and 38 kg/m2. Seventy eight percent of patients were on pre-operative weight loss medications, which included Lomaira, Contrave, Saxenda, and Metformin. There were no differences in percentage of patients with preoperative diabetes (Stage 1-12% vs Stage 2- 6% vs Stage 3- 9%, p = 0.8), hyperlipidemia (17% vs 12% vs 45%, p = 0.09) or OSA (18% vs 29% vs 36%, p = 0.5). Mean duration of balloon use was 6.5 months. All stages of obesity had significant weight loss: Stage 1 BMI pre-op, 3, 6, 12 mo: 32.4, 29.2, 28.6, 28.7 (p < 0.01); Stage 2, BMI pre-op, 3, 6, 12 mo: 37.5, 33.5, 32.2, 31.5 (p < 0.01); Stage 3 BMI pre-op, 3, 6 mo: 48.1, 43.1, 41.3, 40.3 (p < 0.01). Stage 1 had the greatest  % excess weight loss (%EWL) at 3 and 6 months (3 mo: Stage 1-61% vs Stage-2 39% vs Stage 3-24%, p < 0.01; 6 mo: 71% vs 51% vs 33%, p < 0.01). No difference in  %EWL at 12 mo (60% vs 58% vs 40% (p = 0.5). All groups had similar percent decrease in BMI (3 mo: Stage 1- 10% vs Stage 2- 11% vs Stage 3-10%, p = 0.7; 6 mo: 11% vs 14% vs 14%, p = 0.5; 12 mo: 10% vs 16% vs 16%, p = 0.2).

Conclusions: Our study shows significant weight loss following intra-gastric balloon placement among all stages. Weight loss was sustained even after balloon removal.


Analysis of Bariatric Surgical Procedures in Adolescents from National Inpatient Sample

Fereshteh Salimi Jazi, MD 1, Tamta Chkhikvadze, MD2, Junxin Shi, MD, PhD31University of Texas Medical Branch, 2NYU Langone Hospital-Brooklyn, Department of Medicine, NYU School of Medicine, Brooklyn, NY, USA, 3Ohio State University, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA

Purpose: To identify if advancement of minimally invasive surgery and increasing number of trained minimally invasive surgeons had impact on utilization of bariatric surgical procedures in children and adolescents in the era of obesity epidemics.

Methods: We analyzed 10 years of National Inpatient Sample (NIS) throughout 2005-2014yy. We extracted discharges of patients < 20y, with associated ICD-9 diagnosis and procedure codes of morbid obesity (278.01, V85.4), open gastric bypass (OGB- 44.31, 44.39, 43.89), laparoscopic gastric bypass (LGB- 44.38), sleeve gastrectomy (SG-43.82), laparoscopic gastric banding (LAGB- 44.95) and laparoscopic gastroplasty (LG-44.68). Technical and systemic surgical complications were identified using according ICD-9 codes. All extracted numbers were weighted to national estimates. Trends and available socio-demographics were reviewed. Mean length of stay (LOS) and mean charges (MC) adjusted by inflation index were analyzed.

Results: Throughout the analyzed years total number of major bariatric procedures remained relatively unchanged (Table 1), with substitution of most procedures with SG since 2011 (Figure 1). LAGB and LG procedures have been essentially abandoned. OGB constituted only minor portion (2.3%) of total bariatric procedures by 2014. 98% of all bariatric procedures were performed in adolescents 13-19yy, and 2% in children < 12y. By 2014 two of the most commonly performed bariatric procedures in adolescents were SG (64%) and LGB (29%). Sustained significant female (76%) vs. male (24%) predominance, with majority of patients being white (56%), and privately insured (65%), as well as increasing access to treatment for least wealthy patients (21%- > 30%) and those with public insurance (13.5%- > 30%) was noted. While procedures were equally distributed between teaching and non-teaching urban hospitals before 2011, majority of cases have shifted to teaching institutions since (80% vs. 20%). Only non-reportable number of inpatient deaths and overall ~ 2-4% of complication rate was identified, most common being hemorrhage and respiratory complications. No cardiac complications have been reported since 2011, but increased incidents of acute kidney failure were observed. MC have increased($46,300- > $54,049) and LOS has marginally decreased over the years(2.67- > 2.39).

Conclusion: Despite above described favorable shifts in between procedure types and socioeconomics, our study did not demonstrate increase in utilization of weight loss surgery in adolescents. Bariatric procedures are underutilized but continuously performed in this population, following adult curves. SG has demonstrated to be safe, effective and has been extensively performed since 2011, constituting 64% of all adolescent bariatric procedures in 2014. Multidisciplinary efforts should be made to increase identification and referral of eligible candidates for surgery.


Newly Reported Complication After Gastric Bypass: Vertical Band Through the Gastrojejunostomy

Hossam S Alslaim, MD, Renee Hilton, MD; Augusta University

Roux-en-Y gastric bypass (RYGB) is one of the most common procedures currently performed for surgical treatment of morbid obesity in the United States. Dysphagia and chronic abdominal pain after RYGB for morbid obesity are common and often these complications have multiple etiologies. Determining the exact etiology can be challenging but necessary to provide adequate symptom relief. We present a 39-year-old female who underwent RYGB 10 years ago that was complicated by ulceration, perforation and surgical revision. She presented with progressive dysphagia and abdominal pain. Upper digestive endoscopy revealed a vertical tissue band at the gastrojejunal anastomosis. After complete work up to rule out other causes of abdominal pain and dysphagia, she underwent an interventional endoscopy with resection of the band. At follow up she has had complete symptom resolution. Post-operative GI symptoms after RYGB are common. The differential diagnosis for these presentations is broad and the symptoms alone are poor predictors of the endoscopic pathology. Along with our specific case report we discuss treating dysphagia following RYGB based on literature review. With the increasing number of patients undergoing bariatric procedures, not only bariatric surgeons, but also primary providers, general surgeons, and gastrointestinal physicians must understand the treatment of the variable complications. Endoscopy provides a minimally invasive approach to treating complications after surgery, and many times can avoid the need for additional invasive surgery.


Ricotta Cheese Disease: Lactobezoar After Roux-en-Y Gastric Bypass

John Mayo, MD, Robert Conrad, MD, Bridget Colgan, MD, William Harjes, MD, Robert Lim, MD; Tripler Army Medical Center

Background: Gastric bezoar is a rare but known complication following Roux-en-Y gastric bypass (RYGB). These bezoars are typically composed of indigestible plant matter and are usually associated with an underlying stricture. Lactobezoars, on the other hand, are composed of compacted milk proteins and gastric secretions that are reported in the literature to occur almost exclusively in neonates. We present the first case to our knowledge of a lactobezoar occurring after bariatric surgery, specifically without any underlying anastomotic stricture. This also appears to be the first case report of a lactobezoar occurring in an adult patient not taking high-density tube feedings and not critically ill.

Case Presentation: 49-year-old female three weeks status post RYGB for class III obesity presented with symptoms of gastric outlet obstruction after having added ricotta cheese several times daily to her post surgery diet of Greek yogurt and protein shakes. The patient underwent upper endoscopy and was found to have a lactobezoar that was successfully removed endoscopically. There was no underlying anastomotic stricture. The patient then tolerated a full liquid diet and was discharged later that same day.

Conclusion: Lactobezoar is a rare diagnosis in adults, reported to occur in those who are critically ill and on high-density gastric tube feedings. This report shows it can occur in the gastric pouch of a RYGB in patients who consume milk-based protein shakes and in this case ricotta cheese. The treatment is via endoscopy and dietary guidance with nutritionist consultation.


Role of Preoperative Body Mass Index on Estimated Weight Loss, Total Weight Loss, and Remission of Comorbidities After Bariatric Surgery

Cristian Milla Matute, MD, Maria C Fonseca Mora, MD, Mauricio Sarmiento Cobos, MD, Joel S Frieder, MD, Emanuele Lo Menzo, MD, PhD, FACS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Introduction: Currently, bariatric surgery (BS) is the only long-term treatment for obesity. Demographic, medical and social variables have been thoroughly evaluated as influential on BS outcomes. We found scarcity of literature in regards to the impact of preoperative BMI (Body Mass Index) on BS total weight loss and remission of comorbidities. The aim of this study is to understand the impact of preoperative BMI on BS outcomes.

Methods: After IRB approval, a retrospective review of all patients who underwent bariatric surgery from 2004-2017 was performed. Demographics and comorbidities were analyzed. Patients were assigned into three BMI groups; 30-39.9, 40-49.9, > 50. Total weight loss, excess body mass index loss, and comorbidities were analyzed at a 12-month postoperative follow-up period. Student’s T-test and ANOVA was used for means and Chi Square for categorical values, all tests were two-tailed and performed at a significant level of < 0.05.

Results: A total of 1,389 patients were analyzed. This population was predominantly female 70% (n = 972), the most common procedure performed was LSG (Longitudinal Sleeve Gastrectomy) 65.3% (n = 903) and had a mean age of 54 ± 11 years. From this total population 42% (n = 583) were between 30-39.9 kg/m2 BMI, 43% (n = 595) in 40-49.9 BMI and 15% (n = 211) was above 50 BMI. At 12 months follow-up the category 30-39.9BMI had a 66% EBMIL (Percentage of Excess Body Mass Index Loss), the category 40-49.9 BMI had 59% EBMIL and the category above 50BMI had 55% EBMIL (p = 0.02). Regarding Total Weight Loss, category 30-39.9 BMI lost 21.9 ± 14 kg, category 40–49.9 BMI lost 32.3 ± 17 kg and category above 50 BMI lost 49.3 ± 22 kg (p = 0.001). When analyzing remission of comorbidities, we observed equal remission rates of Diabetes, High Blood Pressure, and Dyslipidemia amongst all three BMI categories and all were found to have statistical significance.

Conclusions: Bariatric patients with BMI ranging from 30-39.9 km/m2 had higher % EBMIL, yet patients with BMI above 50 had greater total weight loss. Remission of comorbidities rates were similar among all categories and equally statistically significant. Although many other variables contribute to the weight loss results, it seems that proportionally the initial BMI has an influence the final weight loss outcome.


Resolution of Sleep Apnea After Bariatric Surgery

Babak Katiraee, MD 1, Peter Powles, MD, FRACP, FRCPC, ABSM2, Dennis Hong, MD, MSc, FRCSC, FACS1, Scott B Gmora, MD, FRCSC, FACS1, Mehran Anvari, MB, BS, PhD, FRCSC, FACS11Centre for Minimal Access Surgery (CMAS), Hamilton, ON, CA, 2St. Joseph’s Healthcare Hamilton

Background: Obesity is one of the risk factors for obstructive sleep apnea (OSA), increasing its risk by tenfold. Positive Airway Pressure (PAP) is a proven method of treating obstructive sleep apnea, but compliance is reported to be less than 50%. Although patients achieve important weight loss after bariatric surgery, literature is conflicting regarding improvement of obstructive sleep apnea symptoms.

Purpose: This study aims to assess the effects of bariatric surgery on sleep apnea symptoms, apnea/hypopnea index (AHI) scores, overnight oximetry and use of PAP treatment.

Methodology: A retrospective chart review was completed of patients who underwent bariatric surgery at our institution between March 2013 and September 2014. We included all patients who had completed a preoperative overnight polysomnography, had diagnoses of OSA, and were on PAP prior to surgery. Patients that did not complete a postoperative polysomnography were excluded.

Results: In total 57 patients were recruited (42 RNYGB and 15 VSG), of which 47 were woman. We observed a decrease in body weight (Kg.) of 24%, and a decrease in BMI of 23% in accordance with their post bariatric state. With respect to their sleep apnea, there was a decrease in AHI of 59% and a decrease in their Arousal Index by 34%. The lowest recorded Sa02 levels increased by 11%, while Hypoxia Time decreased by 59%. This lead to a decrease in the requirement of PAP use by 65%. Of the patients remaining on PAP, the pressures required were reduced by 25%. The average interval between surgery and follow-up polysomnography was 22 months.

Conclusions: Bariatric surgery significantly improved OSA scores and decreased PAP use in relation to decreases in BMI and body weight. It also improved oxygen saturation levels and decreased Arousal Index scores leading to better sleep quality. We consider that OSA follow up should be done routinely after bariatric surgery for patients previously on PAP.


‘Gastric Bypass With or Without Cholecystectomy?’ A 10 Year Perspective’

Robert M Cunningham, MD, Jason E Kuhn, DO, Marcus Fluck, James T Dove, Katherine T Jones, Ryan D Horsley, MD, Jon D Gabrielsen, MD, Anthony T Petrick, MD, David M Parker, MD; Geisinger

Introduction: The aim of the study was to evaluate outcomes of selective concurrent cholecystectomy and long term biliary outcomes after Roux-en-Y Gastric Bypass (RYGB).

Methods: We performed a retrospective analysis of patients who underwent Laparoscopic RYGB (LRYGB) between 2008 and 2018. Chi square, Fisher’s exact, or Wilcoxon rank-sum tests were used to compare outcomes.

Results: 3004 patients underwent a RYGB (LRYGB n = 2453, open RYGB n = 533). At time of review, 54.7% (n = 1643) of patients had undergone a cholecystectomy. 31.1% of patients (n = 933) had a cholecystectomy prior to RYGB, 16.9% (n = 509) had a concurrent cholecystectomy and 51.9% (n = 1562) did not have a cholecystectomy. After LRYGB, 12.9% (n = 202) underwent an interval cholecystectomy. Of those who underwent LRYGB, 29.9% (n = 735) had a prior cholecystectomy. Those who underwent concurrent cholecystectomy/LRYGB (n = 328) were compared with LRYGB alone (n = 1231). The concurrent cholecystectomy group were significantly older, higher percentage of females, higher preoperative BMI, higher Charlson Comorbidity index and a higher medication count. The two groups demonstrated no significant difference in BMI nadir, length of stay, complications or mortality.

Conclusions: The study supports that a higher percentage of bariatric patients will undergo cholecystectomy. Long-term follow-up demonstrates a higher rate of interval cholecystectomy than previously reported. Concurrent cholecystectomy can be performed safely without an increase in length of stay, complications or 30-day mortality.

Table 1

Laparoscopic RYGB versus combined RYGB/cholecystectomy


LRYGB only

Concurrent cholecystectomy


n = 1231(%)

n = 328(%)

p value

















%BMI Change, nadir

− 33.3

− 34.6


Comorbidity Score








Length of stay, days




Readmission, 30 Day




Any reintervention




Minor Complication




Major Complication




Mortality, 30 Day





Single Institution Outcomes of ASMBS’ Employing New Enhanced Recovery Goals in Bariatric Surgery (ENERGY) Initiative

Sara Monfared, MD, Marisa Embry, RN, Ambar Banerjee, MD, Dimitrios Stefanidis, PhD, MD; Indiana University

Introduction: Enhanced recovery programs have proven effective after various operations but their value after minimally invasive bariatric surgery is less clear and potentially harder to demonstrate given already speedy recovery. Employing New Enhanced Recovery Goals in Bariatric Surgery (ENERGY) is a new program of the American Society for Metabolic and Bariatric Surgery that aims to improve postoperative outcomes. Our objective was to assess the impact of ENERGY implementation on postoperative outcomes after bariatric surgery and identify strategies that have the highest opioid-sparing effect.

Methods: Prospectively collected data on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database were reviewed. Patient outcomes after laparoscopic roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (SG) during the year before and the year after implementation of ENERGY (July 2017) were compared. Data analyzed included age, gender, procedure type, length of stay (LOS), 30-day complications, readmissions, and reoperations. Multilinear regression analysis was performed to control for age, gender and procedure type as possible confounders. Average morphine equivalent dosage used during their hospital stay was compared between those who received regional anesthetic block and those who did not.

Results: Outcomes from 531 patients were analyzed, 206 before and 325 after ENERGY implementation. Mean LOS decreased by 0.2 days after ENERGY (p = 0.085). The percentage of patients with LOS ≥ 4 days also decreased from 9.2% to 6.5% (p = 0.24). Postoperative complication, readmission and reoperation rates were similar between the two groups (table 1) even after controlling for age, gender and procedure type as possible confounders. Patients who received a local anesthetic regional block used an average of 30.5 mg of morphine less during their hospital stay compared with those who did not (p = 0.052).

Conclusions: Promising downward trends in patient LOS, complication, readmission and reoperation rates were observed after the implementation of ENERGY in our bariatric program that warrant further study and analysis within a larger sample. Regional anesthesia limits opioid use after surgery and should be considered.


Use of Intraoperative Provocative Leak Testing in Elective Laparoscopic Bariatric Procedures

Bhavani Pokala, MD, Priscila R Armijo, MD, Corrigan L Mcbride, MD, Dmitry Oleynikov, MD; University of Nebraska Medical Center

Introduction: Intraoperative leak testing (IOLT), surgical drains, and swallow studies are commonly employed for early detection of gastrointestinal leaks following bariatric surgery, however, their utility remains widely debated. Our aim was to examine the frequency and outcomes of IOLT with laparoscopic sleeve gastrectomy (LSG) and laparoscopic roux-en-y gastric bypass (LRYGB).

Methods: The 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) database was analyzed for adults who underwent primary elective LSG or LRYGB. Emergent cases, those unable to be followed for 30 days, and patients with previous foregut or revisional surgery were excluded. Cases with IOLT and without IOLT (NIOLT) were compared within each procedure group. Statistical analysis was performed using IBM SPSS 25.0, α = 0.05.

Results: 164,567 LSG patients (IOLT = 126,291; NIOLT = 38,276) and 70,148 LRYGB patients (IOLT = 65,007; NIOLT = 5,141) were included in the study. LSG with IOLT had higher rates of staple line reinforcement (69.2% vs 61.3%; p < .001), oversewing (22.5% vs 21.6%; p < .001), and surgical drain placement (21.3% vs 9.5%; p < .001) than LSG NIOLT. For LSG, both bariatric and general surgeons performed IOLT in majority of cases (77.4% and 66.9%, respectively). Mean operative time for LSG with IOLT was 77.2 ± 37.1 min vs 64.7 ± 30.7 min without. For LRYGB, cases with IOLT also had a higher rate of surgical drain placement (32.8% vs 21.8%; p < .001) than NIOLT. IOLT was performed routinely during LRYGB by bariatric (92.6%) and general surgeons (97.5%; p < .001). Mean operative time for LRYGB with IOLT was 116.8 ± 51.7 min vs 106.0 ± 47.8 min NIOLT. For both procedures, leak rates were higher with IOLT (LSG: 0.4% vs 0.3%; p < .001, LRYGB: 1.0% vs 0.4%, p < .001), however, logistic regression revealed that IOLT was not independently associated with post-operative leak.

Conclusions: IOLT is used in the vast majority of LSG and LRYGB cases. Our results show a statistically significant increase in operative time without significant decrease in post-operative leak rates in cases when IOLT was performed. Therefore, we suggest that IOLT may be unnecessary in elective LSG and LRYGB cases. In the future, MBSAQIP should consider capturing results of IOLT and discriminating between recurrent or previously undiagnosed leak in the post-operative setting.


Single Anastomosis (Mini) Gastric Bypass versus Sleeve Gastrectomy: Meta-analysis of Randomized Clinical Trials

Zhamak Khorgami1, Saeed Shoar, MD2, Philip R Schauer, MD2, Stacy A Brethauer, MD2Ali Aminain, MD 21University of Oklahoma, College of Medicine, Tulsa, OK, 2Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH

Introduction: While sleeve gastrectomy (SG) is the most common bariatric procedure worldwide, single anastomosis (mini) gastric bypass (SAGB) is rapidly gaining acceptance. As mid- to long-term effects of SAGB on weight and obesity-related comorbidities become available, a systematic review of the literature to summarize the available high quality data is required to direct future investigations and clinical practice.

Methods: A systematic literature review was conducted in PubMed/Medline and Cochrane Database through September 2018 to identify RCTs which compared weight loss outcome, diabetes mellitus (DM) and hypertension (HTN) remission, and postoperative complications between SAGB and SG.

Results: 3 RCTs encompassing 595 patients (297 SAGB patients and 298 LSG patients) were eligible to be enrolled into this meta-analysis. The longest follow-up was 5 years for 2 RCTs and 3 years for 1 RCT. Weight loss outcome was pooled based on percentage of total weight loss in 2 studies (significant in favor of SAGB) and percent excess weight loss in 2 studies (not significantly different). Moreover, while SAGB had a mild superiority in DM remission (effect size = 0.16, p = 0.02), the difference was not significant for HTN resolution (effect size = 0.17, p = 0.06). Postoperative adverse events were comparable between the 2 procedures (odds ratio = 0.80, p = 0.42).

Conclusion: Findings of this meta-analysis suggest that SAGB is associated with more weight loss compared with SG. Furthermore, while SG has remarkable effects on DM and HTN, SAGB is associated with about 15% higher chance of remission for both comorbidities. Both procedures are comparably safe.

Figure. Comparison of weight loss outcome (above:  %weight loss and  % excess weight loss), resolution of comorbid diabetes mellitus and hypertension (middle), and postoperative adverse events (below)


The Impact of Impulsivity on Weight Loss after Bariatric Surgery – A Systematic Review

Charleen Yeo, Danson Yeo, Rachel Chen, Gabriel Low, Jiazheng Yeo, Myint Oo Aung, Jaideepraj Rao, Aaryan Koura, Sanghvi Kaushal, Adrian Toh; Tan Tock Seng Hospital, Singapore

Background: Psychopathology has been associated with poorer outcomes after bariatric surgery. Impulsivity has been shown to be associated with obesity through links to pathological eating behavior such as binge eating. Recent literature suggests that impulsivity is linked to poorer outcomes post-bariatric surgery. The aim of this systematic review is to synthesize the current evidence on the impact of impulsivity on post-bariatric surgery weight loss.

Methods: A literature review was performed in August 2018. Original studies investigating the relationship between impulsivity and weight loss post-bariatric surgery were evaluated.

Results: Six studies with a total of 911 patients were analyzed. There were two case–control, two prospective observational and two retrospective observational studies. The post-operative follow-up ranged from 0.5 to 12 years. The most common measure of trait impulsivity was the Barratt Impulsivity Score (BIS), which was used in five studies. Only one study demonstrated a direct association between BIS scores and post-operative weight loss. Two studies reported an indirect effect of impulsivity on weight loss, mediated via pathological eating behavior. Scores specific to state impulsivity showed a significant impact on post-surgical weight loss.

Conclusion: Impulsivity may adversely affect post-operative outcomes after bariatric surgery. However, this may be specific to state impulsivity rather than trait impulsivity. Patients with a higher state impulsivity may benefit from closer follow-up post-bariatric surgery.


Liver Abscesses without leaks in Revisional Bariatric Surgeries: Management and Outcomes

A Zaw, MD, G Khair, MD, FACS, K Singh, MD, FACS, FASMBS, MBA; St Agnes

Introduction: Obesity is a global epidemic and has become a public health crisis in the United States. Bariatric surgery is considered the most effective way to achieve long term weight loss. Roux-n-Y gastric bypass (RYGB) and sleeve gastrectomy are two of the most commonly performed bariatric procedures. Most significant complications are staple line bleeding, stricture, and staple line leak. Formation of liver abscess without intra-abdominal infectious process is a rare complication after bariatric surgery.

Methods and Procedures: Two cases of liver abscesses after revisional bariatric surgery.

Results: We report two cases of pyogenic liver abscesses after laparoscopic gastric bypass revision and sleeve gastrectomy. These were managed by percutaneous drainage and antibiotics.

Conclusion: Liver abscess is a rare complication of revisional bariatric surgery and could be due to multiple factors; it could be due to a clinical leak, subclinical leak, pyelophlebitis of the porto-mesenteric veins or from the combination of parenchymal liver injury and bacterial seeding from staple line when leak is not evident. Most liver abscesses respond to percutaneous drainage and antibiotic administration.


Diabetes Improvement and Resolution Following Laparoscopic Sleeve Gastrectomy Versus Sleeve Gastrectomy with Loop Bipartition

Vladimir Grubnik, MD, Professor, Vadim Ilyashenko, PhD, Viktor Grubnyk, Stanislav Usenok, PhD; Odessa National Medical University

Introduction: The prevalence of type 2 diabetes is growing internationally. Obesity is an independent risk factor for development of type 2 diabetes mellitus (DM) and other metabolic disorders. The aim of this study was to compare the effectiveness of laparoscopic sleeve gastrectomy (LSG) with new surgical procedure: sleeve gastrectomy with loop bipartition (LSG + LB).

Methods: 28 obese patients with DM type 2 were divided in two groups: I group (15 patients) consisted from 9 women and 6 men age 36 to 64 years, mean body mass index (BMI) was 49.7 ± 8.6 kg/m2. LSG was performed in all patients of the I group. II group (13 patients) consisted from 7 women and 6 men, age 39-69 years, mean BMY was 51.8 ± 7.4 kg/m2. LSG + LB was performed in all patients of the II group. These was no statistically significant difference between two groups in demographic, BMY, and comorbidities. Excess weight loss percentage (%EWL), the total weight loss percentage (%TWL) and diabetes improvement were analyzed.

Results: There were no serious complications and mortality in the both groups. After 18 months the patients of the II group lost more %TWL and %EWL and the difference was statistically significant (p < 0.05). %EWL in the I group was 69.7 ± 9.2%, in the patients of the II group - 80.7 ± 13.4% (p < 0.05). Resolution of DM type 2 was in 7 (47%) patients from the I group and in 10 (77%) from the II group (p < 0.01).

Conclusion: Sleeve gastrectomy with loop bipartition is more effective than LSG in the treatment of DM type 2 associated with obesity.


Lipid Profiles Following Sleeve Gastrectomy Vs Roux-En-Y Gastric Bypass – A Meta-Analysis

Caleb J Ba Mendoza 1, Aisha Tabba1, Osamuyi Idubor1, Joel Miller1, Aliu Sanni, MD, FACS21Philadelphia College of Osteopathic Medicine, 2Eastside Bariatric and General Surgery LLC

Introduction: Morbid obesity is associated with increased mortality secondary to cardiovascular risk factors including diabetes, hypertension and dyslipidemia. The most effective intervention for morbid obesity and associated risk factors is bariatric surgery. The aim of this study is to evaluate changes in lipid profiles following Laparoscopic Gastric Sleeve (LSG) or Laparoscopic Roux-en-Y Gastric Bypass (LRYGBP) one year after surgery.

Methods and Procedures: A systematic review of studies between 2005 and 2017 was conducted through Pubmed to identify studies with comparative data on lipid levels between Sleeve Gastrectomy and Roux-en-Y Gastric bypass postoperatively at 1 year. Outcomes analyzed were total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, and BMI. The results are expressed as standard difference in means with standard error. Statistical analysis was done using fixed-effects meta-analysis to compare the mean value of the two groups. (Comprehensive Meta-Analysis Version 3.3.070 software; Biostat Inc., Englewood, NJ).

Results: Four out of 101 studies were quantitatively assessed and included in this meta-analysis. Among the studies, 1405 patients underwent Laparoscopic Roux-en-Y Gastric Bypass and 198 patients underwent Laparoscopic Sleeve Gastrectomy. There was significantly lower cholesterol (-0.667 ± 0.102; p < 0.05) and LDL levels (-0.714 ± 0.103, p < 0.05) for those patients who underwent LRGYBP as compared to LSG. HDL levels (-0.107 ± 0.001, p = 0.287), Triglyceride levels (-0.149 ± 0.101, p = 0.140), and BMI (0.119 ± 0.163, p = 0.463) at 12 months postoperatively were similar in both groups.

Conclusion: Lipid profiles are significantly reduced following LRYGBP when compared to LSG in bariatric patients.


Bariatric Surgery Outcomes as a Function Of Patient Characteristics and Subjective Experience

Jamil S Samaan, BS, Evan T Alicuben, MD, Elaine Qian, BS, Kulmeet Sandhu, MD, Adrian Dobrowolsky, MD, Kamran Samakar, MD; University of Southern California

Introduction: Primary outcomes of bariatric surgery are often defined as excess weight loss and comorbidity resolution. Sparse literature exists on the relationship between psychosocial characteristics and patient outcomes. Similarly, little is known about the relationship between patient satisfaction after surgery and psychosocial characteristics. We sought to examine subjective measures of satisfaction as a function of personal and behavioral characteristics.

Methods and Procedures: A retrospective chart review was conducted on patients who underwent laparoscopic sleeve gastrectomy (LSG) and roux-en-y gastric bypass (RYGB) from August 2002 to November 2017 at a single institution, multi-surgeon, tertiary care academic hospital. Preoperative surveys were reviewed and a telephone questionnaire was performed for gathering demographic and personal data. The telephone survey consisted of a standardized satisfaction survey using a leikert scale to assess response to the following statements: bariatric surgery improved my quality of life (Q), I am satisfied with my surgical outcomes (S), I would undergo bariatric surgery again (A). Inclusion criteria was patients who completed a telephone interview. Exclusion criteria was those who did not complete the interview. Fishers exact test was used for statistical analysis.

Results: A total of 514 patients were included. 76% were female, 71% underwent RYGB and 29% underwent LSG. Median age at time of surgery was 47.0 (95% Cl 45.6-48.8). Average follow up was 6.99 years (SD = 4.30).

Conclusion: Bariatric surgery patients are overwhelmingly satisfied largely independent of psychosocial characteristics. There were some notably interesting findings that predicted lower satisfaction scores including preoperative smoking status and the reasons for overeating.


Retrograde Jeujunojeujnal Intussusception Post Roux En Y Gastric Bypass

Ahmed Abdelhady, MD, FACS, MRCS, Ghaleb Aboalsamh, MBBS, SBGS, Msc; National Guard Health Affairs

The patient was a 46 year-old female who presented to the emergency room with a sudden severe abdominal pain as well as nausea and vomiting that began the day before after a meal. She is 3 years post retrocolic RYGBP. On examination, the patient was well nourished, afebrile, and with normal vital signs. She was in moderate distress with pain out of proportion to the physical examination. Her abdomen was soft, and there were no signs of peritoneal irritation or distension. Laboratory data were unremarkable. Computed tomography scan revealed a long segment obstructive retrograde small bowel intussusception adjacent to the jejuno-jejunal anastamosis and associated with complete proximal small bowel obestruction.The patient was immediately taken to the operating room.


Comparison of Long-Term Weight Loss After Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-En-Y Gastric Bypass from a Single Center in Thailand

Pattharasai Kachornvitaya, MD, Suthep Udomsawaengsup, MD, Chadin Tharavej, MD, Suppaut Pungpapong, MD, Krit Kitisin, MD, Patpong Navicharern, MD; Chula Minimally Invasive Surgery Center, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

Introduction: A sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are two of the most widely used bariatric procedures in Thailand but comparison of long-term outcomes are still limited. The aim of this study is to compare the degree of long-term weight loss after the laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG).

Materials and Methods: A retrospective analysis was performed for all patients who underwent LSG or LRYGB between April 2005 and May 2018 at a single institution with at least 1 year to 5 years of follow up. Demographic data comprised age, sex, preoperative body weight, excess body weight, body mass index (BMI) and co-morbidities. The primary outcomes were percentage total weight loss and percentage excess weight loss. The secondary outcomes was postoperative complications.

Results: Of the total 368 patients, 163 underwent primary LSG and 205 patients underwent LRYGB between April 2005 and May 2018. Preoperative BMI in the LSG group was significantly more than the LRYGB group (53.7 ± 12.3 kg/m2 vs 48.4 ± 8.3 kg/m2, p < 0.001). Co-morbidities between LSG and LRYGB were similar. Mean percentage of excess weight loss (%EWL) at 5 years was 36.7 ± 51.0% in the LSG group vs 62.3 ± 25.3% in the LRYGB group (p = 0.04). Mean percentage of total weight loss (%TWL) at 5 years was 19.2 ± 23.0% in the LSG group vs. 27.9 ± 11.8% in the LRYGB group (p = 0.252). At 5 years, no significant difference was found in the percentage of patients who had > 50%EWL between groups. Overall complications were 4.3% in the LSG group vs. 11.7% in the LRYGB group (p = 0.011). The mortality rate was 0%.

Conclusion: Our center revealed LRYGB had better results than LSG in terms of percentage excess weight loss at 5 years. On the other hand, LSG had lower overall complications than LRYGB.


Early Signs of Postoperative Hemorrhage in Bariatric Surgery

Michael Farrell, MD, MS, Zugui Zhang, PhD, Bayo Gbadebo, MBA, Caitlin Halbert, DO, MS; Christiana Care Health System

Introduction: The aim of this study is to identify potential risk factors or early indicators, specifically related to perioperative blood pressure, and its association with perioperative hemorrhage in the bariatric population. Laparoscopic bariatric surgery in the United States has been steadily increasing over the past several years. Between 2011 and 2015, the annual number of cases has increased by 24%. Although rare, hemorrhagic complications (HC) occur at a rate of 1-5% and can lead to significant morbidity and mortality. By identifying factors which may place a patient at a higher chance of HC, surgeons can potentially mitigate those risks. These modifications could reduce morbidity and limit the requirement of transfusions or reoperations.

Methods and Procedures: A retrospective case–control series was performed to include all patients who underwent either laparoscopic sleeve gastrectomy (SG) or laparoscopic Roux-en-Y gastric bypass (GB) between 2015 and 2018 at a single bariatric center of excellence. Propensity matching was completed for age, gender, procedure, body mass index, and comorbidities including diabetes, hypertension, heart disease, anticoagulation/antiplatelet use and smoking status. Maximum and minimum systolic blood pressures (SBP), diastolic blood pressures (DBP), and mean arterial pressures (MAP) were compared between groups at time of admission, intraoperative, and during the remainder of initial hospital stay. Chi square and odds ratio estimates were used to compare groups.

Result: A total of 1488 procedures were performed with 1203 de novo SG, and 285 de novo GB. Revisional and robotic bariatric cases were excluded from the study. HC occurred in 11 (0.74%) total patients, 8 GS and 3 GB. Three patients required transfusion transfusion of one unit packed red blood cells (pRBCs). Eight patients required at least 2 units pRBCs and all required operative treatment. There was no difference between the procedure performed and risk of developing HC (p- = 0.96). Additionally, there was no difference between groups for preoperative or intraoperative blood pressure findings or postoperative DBP or MAP (p = 0.3-0.95). After accounting for baseline hypertension, mean postoperative maximum (102 vs 146 mmHg) and minimum SBP (102 vs 112 mmHg) were significantly lower in patients who developed HC (p < 0.001).

Conclusion: Relative decreased SBP in the immediate post-operative period may be an early sign of HC in bariatric patients. There was no associated increased risk of developing HC with preoperative or intraoperative blood pressure changes


Challenges Associated with the Bariatric Surgery in Poland

Tomasz Stefura 1, Jakub Dros1, Artur Kacprzyk1, Katarzyna Chlopas1, Oksana Skomarovska1, Marta Krzysztofik1, Katarzyna Major2, Mateusz Rubinkiewicz, MD3, Mateusz Wierdak, MD3, Michal Wysocki, MD3, Magdalena Pisarska, MD3, Piotr Malczak, MD3, Michal Pedziwiatr, MD, PhD3, Andrzej Budzynski, MD, PhD3, Piotr Major, MD, PhD31Students’ Scientific Group at 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, 2Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland, 32nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland

Introduction: Due to constantly growing demand for surgical treatment of obesity in Poland, there is a need for creating new bariatric centers and further improving presently active ones. Therefore, we aimed to identify which stages conducting peri-operative care and organizing modern bariatric center pose the greatest challenge currently in Poland.

Materials and Methods: An anonymous survey was designed and distributed to Polish bariatric surgeons. Our questionnaire was divided into three parts: demographic characteristics, difficulties assessed on a scale 1-5 associated with peri-operative care for bariatric patients and organization and running of bariatric centers in which participants are currently working.

Results: Overall, 70 surgeons and surgical residents from 17 Polish surgical centers participated in our survey. The most difficult element of the pre-operative care was compliance with recommendation to cease smoking (3.47 ± 1.28). The most difficult obstacle during postoperative care period was implementation of the ERAS protocol (2.27 ± 1.31). Funding for the bariatric treatment was obtained exclusively from National Health Fund by 60 respondents (85.7%) working in 15 different bariatric centers (88.2%). Among elements of bariatric infrastructure access to operating theater equipment sized for morbidly obese patients was reported to be the most difficult (3.8 ± 1.68).

Conclusion: Pre-operative recommendations including smoking, physical activity or weight-loss are difficult to execute. Introducing ERAS protocol based peri-operative care in bariatric departments remains to be difficult in polish reality. The development of specialized bariatric centers included in the centralized register and equipped with specialized infrastructure for obese patients seems to be the next step to improve post-operative results.


Impact of Preoperative Opioid Use on Surgical Outcomes Following Bariatric Surgery

Chenchen Tian, BHSc 1, Azusa Maeda, PhD2, Allan Okrainec, MDCM, MHPE, FACS, FRCSC2, Timothy Jackson, MD, MPH, FRCSC, FACS21University of Toronto, Faculty of Medicine, 2University Health Network, Division of General Surgery

Introduction: With rising opioid-related morbidity and mortality, it is critical to understand the implications chronic opioid use on surgical outcomes. Preoperative opioid use before elective abdominal and emergency general surgery has been associated with increased length of stay, costs of care, and readmission rates. Thus, preoperative opioid use represents a potentially modifiable risk factor and a novel target to improve surgical quality of care. The objective of this study was to explore the implications of preoperative opioid use in patients undergoing bariatric surgery on surgical outcomes.

Methods: A single-center retrospective cohort study was performed using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Ontario Bariatric Network (OBN) databases. Patients were selected if they underwent any bariatric procedure between January 1, 2010 and March 31, 2018. Preoperative opioid use, coded as a binary exposure variable, was retrospectively identified from the home medication list in the preoperative evaluation. The primary outcome was the rate of postoperative complications within 30-days of surgery. Secondary outcomes included hospital length of stay, intraoperative complications, and operative time. Continuous variables were compared using Student t-test or Wilcoxon rank-sum test, as appropriate. Categorical variables were compared using Chi squared tests.

Results: Overall, 2479 patients met inclusion criteria. Among those, 291 (11.7%) patients used opioids preoperatively. The majority case mix consisted of Roux-en-Y (88%) and sleeve gastrectomy (11.9%). Opioid users (compared to opioid-naïve) had longer operative time (151 m vs 144 m, p < .05) and higher rates of intraoperative complications (3.8% vs 2.0%, p < .05).

In a subset of 1266 patients evaluated postoperatively, 123 (9.7%) patients used opioids preoperatively. The majority case mix consisted of Roux-en-Y (85.8%) and sleeve gastrectomy (14.1%). In this cohort, opioid users (compared to opioid-naïve) had higher but not statistically significant rates of postoperative complications (9.0% vs 6.3) and statistically significantly longer hospital length of stay (2.6 vs 2.1 days, p < .001).

Conclusions: Based on MBSAQIP and OBN registry data, opioid users (compared to opioid-naïve) had prolonged operative time, higher rates of intraoperative complications, and prolonged hospital length of stay after bariatric surgery. Preoperative opioid use may complicate perioperative and postoperative management in bariatric procedures. Further investigation is needed to evaluate preoperative opioid use as a potentially modifiable risk factor to improve bariatric quality of care and postoperative outcomes.


Risks of Sleeve Gastrectomy Versus Gastric Bypass Among Patients with Kidney Disease

John R Montgomery, MD 1, Seth A Waits, MD1, Justin B Dimick, MD, MPH2, Dana A Telem21University of Michigan, Dept Transplant Surgery, 2University of Michigan, Center for Healthcare Outcomes & Policy

Objective: Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) have similar long-term weight-loss and comorbidity-improvement among obese patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD). As such, the decision to proceed with RYGB versus LSG can be controversial and is often left to surgeon and/or patient preference. No published, generalizable data exists about the perioperative risks of these operations. To inform operative decision-making, we performed an analysis of perioperative safety of RYGB versus LSG in obese patients with CKD or ESRD using a national registry capturing > 95% of bariatric operations.

Methods: Patients with CKD (creatinine ≥ 2 mg/dL, but not on dialysis) or dialysis-dependent ESRD who underwent primary, laparoscopic-RYGB or LSG between 2015-2016 were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use file. The primary outcome was a composite variable of death and severe, life-threatening complications within 30-days of operation. Logistic regression was used to compare adverse outcomes between patients who underwent RYGB versus LSG. Subgroup analyses were then performed among CKD and ESRD patients.

Results: During the study period, 2,357 primary, laparoscopic bariatric operations were performed on obese patients with CKD (n = 1521, 64.5%) or ESRD (n = 836, 35.5%); of these, 1,704 (72.3%) were LSG and 653 (27.7%) were RYGB. After adjusting for patient age, smoking status, hypertension, diabetes, and functional status, there was a trend towards RYGB association with the primary outcome of death or severe, life-threatening complications (6.7vs4.9%), but this was not statistically significant (aOR 1.41[0.96-2.07], p = 0.078). Major contributors to the composite primary outcome between RYGB and LSG patients were reoperation (4.0vs3.1%, p = 0.3), major infection (1.8vs0.6%, p = 0.005), transfusion ≥ 3 units (1.2vs0.5%, p = 0.046), and leak (0.9vs0.4%, p = 0.084). In the CKD subgroup, RYGB was associated with progression to renal failure requiring dialysis (2.8vs0.8%, p = 0.002), and major infection (2.0vs0.5%, p = 0.006). In the ESRD subgroup, RYGB was associated with myocardial infarction (0.7vs0.0%, p = 0.033).

Conclusion: In a contemporary cohort of bariatric surgeries, nearly one-third of obese CKD and ESRD patients undergo RYGB. Our analysis shows increased risk of major infection and transfusion ≥ 3 units among RYGB patients when compared to LSG. Furthermore, CKD patients undergoing RYGB are three times more likely to experience progressive renal failure requiring dialysis. Given the clinical similarity of LSG and RYGB in terms of weight-loss and comorbidity-improvement among CKD and ESRD populations, we strongly recommend LSG as the preferred bariatric surgery unless otherwise contraindicated.


The Use of Bariatric Surgery for Treatment of Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis

Yung Lee, BHSc 1, Aristithes Doumouras, MD, MPH, FRCSC1, James Yu, BHSc1, Karanbir Brar, BHSc2, Laura Banfield, MLIS, MHSc1, Scott Gmora, MD, FRCSC, FACS1, Mehran Anvari, MD, PhD, FRCSC, FACS1, Dennis Hong, MD, MSc, FRCSC, FACS11McMaster University, 2University of Toronto

Introduction: We aim to conduct a systematic review and meta-analysis to critically evaluate the benefits and harms of bariatric surgery on Nonalcoholic fatty liver disease in patients with obesity. NAFLD has become one of the most common chronic liver diseases in the world, affecting 20–30% of the general population in Western countries and costing the US healthcare system $32 billion annually. There is a rapidly growing body of evidence demonstrating the complete resolution of NAFLD following the sustained weight loss induced by bariatric surgery.

Methods: MEDLINE, EMBASE, CENTRAL, and Web of Science were searched up to May 2018. Studies were eligible for inclusion if a study compared biopsy results of NAFLD before and after bariatric surgery in patients with obesity. Exclusion criteria were studies with < 10 patients or cirrhosis. Primary outcomes were biopsy-confirmed resolution of NAFLD (steatosis, inflammation, ballooning degeneration, fibrosis) and NAFLD activity score (NAS); secondary outcome was worsening of NAFLD (liver side effects) and change in liver volume after surgery. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) to assess quality of evidence. Pooled proportions and mean differences (MD) were calculated using the random effects meta-analysis and Freeman-Tukey double arsine transformation. Heterogeneity was quantified using the I2 statistic and publication bias was assessed using a funnel plot.

Results: Among 1,695 studies identified, 32 cohort studies involving a total of 3,093 biopsies met the inclusion criteria. Bariatric surgery resulted in a biopsy-confirmed resolution of steatosis in 66% (95% Confidence Interval (CI), 56–75%), inflammation in 50% (95% CI, 35–64%), ballooning degeneration in 76% (95% CI, 64–86%), and fibrosis in 40% of patients (95% CI, 29–51%). NAS was significantly reduced after bariatric surgery (Mean Difference (MD) 2.39; 95% CI, 1.58–3.20; p < 0.001). Liver volume by magnetic resonance imaging and showed significant reductions in liver volume 6 months after bariatric surgery (MD 469.35 cm3; 95% CI, 297.02–641.68, p < 0.001). However, bariatric surgery resulted in new or worsening features of NAFLD such as fibrosis in 12% of patients (95% CI, 5–20%). The overall GRADE quality of evidence was very low.

Conclusions: Bariatric surgery performed on obese patients with NAFLD leads to complete resolution of NAFLD in a substantial proportion of patients. However, there is a minor chance of patients developing new or worsening histological features of NAFLD. High quality randomized controlled trials are needed to confirm the therapeutic benefits of bariatric surgery for NAFLD.


The Role of Serum Ferritin as Marker of Chronic Inflammation in Patients Undergoing Bariatric Surgery

Cristian Milla Matute, MD, Rene Aleman, MD, Maria C Fonseca Mora, MD, Francisco Ferri Abreu, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Introduction: Ferritin is a cellular protein for iron storage, and it has been recently recognized as an acute phase reactant and marker of acute and chronic inflammation. Along with transferrin and the transferrin receptor, ferritin is a member of the protein family that orchestrates cellular defense against oxidative stress and processes. Obesity is a well-known chronic inflammatory state. The aim of this study is to analyze the variations of serum ferritin as an alternate potential marker of inflammation in severely obese subjects that undergo bariatric surgery.

Methods: After IRB approval, we retrospectively reviewed the electronic charts of all patients who underwent bariatric surgery at Cleveland Clinic Florida from 2005 to 2016. We included all patients with serum ferritin measurements at the time of the surgery and a control measurement at 12 and 24 months after bariatric surgery. Demographics, type of procedure and comorbidities were reviewed. High values were determined > 120 ng/dl as a mean for both genders. Patients with hematologic pathology, cancer, and autoimmune diseases were excluded from this analysis. SPSS software was used to apply a t-test for means.

Results: From the of 1,260 patients analyzed with serum ferritin measurements before, surgery and at 12 and 24 months after surgery at follow up, a total of 24.7% (n = 312) patients had abnormally high ferritin measurements before surgery. This population had a mean age of 57 years, a mean BMI of 42 ± 7 before bariatric surgery, and Female gender was predominant with 62% (n = 192). Regarding the type of procedure laparoscopic sleeve gastrectomy (LSG) was performed in 58% (n = 183), Roux-N-Y Gastric Bypass (RNYGB) in 33% (n = 103) and Laparoscopic Gastric Banding (LGB) in 8% (n = 25). At the time of bariatric surgery, the serum measurements of ferritin had a mean value of 153.7 ± 27 and after surgery a mean value of 137 ± 23 (p = 0.32).

Conclusions: Our study shows no statistically significant difference in serum ferritin level before and after surgery. Although many different indicators of chronic inflammation vary after bariatric surgery, Ferritin by itself does not seem to be helpful as surrogate for chronic inflammation measurements in this patient population. Further studies with a higher number of patients should be performed on an in order to better understanding the role of ferritin as an inflammatory marker.


Early Outcomes Following Bariatric Surgery: Primary Vs Revisional Surgery

Connal Robertson-More, MD1Aryan Modasi, MD, MSc 2, Jerry T Dang, MD2, Noah Switzer, MD, MPH3, Daniel W Birch, MD, MSc2, Shahzeer Karmali, MD, MPH21University Hospitals Coventry and Warwickshire NHS Trust, 2University of Alberta, 3Ohio State University

Introduction: Secondary to insufficient weight loss, weight regain or complications related to primary bariatric surgery, a growing proportion of individuals are seeking revisional bariatric surgery. Despite this, limited knowledge regarding the complication profile of revisional compared to primary bariatric procedures exists.

Methods and Procedures: The MBSAQIP datasets from 2015 and 2016 were combined in a single database and individuals undergoing primary and revisional laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were identified based on CPT codes. Standard demographic information and complications within 30 days of surgery were analyzed for differences between those undergoing primary versus revisional procedures.

Results: Within the combined 2015/2016 MBSAQIP database, 278,869 and 20,159 individuals underwent primary and revisional procedures, respectively. Proportionally, LSG represented 71.7% and 60.1% of the primary and revisional procedures, respectively. Individuals undergoing revisional procedures had a greater mean age (44.7 vs. 47.8 yrs), a lower pre-operative BMI (45.5 vs. 42.3 kg/m2), represented a greater proportion of females, and displayed similar pre-operative comorbidity profiles outside of a lower proportion of individuals with diabetes, and sleep apnea. Additionally, a greater proportion of individuals with gastroesophageal reflux disease was observed in the revisional groups.

With respect to early peri-operative complications, revisional LRYGB was associated with a significantly higher mortality rate (0.015 vs. 0.26%, p = 0.025). Both revisional groups had a greater serious complication rate (2.7 vs. 4.4%, p < 0.001 and 6.4 vs. 10.4%, p < 0.001, pLSG vs rLSG and pLRYGB and rLRYGB), in particular, a greater post-operative bleed, leak and 30-day readmission, reoperation and reintervention rates. Multivariable logistic regression analysis determined that revisional LRYGB procedures were independently predictive of serious complications (OR 1.52, 95% CI 1.40 to 1.65, p < 0.001), leaks (OR 2.40, 95% CI 1.97 to 2.92, p < 0.001) and bleeds (OR 1.44, 95% CI 1.23 to 1.69, p < 0.001). Whereas revisional LSG procedures were independently predictive of serious complications (OR 1.46, 95% CI 1.33 to 1.61, p < 0.001) and leaks (OR 2.14, 95% CI 1.77 to 2.59, p < 0.001).

Conclusions: Utilizing the MBSAQIP database differences in demographic and comorbidity profiles were found between individuals undergoing primary vs revisional bariatric surgery. Further, revisional LRYGB procedures were observed to have a higher perioperative mortality and to be independently associated with the risk of serious complications, bleeds and leaks. On the other hand, revisional LSG was independently associated with the risk of serious complications and leaks.


Utility of Inflammatory Markers in Detection of Perioperative Morbidity After Bariatric Procedures – Multicenter Study

Piotr Major, MD, PhD 1, Michal Wysocki, MD1, Tomasz Stefura1, Jakub Dros1, Artur Kacprzyk1, Katarzyna Chlopas1, Katarzyna Major2, Piotr Malczak1, Magdalena Pisarska1, Michal Pedziwiatr1, Andrzej Budzynski, Professor112nd Department of General Surgery, Jagiellonian University Medical College, 2Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland

Introduction: We aimed to determine if there are correlations between of C-reactive protein, procalcitonin and white blood count measured in first, second and third postoperative day after bariatric surgeries and postoperative morbidity (1-month and 12-months), length of hospital stay (LOS) and hospital readmissions.

Methods and Procedures: Retrospective cohort study of patients who underwent laparoscopic sleeve gastrectomy (SG), Roux-en-Y gastric bypass (GB) or mini-gastric bypass (MGB) for morbid obesity in seven referral bariatric centers. Patients were divided into two groups: complicated group – patients with postoperative complications (in 1 month or 12 months postoperative period) and non-complicated group – patients without postoperative morbidity. Primary endpoint: to determine utility of routinely tested inflammatory markers in prognosis of perioperative (30-days) and postoperative (12-months excluding first 30-days) morbidity rates. Secondary endpoints: utility of inflammatory markers to determine risk of LOS after bariatric surgeries and readmissions.

Results: 2125 patients, 1448 females (68%) and 677 males (32%) in median age of 43 (35-52) years were included. Postoperative morbidity was 155 patients (7.29%), of who 112 cases occurred in first postoperative month and 43 cases after first postoperative month during 12-months follow-up. Sex, age, BMI and co-morbidities did not differ complicated and non-complicated cases. In complicated group LOS was significantly longer as well as readmission rate. CRP (OR: 1.02, 95%CI: 1.01-1.03), WBC (1.23, 1.15-1.32), PCT (17.18, 3.09-95.46) on POD1 used as continuous variables were significantly increasing OR for perioperative morbidity. ROC analysis indicated suggested cut-off point of CRP on POD1 indicating for risk of perioperative morbidity for 23.8 mg/L, WBC for 10x103/mm3, and PCT for 0.22 ng/mL. In case of postoperative morbidity inflammatory parameters on POD1 were not significantly related to ORs (p-values respectively: 0.713, 0.189, 0.889). CRP (OR: 1.02, 95%CI: 1.01-1.03), WBC (1.10, 1.02-1.20), PCT (4.7, 1.12-19.64) were increasing OR for prolonged LOS. ROC analysis indicated suggested cut-off point of CRP on POD1 indicating for risk of prolonged LOS for 35 mg/L, WBC for 8.9x103/mm3, PCT for 0.05 ng/mL. CRP (OR: 1.01, 95%CI: 1.00-1.03), WBC (1.21, 1.09-1.33) on POD1 were significantly increasing OR for readmissions, while PCT was not (6.67, 0.97-45.80). ROC analysis indicated suggested cut-off point of CRP on POD1 indicating for risk of readmissions for 94 mg/L, WBC for 14.5x103/mm3.

Conclusion: Even moderate increase in inflammatory parameters on POD1 should alert surgeon for possibility of increased chance for perioperative morbidity, prolonged LOS and hospital readmissions.


Internal Hernia Following Roux-En-Y Gastric Bypass: Our Institution’s 5 Year Experience

Victoria Needham, MD 1, Jazmin Juarez2, Diego Camacho, MD11Montefiore Medical Center, 2Albert Einstein College of Medicine

Introduction: We investigated the incidence of internal hernia (IH) in patients undergoing abdominal exploration at any interval following Roux-en-Y gastric bypass. Of patients found to have IH, we evaluated their clinical and radiographic presentations leading up to operative re-intervention, as well as the technical aspects of their initial bypass, in efforts to elucidate predictors of this bariatric morbidity.

Methods: We used a single-institution database from 2013-2017 to conduct a review of 213 cases of abdominal exploration (diagnostic laparoscopy or exploratory laparotomy) in patients with a history of bariatric surgery.

Results: 110 patients had a history of Roux-en-Y gastric bypass (11 open, 99 laparoscopic). In this group, upon operative re-exploration, 29 patients (26.1%) were found to have IH via one of the defects created by the prior bypass surgery. Of these, 15 underwent antecolic configuration of the roux limb and 11 underwent retrocolic configuration (3 unknown) at their index operation. All patients presented with abdominal pain, while physical exams ranged from mild tenderness to peritonitis. The mean white blood cell count at presentation was 9.4 (SD 3.4). 69% of patients had a CT scan with at least one finding concerning for internal hernia: swirl sign (58.6%), mesenteric edema (41.4%), free fluid (20.1%) and jejunojejunostomy (JJ) to right of midline (17.2%). 5 patients (17.2%) had a definitive small bowel obstruction diagnosed on preoperative CT scan, defined as oral contrast cutoff at a transition point in the small bowel. Of patients with an internal hernia with available operative records, 1 patient herniated through a JJ mesenteric defect not closed at initial operation, 6 via a closed JJ defect, 8 via an unclosed Petersen’s defect, 9 via a closed Petersen’s defect, and 3 via a transverse mesocolic defect. All defect closure that was performed during initial bypass surgery was noted to be done using nonabsorbable polyester sutures.

Conclusions: In our population, IH was found in over a quarter of patients who underwent abdominal exploration following Roux-en-Y gastric bypass. Abdominal pain and CT findings concerning for internal hernia appear to be valuable factors in predicting the presence of IH. However physical exam, leukocytosis and complete bowel obstruction on CT appear to be less reliable as grounds for suspicion. Closure of mesenteric defects did not appear to prevent IH, however further investigation is needed to determine the role of surgical technique in the risk of developing eventual IH.


Effects of Social And Behavioral Risk Factors on Bariatric Surgery Success

Jamil S Samaan, BS, Evan T Alicuben, MD, Elaine Qian, BS, Yousaf Malik, BS, Stephanie Chang, BS, Kamran Samakar, MD; University of Southern California

Introduction: Bariatric patients are a unique population whose personal characteristics, behavioral patterns and social risk factors are poorly understood. A greater understanding of this patient population may lead to improved whole person care. We aim to examine the biographical, social, and medical profile of our bariatric patient population and determine if any of these factors correlate with weight loss success after surgery.

Methods and Procedures: A retrospective chart review was conducted on patients who underwent laparoscopic sleeve gastrectomy (LSG) and roux-en-y gastric bypass (RYGB) from August 2002 to November 2017 at a single institution, multi-surgeon, tertiary care academic hospital. Preoperative surveys were reviewed for gathering demographic and personal data. Inclusion criteria was patients who completed preoperative surveys. Exclusion criteria was those who did not complete preoperative surveys. Fisher’s exact test was used for statistical analysis.

Results: 513 patients were included in the study. 72.7% were female, the average age at the time of surgery was 47 (SD = 11.98), average BMI at the time of surgery was 44.7 (SD = 8.61) and the average follow up was 5.5 years (SD = 4.09). Results are reported as percentage of patients achieving greater than 50% excess weight loss.

Conclusion: Demographic data for our patient population is similar to published reports. Weight loss surgery success was improved in younger patients, those who had known someone to previously undergo bariatric surgery, and in patients with lower starting BMI. Boredom as the reason for eating was associated with decreased rates of surgical success.


What Makes Bariatric Operation Difficult – Result of National Survey

Tomasz Stefura 1, Mateusz Rubinkiewicz, MD2, Mateusz Wierdak, MD2, Jakub Dros1, Artur Kacprzyk1, Oksana Skomarovska1, Marta Krzysztofik1, Katarzyna Chlopas1, Michal Wysocki, MD2, Magdalena Pisarska, MD2, Piotr Malczak, MD2, Michal Pedziwiatr, MD, PhD2, Andrzej Budzynski, MD, PhD2, Piotr Major, MD, PhD21Students’ Scientific Group at 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, 22nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland

Introduction: The most commonly performed bariatric procedures include laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB) and mini gastric bypass, also known as one anastomosis gastric bypass (MGB-OAGB). A study comparing the degree of difficulty of those procedures could serve as a guide for decision making in bariatric surgery. Moreover, it would help to further improve training programs and curriculums for general surgery trainees.

Materials and Methods: An anonymous internet-based survey was designed to evaluate subjective opinions of surgeons and surgical residents in training in Poland. It covered baseline characteristics of the participant, incidence of technical difficulties during bariatric operations in groups of patients based on the Body Mass Index (BMI), difficulty of LSG, MGB-OAGB, LRYGB and particular stages of each operation assessed on a scale 1-5.

Results: Overall, 70 surgeons and residents from 16 Polish surgical centers participated in our survey. Surgeons reported the highest incidence of technical difficulties during bariatric operation in patients with BMI above 60. The incidence of difficulties seems to correlate with increasing BMI. Mean difficulty degree of LSG was 2.34 ± 0.89. The reinforcing staple line with sutures was considered most difficult stage of this operation (3.17 ± 1.19). The LRYGB operation had an average difficulty level of 3.87 ± 1.04. Creation of the gastrojejunostomy was considered the most difficult stage of LRYGB with mean difficulty level (3.68 ± 1.16). Responders to our survey assessed mean degree of difficulty of MGB-OAGB’s as 2.34 ± 0.97. According to participating surgeons creating the gastrojejunostomy is the most difficult phase of this operation (3.68 ± 1.16).

Conclusion: The LSG is perceived by surgeons as relatively easy operation and good to start with. The LRYGB was considered to be the most technically challenging procedure among operations included in our survey. Operative stages, which require intra-abdominal suturing with laparoscopic instruments seem to be the most difficult phases of any operation.


Bariatric Surgery in Patients with BMI Greater Than 70 and/or Age Greater Than 70: Outcomes Analysis

David M Pechman, MD 1, Ruben Salas, MD1, Corin M Kinkhabwala, BA2, David Weithorn1, MD, Diego R Camacho, MD11Montefiore Medical Center, 2Albert Einstein College of Medicine

Introduction: Bariatric surgery offers patients tremendous benefits to their short and long-term health and their quality of life. Careful patient selection and consideration of risk is especially critical in elective surgical procedures. Risk aversion is important, however “high risk” patients may have the greatest potential to benefit from weight-loss surgery and improvement of comorbid disease. Evidence-based medicine is instrumental in the assessment of risk versus benefit, however data is lacking for several high risk patient populations, including those at the extremes of BMI or age. This study assessed morbidity and mortality data for patients with BMI greater than 70 kg/m2 or age greater than 70 years.

Methods: Patients were selected from operative logs at Montefiore Medical Center from 2014-2017. Patients were included if they underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (GB). Patients with preoperative BMI greater than 70 kg/m2 were assigned to the BMI 70 + cohort. Patients age 70 and above were assigned to the AGE 70 + cohort. All other patients were assigned to the control cohort. Length of stay and 30-day morbidity and mortality were assessed.

Results: 3451 patients underwent non-revisional bariatric surgery, including 2300 (66.6%) SG and 1151 (33.3%) GB. The BMI 70 + cohort included 34 (1.0%) patients, 30 SG and 4 GB. The AGE 70 + cohort included 11 (0.3%) patients, too few for comparison. The BMI 70 + patients were younger (36.2 vs 41.6 years, p = 0.009) and more frequently male (35.3% vs 16%, p = 0.002) than control patients, but demographics were otherwise similar. Rates of comorbid conditions were similar as well. Operative time was similar for BMI70 + undergoing SG (61.5 vs 67.5 min, p = 0.248) and GB (112 vs 107 min, p = 0.778) relative to control. BMI70 + was associated with increased incidence of pulmonary embolism (2.9% vs 0.1%, p = 0.029) and readmission (8.9% vs 3.2%, p = 0.061). BMI70 + and control patients had similar lengths of stay (2.1 vs 1.8 days, p = 0.097) and comparably low rates of surgical site infection (0 vs 0.9%, p = 0.942), acute coronary syndromes (0% vs 0.06%, p = 0.98), pneumonia (0 vs 0.03%, p = 0.990), renal failure (none), and mortality (0% vs 0.09%, p = 0.971).

Conclusion: BMI70 + patients undergoing bariatric surgery had increased rates of pulmonary embolism and readmission, however overall major morbidity and mortality were similar to control patients. Further study is warranted to help guide patient selection and operative planning for patients at the extremes of BMI and age. We next plan to assess preoperative factors and outcomes using national MBSAQIP and NSQIP databases.


Development of Consensus-Derived Quality Indicators for Laparoscopic Sleeve Gastrectomy

Shannon Stogryn, MSc, MBBS, FRCSC, Alistair Sharples, MBChB, MSc, FRCS, Krista Hardy, MSc, MD, FRCSC, FACS, Ashley Vergis, MMEd, MD, FRCSC, FACS; University of Manitoba

Introduction: Synoptic operative reporting has gained popularity due to the poor overall quality of dictated narrative reports. Bariatric surgery is a rapidly expanding field and sleeve gastrectomy is the most common bariatric procedure. The objective was to systematically develop a list of operative report quality indicators for a laparoscopic sleeve gastrectomy (LSG) to generate validated items to include in a synoptic operative report for LSG.

Methods: A Delphi protocol was used to determine quality indicators for a LSG report. Bariatric surgeons across Canada were recruited with physician key stakeholders to participate via a secure web-based platform. We aimed for one representative bariatric surgeon from all Royal College of Physicians and Surgeons Regions in Canada. Participants initially submitted quality indicators for a LSG. Suggested quality indicators were assessed and grouped by theme. Items were then rated on a 5-point Likert scale in subsequent rounds. For consensus, a score of 70% (mean 3.5/5) or greater indicated inclusion of an item and 30% (mean 1.5/5) or less denoted exclusion. Elements scoring 30 - 70% consensus were re-circulated in subsequent rounds to generate the final list of quality indicators.

Results: Seven bariatric surgeons were invited. We one representative from all regions in Canada. The 3 multidisciplinary invitees were comprised of: 1 academic minimally invasive/acute care surgeon, 1 tertiary abdominal radiologist, and gastroenterologist with expertise in endoscopic management of bariatric complications. The overall survey response rate was 90.0% (9/10) and identified 61 potential quality indicators for consideration. In the second-round survey 53 items reached inclusion consensus (see Table 1).



# items


Team demographics



Patient demographics



Pre-operative events


Weight lost on pre-op diet

Intra-op details


Leak test

Sleeve formation


# stapler firings 

Closure details


Port closure 

Post-op details


Post-operative condition 

Conclusion: This study established consensus-derived multidisciplinary quality indicators for LSG operative reports. This will allow further assessment of the quality of existing documentation and will afford the development of a synoptic report that may improve this documentation.


Laparoscopic Sleeve Gastrectomy as a Proposed Treatment for Gastroparesis - A Case Series

Katelin A Mirkin, MD, Ann M Rogers, MD; Penn State Health Milton S. Hershey Medical Center

Introduction: In patients with severe obesity and gastroparesis, sleeve gastrectomy can improve symptoms and may be a reasonable treatment option. We report a case series of four patients with gastroparesis documented by preoperative nuclear gastric emptying study, who experienced improvement in symptoms after laparoscopic sleeve gastrectomy.

Methods and Procedures: A prospectively maintained database of all patients who underwent sleeve gastrectomy at our institution from 2008-2017 was reviewed, searching for patients with preoperative clinical diagnosis of gastroparesis and gastric emptying studies. Outcomes assessed were clinical resolution of symptoms with follow-up of 1 year.

Results: Four patients met inclusion criteria, all females, ages 34 to 58, with BMIs ranging from 41-44. Preoperatively, the patients had symptoms of nausea and vomiting that failed to improve with medical management. Two of the patients had insulin-dependent diabetes. All four patients underwent laparoscopic sleeve gastrectomy; one also underwent anterior cruraplasty for a small hiatal hernia, without complications. Two of the patients were discharged on post-operative day one and the others on post-operative day two, all tolerating a liquid diet. At 1 year follow up, BMI had decreased by an average of 5.9 points. At 1 year follow-up, all four patients reported complete resolution of symptoms.

Conclusions: To date there are only 13 reported cases in the literature of improvement of gastroparesis after sleeve gastrectomy. In bypass patients, gastroparesis was previously treated with an adjuvant gastrostomy tube in the remnant stomach to prevent nausea or distention. This is likely unnecessary. Sleeve gastrectomy led to resolution of gastroparesis in all patients in our database, and may be the bariatric procedure of choice for patients with this diagnosis.


Factors Associated with Open Conversion During Laparoscopic Roux-En-Y Gastric Bypass: A National Database Analysis

Eric S Wise, MD, Adam Sheka, MD, Keith Wirth, MD, Sayeed Ikramuddin, MD, Daniel Leslie, MD; University of Minnesota

Introduction: Open conversion (OC) is an infrequent, highly undesirable necessity during elective minimally invasive bariatric surgery. Characterization of those patients at greatest risk for OC is poor. In this study, we seek to determine those preoperative variables that may portend an increased risk of OC. We also aim to characterize the association of OC on postoperative morbidity and mortality.

Methods and Procedures: Using the robust Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2016 dataset, 38,907 patients (≥ 18 years of age, body-mass index [BMI] ≥ 35 kg/m2) who underwent elective, multi-port laparoscopic Roux-en-Y gastric bypass (LRYGB) were included. Preoperative patient and surgeon factors were tested for associations with open conversion using bivariate and subsequent multivariate nominal logistic regression analysis. Bivariate analysis was subsequently used to characterize the association between OC and a panel of 30-day postoperative morbidities. The Mann–Whitney U test and Chi squared test were used for continuous and categorical data comparisons, respectively. All patient variables and outcomes were as defined by the Participant Use Data File User Guide. A criterion of P ≤ .05 was taken to denote statistical significance.

Results: Among the 38,907 patients, there were 79 (0.2%) OCs. On bivariate analysis, variables associated with OC were advanced age, African American race, greater BMI, gastroesophageal reflux disease, chronic obstructive pulmonary disease, hypertension requiring 3 + medications, therapeutic anticoagulation use, prior obesity/foregut surgery, chronic steroid use and non-independent functional status (P ≤ .05). The multivariate nominal logistic regression model considering patient variables with sufficient prevalence (n ≥ 5 among OC patients) generated an area under the receiver-operating characteristic curve of 0.75 (n = 35,008, r2 = .06, Chi squared = 66.3, P < .001). Independent risk factors for OC included advanced age (P < .001, odds ratio 1.04, 95% confidence interval [1.02-1.06]), higher BMI (P < .001, 1.06 [1.04-1.08]), and previous foregut/obesity surgery (P < .001, 3.9 [2.3-6.5])(Table 1). OC patients had longer lengths of stay (median 4 vs. 2 days, P < .001) and operative times (median 238 vs. 110 min, P < .001), as well as greater rates of perioperative transfusion (P = .03), unplanned ICU admission (P < .001), 30-day mortality (P < .001), 30-day reoperation (P = .02) and 30-day readmission (P < .001)(Table 2).

Conclusions: During elective LRYGB, OC is rare and associated with increased 30-day postoperative morbidity and mortality. We have identified several critical risk factors independently associated with OC. Derived from a robust national database, these data may guide intraoperative and postoperative expectations for the patient and bariatric surgical team.


Roux-en-Y Gastric Bypass vs. Vertical Sleeve Gastrectomy for Diabetic Patients: 5 Year Outcomes

Vanessa Boudreau, MD, Karen Barlow, Hons, BSc, Scott Gmora, MD, Dennis Hong, MD, Mehran Anvari, MD, PhD; Center for Minimal Access Surgery, McMaster University, Ontario, Canada

Introduction: Bariatric surgery is a known effective treatment for diabetes in obese patients.

Methods: Analysis of the Ontario Bariatric Registry data was performed to compare long term outcomes in diabetic patients who underwent Roux-en-Y Gastric Bypass (RYGB) or Vertical Sleeve Gastrectomy (VSG) between 2010-2018. Intention-to-treat analysis was performed. Results include conversions and revisions.

Results: Of the 5,101 diabetic patients that underwent bariatric surgery, 4,244 (83%) had RYGB (BMI 48.2, age 49.1; 75% female) and 847 (16.6%) had VSG (BMI 53.3, age 52.5; 69.1% female). There were 786 patients with RYGB available for follow up at 3 years and 198 patients at 5 years. Among the VSG patients, 92 were available for follow-up at 3 years and 17 at 5 years. There were 38 VSG patients that required a conversion due to weight regain/ineffective weight loss compared to 2 RYGB patients. Data below includes converted patients using intention to treat analysis.




Conversion Rate

3 years

5 years







Weight Loss


3 years

5 years







Diabetes Control

No Diabetes Medication

3 years

5 years








3 years

5 years







Remission (HbA1c < 6%)

3 years

5 years







Partial Remission (HbA1c < 6.5%)

3 years

5 years







Conclusion : Both RYGB and VSG are effective with favorable weight loss and diabetes control. RYGB resulted in lower diabetes medication use and lower HbA1c at each follow-up.


The Impact of Bariatric Surgery on Hypothyroidism: A Two Year Follow Up

Michael Zhou, BA, Jordan Grubbs, MD, David Berler, MD, Benjamin E Schneider, MD, Sara A Hennessy, MD; University of Texas Southwestern Medical Center

Introduction: Thyroid dysfunction and obesity are intricately connected with a positive correlation between BMI and TSH. Bariatric surgery is one of the most effective long-term treatments of obesity and its co-morbidities. Likewise, changes in thyroid function, correlating decrease of medication dosage, and even resolution of hypothyroidism have been reported in post-operative patients. However, the literature is sparse on the long-term effects of bariatric surgery on hypothyroidism. In this study, we aimed to review the effects of bariatric surgery on hypothyroidism over 2 years.

Methods and Procedures: A retrospective review was conducted of patients undergoing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RNYGB) procedures at a university-affiliated academic institution from 2014 to 2016. Patients with hypothyroidism were evaluated for changes in thyroid stimulating hormone (TSH) and dose of hypothyroid medication over follow up periods of 6, 12, and 24 months were evaluated. Patients were compared by comorbidities, type of surgery, BMI change and outcomes.

Results: Of the 401 bariatric surgery patients, 63 patients had preoperative diagnosis of hypothyroidism. Of the patients with hypothyroidism, 24 patients had adequate TSH follow up. Preoperative mean TSH was 2.15 with a BMI of 43.6. At 24 months there was a decrease to a TSH of 1.33 and a BMI of 33.2 (Table 1). Of these patients, 4 (16.7%) had a dose decrease in their thyroid replacement medication postoperatively with an average of reduction in dose by 31.2%.

When comparing SG and RNYGB in hypothyroid patients, there was a significant difference in BMI change of 7.97 and 13.5, respectively (p = 0.03), and TSH decreased by 0.21 and 0.64, respectively (p = 0.04).

Table 1. TSH and BMI changes over follow up periods.*: Statistical significant decrease in BMI occurred post-operatively (p < 0.01). There was no statistically significant decline in TSH and no correlation between BMI and TSH changes.

Conclusion: Bariatric patients with well-controlled preoperative hypothyroidism are safe to undergo either sleeve gastrectomy or Roux-en-Y gastric bypass surgery. They can continue to achieve adequate control of their hypothyroidism without a negative impact on absorption of hypothyroid medications. There is a trend towards improvement in hypothyroidism with decreases in thyroid medication doses. Roux-en-Y gastric bypass is potentially superior to gastric sleeves in treatment of hypothyroidism, with significant improvement in thyroid function. A prospective study is necessary to understand the true impact of bariatric surgery on hypothyroidism.


Outcomes After Laparoscopic Sleeve Gastrectomy at a High Volume Center

Chetna Bakshi, MD, Sara Siskind, MD, Christopher Taglia, MD, Larry Gellman, MD, Dominick Gadaleta, MD; Zucker School of Medicine at Hofstra/Northwell

Background: Laparoscopic sleeve gastrectomy has gained interest in the United States due to its efficacy and relative safety1. Many studies have been done comparing sleeve gastrectomies with other bariatric procedures. High volume centers have developed early recovery protocols to decrease hospital length of stay without increasing morbidity or post-operative re-admissions2. The aim of this study was to demonstrate superior outcomes and lower complication rates at a high volume center for sleeve gastrectomies, using a similar technique.

Methods: A retrospective chart review was undertaken, looking at outcomes after sleeve gastrectomies performed between 2012 and 2017 by three surgeons who utilize a similar technique at a single Bariatric Center of Excellence. All patients who had additional bariatric procedures listed, such as gastric band removal, were excluded. The primary end points were post-operative complications including ICU stay, mortality, and readmission rates.

Results: 812 patients were included in the study with a mean BMI of 45.59 ± 7.36. Average hospital length of stay was 1.15 ± 1.19 days for the index hospitalization. None of the patients experienced any intra-operative complications. Only four patients (0.49%) had an ICU admission within 30 days, and there was only one mortality (0.12%). Four patients (0.49%) required discharge to a rehabilitation facility, and four patients (0.49%) experienced dehydration requiring treatment. Twenty patients (2.46%) presented to the ED but only 16 (1.97%) required re-admission, and only 5 of these (0.62%) required an intervention.

Conclusions: The overall complication rate in this study is lower than that described in the literature. The re-admission rate was 1.97%, significantly lower than the 3.8% quoted in previous studies3. Re-admission complications in this study included venous thromboembolic events, wound infections, and dehydration. Notably, no leaks were seen. This study effectively demonstrates that high volume bariatric centers with standardized techniques and protocols can achieve lower complications rates, thus minimizing patient injury and preserving valuable healthcare resources.


Surgical Complications Following Roux-En-Y Gastric Bypass and Sleeve Gastrectomy in Patients Aged ? 65 Years from 2006-2016

Rebekah Wood, BS 1, Mukund Srinivas, BS1, Mike Bottomley, MS2, Priti Parikh, PhD1, Joon K Shim, MD, MPH, FACS11Wright State University Boonshoft School of Medicine, 2Wright State University

Introduction: With the obesity epidemic in America, this study aimed to evaluate the outcomes of obese patients over the age of sixty-five after either laparoscopic/robotic Roux-En-Y or laparoscopic/robotic sleeve gastrectomy in one single tertiary institution. There are an increase number of patients over the age of sixty-five with indications for bariatric surgery. Studies have shown efficacy and safety of bariatric surgery in this age group.

Methods: We retrospectively reviewed 70 laparoscopic/robotic Roux-En-Y gastric bypass and 74 laparoscopic/robotic sleeve gastrectomy that were performed on patients aged ≥ 65 years at a tertiary center from January 2006 to December 2016. Revisional surgeries were excluded. A logistical regression was run with ‘yes/no’ to ‘patient experienced a complication’ as the dependent variable. Demographic characteristics and perioperative data were analyzed including type of procedure, gender, smoking status, and BMI as independent variables. SAS version 9.4 (SAS Institute, Inc., Cary, NC) was used for analysis.

Results: Tukey’s multiple comparison procedure adjusts the P-values to control for the number of comparisons made so that the experiment-wise type I error rate is held constant at alpha = 0.05. The odds ratio estimate for laparoscopic/robotic Roux-En-Y gastric bypass is 3.183. The adjusted 95% confidence interval for the true odds ratio is (1.082, 9.366). Based on the adjusted P-value of 0.03, there is strong evidence to suggest there is a significant difference in the odds of having a complication for patients who underwent laparoscopic/robotic Roux-En-Y gastric bypass versus patients who underwent laparoscopic/robotic gastric sleeve. There were a total of 32 patients who experienced a complication after laparoscopic/robotic Roux-En-Y gastric bypass. Eight of these 32 patients experienced more than 1 complication. There were a total of 17 patients who experienced a complication after laparoscopic gastric sleeve. No patients experienced multiple complications. Ulcer, perforation, surgical site infection, respiratory failure, acute kidney injury and bleeding were observed more frequently in laparoscopic/robotic Roux-En-Y gastric bypass. These complications were further categorized as short and long term complications.

Conclusion: For obese patients over the age of sixty-five, the odds of experiencing a complication postoperatively for patients undergoing laparoscopic/robotic Roux-En-Y gastric bypass were 3.183 times the odds of experiencing a complication postoperatively for patients undergoing a laparoscopic/robotic sleeve gastrectomy at our center. However, the 95% confidence interval indicates that the true odds ratio could be as low as 1.082 times more likely or as high as 9.366 times more likely in patients undergoing laparoscopic Roux-En-Y gastric bypass.


The Safety and Efficacy Of Bariatric Surgery in the Elderly

Brian J Shea, MD 1, William Boyan, MD1, Jonathan Decker, MD1, Ethan Paulin, MD1, Vincent Almagno, BS2, Wiley Abbott, BS2, Joseph Bahgat, BS2, Gurdeep Matharoo, MD, FACS, FASMBS1, Steven Binenbaum, MD, FACS, FASMBS1, Frank Borao11Monmouth Medical Center, 2St. George’s University School of Medicine

Introduction: Bariatric surgery has been demonstrated to improve obesity related comorbidities and be superior to medical therapy alone. Many of these trials demonstrating this benefit studied patient populations at average risk for surgery, which typically included younger patients. This study seeks to examine the safety of bariatric surgery in the over 60 population, and to determine if these patients share the same the benefits in terms of weight as their younger counterparts.

Methods and Procedures: The records of all patients undergoing bariatric surgery at a bariatric surgery center of excellence were examined between January 2012 and December 2016. Patients were separated into two groups; those over the age of 60 and those under age 60. Data for perioperative factors were then recorded, including length of stay, complications, thirty day readmission and reoperation. Follow up data was then recorded, including patient’s excess body weight loss and percentage change in body mass index. Weight loss was followed over four time intervals: one week post-operative, short term (1-3 months) intermediate term (4-8 months) and long term (9 months to last available follow up). Student’s T Test and Chi square analysis was used to determine if differences in the above characteristics were statistically significant.

Results: There were 90 patients in the over 60 group, and 453 in the under 60 group. Average age in these groups were 64.3 years and 42.9 years respectively. Average ASA classification was significantly higher in the over 60 group (3.01 vs. 2.76; p < 0.001). There was no significant difference in length of hospital stay between groups (2.3 vs 2.1; p = 0.15). Rates of complications were similar between groups (7.7% vs 5.1%; p = 0.5). There was also no statistically significant difference in readmission (2.2% vs 3.5%; p = 0.5) or reoperation (11% vs. 9%; p = 0.55). The mean follow up time for patients in the over 60 group was 14.2 months, and 12.1 months in the under 60 group. In terms of weight loss, with longer term follow up younger patients experienced more excess body weight loss (54.7% vs 46.2%; p = 0.008).

Conclusion: The results of this series demonstrate that bariatric surgery in elderly patients is not only safe, but effective. Although younger patients tended to lose more weight, elderly patients still lost a clinically significant amount of weight. Age alone should not preclude a patient from undergoing bariatric evaluation.


Obesity and Non-alcoholic Fatty Liver Disease: Cause and Effect?

Khaleel Mohammad, MD1Marcoandrea Giorgi, MD 1, Jawad Ali, MD1, Rouzbeh Moustaedi, MD2, Aaron Carr, MD1, Mohamed Ali, MD11UC Davis Medical Center, 2The Permanente Medical Group

Introduction: Obesity has been commonly cited to be a major risk factor for the occurrence and progression of non-alcoholic fatty liver disease (NAFLD). In particular, bariatric surgery patients are hypothesized to be at highest risk for NAFLD and its consequences. In this study, we sought to characterize the extent of NAFLD, the prevalence of progression to NASH and fibrosis, and identify patient characteristics that correlate with fatty liver disease in this high-risk population.

Methods: Core liver biopsy was obtained on 529 consecutive patients undergoing bariatric surgery and assessed for the degree of steatosis, portal inflammation, and hepatic fibrosis. Demographic, anthropometric, laboratory, and co-morbidity data were collected and analyzed to identify relationships between the clinical condition of the patient and NAFLD.

Results: The study included 529 patients with an average body mass index (BMI) and age of 45.3 ± 7.5 kg/m2 and 45.3 ± 11.2 years, respectively. Metabolic syndrome was present in 71.8% of patients. Hepatic steatosis, NASH and fibrosis were present in 69.6, 44.2 and 18.1% of patients, respectively. There was a significant direct correlation between degree of steatosis and preoperative BMI (p < 0.05), serum triglycerides (p < 0.0001), and hemoglobin A1C (HbA1C) (p < 0.0001), while HDL showed an inverse correlation with the degree of hepatic steatosis (p < 0.001). Patients with metabolic syndrome had more steatosis (p < 0.0001) and steatohepatitis (p < 0.005) than patients without metabolic syndrome.

Conclusions: Factors such as elevated BMI, triglycerides, HbA1C and presence of metabolic syndrome correlated with the degree of hepatic steatosis. Although the majority of patients in this study exhibited hepatic steatosis, 30.4% of patients did not have steatosis despite having the high risk traditionally ascribed to advanced obesity. These findings suggest that the mere presence of obesity may not be enough to promote the progression of NAFLD to NASH and fibrosis and indicate that metabolic dysregulation may play a more vital role.


Despite Risk Factors, the Incidence of C. Difficile Infection in Bariatric Patients Remains Low and Laparoscopic Sleeve Gastrectomy Confers the Lowest Risk

Luke Putnam, MD, Sahil Gambhir, MD, Gabrielle Stretz, BSc, Areg Grigorian, MD, Megan T Smith, PhD, Brian R Smith, MD, Ninh T Nguyen, MD, Shaun Daly, MD; University of California Irvine Medical Center

Introduction/Objectives: Clostridium Difficile is a significant source of morbidity in hospitalized patients. Obesity and major gastrointestinal operations are known risk factors for clostridium difficile infection (CDI). Currently, there is limited data suggesting laparoscopic roux-en-Y gastric bypass (LRYGB) is also associated with an increased incidence of CDI compared to laparoscopic sleeve gastrectomy (LSG). We hypothesized the rate of CDI in the bariatric population is elevated given inherent risk factors of this patient population and that LSG may confer less risk than LRYGB.

Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was queried to identify patients who underwent LSG and LRYGB between 2015 and 2016. Data was collected from each patient’s index admission. As a surrogate for the true incidence of CDI, treatment of CDI was used. Descriptive statistics and multivariable logistic regression analyses were performed to obtain odds ratios (OR) and 95% confidence intervals (CI).

Results: During the study period, 167,563 (71%) patients underwent LSG and 67,525 (29%) underwent LRYGB. The overall incidence of CDI in our study population was 0.07%. The incidence of CDI in index hospital admission in patients undergoing LSG was 0.05% compared to 0.09% in patients undergoing LYRGB. The risk of CDI during the index hospital admission in LSG patients compared to LRYGB patients was 0.64 (95% CI 0.47-0.88; p = 0.006).

Conclusion: While literature reports obesity remains a risk factor for development of CDI, the overall incidence of 0.07% remains low in postoperative bariatric patients. CDI does not represent a significant source of postoperative morbidity during index admission. In bariatric patients, those undergoing LSG have a significantly decreased risk of developing CDI compared to LRYGB patients.


Opioid Use Reduction Secondary to Remission of Osteoarthritis Associated Pain in Severely Obese Subjects Undergoing Bariatric Surgery

Maria C Fonseca, MD, Cristian Milla Matute, MD, Camila Ortiz Gomez, MD, Francisco Ferri, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Background: Unbearable pain associated with symptomatic Osteoarthritis(OA) is among the causes of work loss worldwide. Schedule II/III opioids are frequently used for this purpose, however is highly associated to abuse. The aim of this study is to describe OA in our population and the opioid reduction and cessation after undergoing Bariatric Surgery.

Methods: After IRB approval, we performed a retrospective analysis of all severely obese patients with a BMI above 35 kg/m2 and Osteoarthritis who underwent bariatric surgery from January 2004 to February 2018 at our institution. OA remission was assessed by the decrease in the dose of opioid medication for pain management or cessation during 6 and 12 months. Patients were matched for demographics. We excluded patients who received opioids due to Polymyalgia rheumatic and fibromyalgia.

Results: From 4226 patients, 11% (N = 483) met the inclusion criteria. Female gender was predominant (N = 335; 69.4%). Average BMI was 43.93 ± 8.8 kg/m2. Performed surgeries were as follows: LSG in 43.8% (N = 213) patients, RYGB in 39.9% (N = 194) patients and AGB in 16.1% (N = 78) patients (table 1). Remission was achieved in 95% (N = 495) and 97% (N = 471) of the patients at 6 and 12 months respectively. Overall statistical significance was attributed to Opioid dose reduction at 6 and 12 months was found in 54.2% (N = 13) and 75% (N = 9) (p = 0.02 and P = 0.06) respectively, when compared to preoperatively. Oxycodone was predominantly prescribed at 6 months in 54.2% (N = 13) and 12 months in 41.7% (N = 5) of the patients, with no statistical difference among procedures (p = 0.15 in both terms) (Table 2).

Conclusion: In spite of the discriminated consumption of opioids for pain control, Bariatric Surgery seems to reduce substantially their use, by achieving OA remission in 97% of our patients at 12 months. Further studies will need to be done to confirm these findings.


Laparoscopic Selective Intra-abdominal Denervation Associated to a Duodenum Ileal Interposition and Sleeve Gastrectomy for the Treatment of Type 2 Diabetes (SID-DISG)

Luciana J El-Kadre, MD, PHD, FACS 1, Aureo L De Paula, MD, PHD2, Augusto C Tinoco, MD, PHD, FACS1, Surendra Ugale, MD3, Jose Ribamar De Azevedo, MD, PHD, FACS4, Carolina De Paula, MD2, Leonardo Ferraz, MD51Sao Jose do Avai Hospital, 2Hospital de Especialidades, 3Kirloskar Hospital, 4Americas Hospital, 5Bonsucesso Federal Hospital

No single medication can approach all the pathophysiologic disturbances that characterize type 2 diabetes (T2D). Current medical therapy involves the combined use of multiple drugs to control the disease. With this concept in mind, the laparoscopic duodenum ileal interposition and sleeve gastrectomy (DISG) is an operation that intends to address the different components of the pathophysiology of T2D. The objective of this study is to evaluate the early results of this operation combined with a selective intra-abdominal denervation in diabetic patients with BMI below 35.The procedure was performed in 33 patients. 29 were men and 4 women. Mean age was 56.3 years (34-71). Mean BMI was 32.2 kg/m2 (26.7-34.9). All patients had evidence of stable treatment with oral hypoglycemic agents and or insulin for at least 12 months. Insulin therapy was been used by 36% of the patients. Mean duration of T2DM was 11.4 years (4-32). Mean A1c was 9%. Coronary heart disease was diagnosed in 27.3, hypertension in 72.7, dyslipidemia in 94, retinopathy in 24.2, nephropathy in 24.2 and cholelithiasis in 18.2% of the patients.Mean post-operative follow-up was 22 months (9-33). Mean postoperative BMI was 23.3 kg/m2 (19.6-27). Mean A1c was 5.8%, ranging 4.6 to 8. Overall, 87.9% of the patients achieved an adequate glycemic control (A1c ≤ 6) without anti-diabetic medication and 83.3% had fasting glucose < 126 mg/dl. Arterial hypertension was controlled in 95.8% of the patients, hypercholesterolemia in 96.8%, and hypertrygliceridemia in 93.1%. The results of this short-term study demonstrated that the combination of a selective intra-abdominal denervation to the laparoscopic DISG improved the glycemic, hypertensive and dyslipidemic remission rates of T2D patients with BMI below 35. The scalpel seems to be an effective tool in controlling diabetes using the concept of an endocrine-based, pathophysiological, understanding of the disease.


The Role of Laparoscopic Bariatric Procedures in the Improvement of Pre-operative Uncontrolled/Resistant Hypertension and its Impact on the 10-Year Risk of Cardiovascular Disease

David Romero Funes, MD, David Gutierrez Blanco, MD, Camila Ortiz Gomez, MD, Joel S Frieder, MD, Cristian Milla Matute, MD, Emanuele Lo Menzo, MD, Samuel Szomstein, MD, Raul Rosenthal, MD; Cleveland Clinic Florida

Introduction: Although several studies have addressed the improvement of hypertension (HTN) after bariatric surgery, only a few of them specifically addressed the effects of the procedures on uncontrolled/resistant HTN. The aim of our study is to assess the remission of uncontrolled/resistant hypertension and its impact in the risk of cardiovascular disease (CVD) of morbidly obese patients following laparoscopic bariatric procedures.

Methods: We retrospectively reviewed all patients who underwent Laparoscopic Bariatric surgery at our institution from 2010-2014. We used the guidelines of the American College of Cardiology (ACC) to define HTN and uncontrolled/resistant hypertension. Only patients who met the criteria for the ACC and the calculation of the Framingham-BMI 10-year risk score pre-operatively at 3 months and at 12 months follow-up were included.

Results: Of the 1,200 patients reviewed, 203(16.91%) met the required criteria of uncontrolled/resistant HTN according to the ACC and had the required variables for the risk assessment of CVD using the Framingham-BMI 10-year risk score. The most prevalent procedure was Laparoscopic sleeve gastrectomy LSG n = 133 (65.51%). The most significant improvement found was an amelioration of 15mmhg and 13mmgh when comparing of systolic blood pressure pre-operatively, at 3 and 12 months follow-up respectively(P = 0.0001). The improvement in the risk of CVD is shown by an absolute risk reduction(ARR) of 14% at 3 months and 15% at 12 months follow-up, both evidencing statistically significant (P = 0.0001) In the patients with resistant hypertension the mean heart age was 80.81 ± 9.11.

With regard to the Heart age, we observe an improvement of 6.76 and 7.33 years when comparing heart age pre-operatively, at 3 months and at 12 months follow-up. Both showing statistical significance (p = 0.0001)

Conclusions: Our results suggest that laparoscopic bariatric procedures have a positive impact on patients with uncontrolled/resistant hypertension. This results also translates into significant cardiovascular disease risk reduction. Furthermore, the Cardiovascular disease risk reduction also demonstrates a most dramatical improvement in patients with resistant hypertension.


Gastric Cancer After Roux-en-Y Gastric Bypass: Case Report

Diego L Lima, MD 1, Victor M Diniz, MD1, Camila Maria N Firme, MD1, Jose Julio F Arruda, MD1, Raquel N Cordeiro, Medical Student2, Lucas M Aires Camara, MD1, Lucas M Vasconcelos De Albuquerque, MD1, Marconi Roberto L Meira, MD, MsC1, Geraldo Jose P Wanderley, MD11State Servers Hospital, 2Pernambuco Health Faculty

Introduction: The incidence of gastric adenocarcinoma in patients undergoing Roux-en-Y gastric bypass (BPGYR) is rare. Over the past 10 years, just over 30 cases have been reported, most of which were in the excluded stomach. The pathogenesis is still unknown. However, it is believed that chronic reflux, H. pylori infection and gastric stasis of undigested food would be associated with the genesis of cancer. Symptomatology usually includes nonspecific symptoms, the most common being abdominal pain. The most accurate diagnostic method is upper GI. However, the difficulty in accessing the remaining stomach in patients submitted to bypass, ends up delaying the diagnosis in these patients.

Case Report: A 68-year-old woman who had been submitted to BPGYR for morbid obesity 15 years ago presented with epigastric pain and melena, and a mass was identified by computed tomography of the abdomen and Upper GI. In view of persistent bleeding and acute anemia, laparotomy with total gastrectomy and esophageal-jejunal anastomosis was performed. Histology showed a well differentiated adenocarcinoma. Surgery had no major bleeding and no further complications. Patient was discharged and had adjuvant chemotherapy.

Conclusion: Gastric adenocarcinoma´s symptomatology is unspecific in most of the patients. Its diagnosis is also postponed because it is very difficult to analyze of the excluded stomach. When these patients present general and unspecific symptoms, it is recommended to perform a CT scan or an Upper GI in a center of excellence.


Reversal of Minigastric Bypass to Normal Anatomy

Ahmed Elgeidie, Elsayed Adel; Gastrointestinal Surgery Center

Background/Aim: One of the big advantages of minigastric bypass (MGB) is being a reversible bariatric procedure. This study was designed to describe and analyze the outcome of laparoscopic reversal of MGB to normal anatomy (NA).

Methods: This is a retrospective analysis of the outcome of reversal of MGB to NA.

Results: Between March 2007 and August 2017, at our gastrointestinal surgery center, Mansoura University, six patients underwent laparoscopic reversal of MGB to NA. The indication for reversal was severe intractable malnutrition (n = 3), severe persistent bile reflux associated with excessive weight loss (n = 1), leakage from gastrojejunostomy after MGB (n = 1), and leakage from the site of previously placed Lap-Band (n = 1). All cases were completed laparoscopically with no conversion to laparotomy. Postoperative complications after reversal to NA for malnutrition were reported in two patients; one patient developed major intraluminal bleeding immediately postoperatively that was controlled by open surgery, and the other patient developed adhesive intestinal obstruction five months postoperatively that was corrected by laparoscopic adhesiolysis. Major leakage was reported in the early postoperative period after reversal to NA for leaking MGB; one from gastrojejunostomy and the other one from gastrojejunostomy and the site of previous band managed by open exploration. The first case was managed by feeding jejunostomy and conservative treatment while the other case required open total gastrectomy with roux-en-Y esophagojejunostomy. No mortality was reported in any case. With a mean follow-up of 11.5 months, all patients completely recovered from their initial condition.

Conclusion: MGB can be reversed to NA. Reversal of MGB to NA as an option for leakage seems not a good one. The outcome of MGB reversal to NA for correction of malnutrition is favorable but on the expenses of high morbidity.

Keywords: Minigastric bypass, reversal, normal anatomy, malnutrition, leakage


Concurrent Paraesophageal Hernia Repair and Sleeve Gastrectomy is Safe and Well Tolerated

Eugene Wang, MD, Chaitanya Vadlamudi, MD, Elizabeth Zubowicz, MD; Medstar Georgetown-Washington Hospital Center

Introduction: The aim of this study is to evaluate short term morbidity, if any, of concomitant paraesophageal hernia repair (PHR) in patients undergoing laparoscopic sleeve gastrectomy (LSG). LSG is now the most widely used surgical intervention for morbid obesity, however significant concern exists about exacerbating or creating de novo gastroesophageal reflux disease (GERD) in these patients. Undiagnosed or untreated paraesophageal hernias may contribute to symptomatic GERD in these patients. They are present in 15% of patients with body mass index (BMI) over 35 kg/m2. Intra-operative diagnosis of hiatal hernias is estimated to occur in 1/3 of LSG performed.

Methods and Procedures: Retrospective, single center case control study (2016-2018) using data from Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Inclusion criteria: patients who underwent concurrent LSG and PHR. Primary endpoints: operative time (minutes), length of stay (LOS, days), BMI difference, emergency department (ED) visits, and mortality. Independent t-test was used for continuous data. Pearson’s Chi squared test was used for categorical data, reported as percentages.

Results: Nine patients were identified with concurrent surgery by LSG and PHR, with 30 day follow-up. 562 control patients during this time period underwent LSG only. There were no statistically significant differences between the two groups’ co-morbidities in terms of diabetes, obstructive sleep apnea, GERD and hypertension. The LSG and PHR group was approached robotically 77.7% of the time, which was more frequent than the LSG only group which was approached robotically 40.5% of the time, p = 0.024. The operative time for the LSG and PHR group was on average 134.2 ± 69.7 min, which was longer than the LSG only group, which averaged 101.4 ± 45.4 min, p = 0.062. There were no statistically significant differences between the two groups in terms of LOS 1.1 ± 0.3 vs 1.4 ± 1.9 days (p = 0.472), BMI difference post-surgery 3.0 ± 0.6 vs 3.3 ± 2.6 (p = 0.242), ED visits 11.1% vs 10.1% (p = 0.924), and mortality 0% vs 0% (p = 0.858).

Conclusion: Concurrent surgery with LSG and PHR is safe to perform during the same operation, with no statistical difference in LOS, weight loss, morbidity or mortality, and only had minimally longer operative times. Given the high incidence of reflux symptoms after LSG, future studies should investigate improvement with LSG and PHR as opposed to LSG alone in those with a concurrent paraesophageal hernia.


Does Adding a Concurrent Surgery to a Laparoscopic Roux en Y Gastric Bypass Lead to Increased Morbidity?

Haley Leesley, MD, Mia Shapiro, MD, Todd Stafford, MD, Beth Ryder, MD, Dean Roye, Sivamainthan Vithiananthan, MD; Warren Alpert Medical School of Brown University/Miriam Hospital, Providence, Rhode Island, USA

Introduction: Morbidly obese patients being evaluated for gastric bypass will often present with concurrent surgical pathology. The aim of this study is to determine if surgical risk is greater in patients undergoing an additional procedure at the time of laparoscopic roux-en-y gastric bypass (LRYGB) as compared to patients undergoing LRYGB alone.

Methods: A retrospective review was performed on all patients who underwent LRYGB or LRYGB plus a concurrent procedure between 2013-2017 at our institution using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. The most commonly performed concurrent procedures we included were paraesophageal hernia repair, ventral/umbilical hernia repair and cholecystectomy for symptomatic cholelithiasis. Our primary outcome was 30-day morbidity as defined by MSBAQIP. Our secondary outcomes included length of surgery, hospital length of stay, thirty-day readmission and major morbidity.

Results: We identified 620 total patients who underwent either a LRYGB or a LRYGB with one of the concurrent procedures listed above. 564 patients (91%) underwent LRYGB alone and 56 (9%) underwent LRYGB with a concurrent procedure. Patients who underwent LRYGB with concurrent procedures were significantly older (median age: 47.0 vs 43.0, p = 0.02), however had a lower preoperative BMI (45 ± 6.7 vs 47.8 ± 7.5 kg/m2, p = 0.004). There were no significant differences in other medical comorbidities, including smoking, COPD, sleep apnea or hypertension. The average length of surgery was higher for patients undergoing a concurrent procedure (163 min ± 47.7 vs. 146.7 min ± 47.5, p = 0.005). In regards to our primary outcome, we found that patients who underwent concurrent procedures were more likely to suffer a post-op morbidity (OR 4.11, 95% CI 1.74-9.72, p = 0.005) when compared to those who had a LRYGB alone. They were also significantly more likely to suffer a major morbidity (OR 2.97, 95% CI 1.06-8.34) and the odds of a 30-day post-operative readmission was over 6 times higher (OR 6.05, 95% CI 1.96-18.8, p = 0.005).

Conclusions: We found that adding a concurrent procedure on to a LRYGB was associated with increased length of surgery, increased rates of 30-day readmissions, and increased overall 30-day morbidity along with major morbidity.


The Impact of Low Preoperative Albumin on Short-term Outcomes After Bariatric Surgery

Amlish B Gondal, MD, Matthew E Mobily, MD, MPH, Iman Ghaderi, MD, MSc, MHPE; University of Arizona

Introduction: Obesity and malnutrition often coexist; malnutrition in turn is an established risk factor for adverse outcomes after surgery. Preoperative albumin is routinely used as surrogate parameter for nutritional status prior to surgery. The aim of this study was to assess the effect of low preoperative albumin on outcomes within 30 days after bariatric surgery.

Methods: An observational study of patients undergoing primary sleeve gastrectomy (SG) and gastric bypass (GB) from the MBSAQIP® PUF 2016 was performed. Chi square and two tailed t-test analyses were used for categorical and continuous outcomes, respectively, with p < 0.05 denoting statistical significance. Logistic regression analysis was performed and odds ratio (OR)along with 95% confidence intervals (CI) were calculated for significant risk factors for Clavien category IV (CD-IV), category V (CD-V) and composite infection rate (CIR) (defined as occurrence of any of the following: pneumonia, superficial SSI, deep SSI, UTI, sepsis, septic shock or clostridium difficile infection) after bariatric surgery.

Results: A totla of 106526 patients were included, 79.7% were female, 73.8% were white, and mean preoperative BMI was 44.3 ± 13.7 kg/m2. SG was performed in 72% in the patients and 28% patients underwent GB. Ten percent patients (n = 11559) had low preoperative albumin (< 3.5 g/dL) where the rest had normal albumin. The group with low and normal albumin had comparable baseline demographics and distribution of comorbidities.

When compared to patients with normal albumin, patients with low albumin experienced higher rates of Clavien category V complication (0.2% vs 0.08%, p < 0.001), Clavien category IV complications (1.3% vs 0.8%, p < 0.001), composite infection rate (2% vs 1.4%, p < 0.001) and 30-day readmission rate (5.3%, 3.8%, p < 0.01). Those with low preoperative albumin also had a longer length of hospital stay (1.9 ± 1.7 vs. 1.6 ± 1.2 days). On logistic regression, low preoperative albumin was associated with higher odds of Clavien category V complications (OR = 2.2, CI = 1.4-3.5, p < 0.001), Clavien category IV complications (OR = 1.4, CI = 1.1-1.6, p < 0.001), and any-cause infection (OR = 1.3, CI = 1.1-1.6). The regression models had good calibration tested through Hosmer- Lemeshow goodness-of-fit test (for CD-V: χ2 = 10.8, p = 0.21; for CD-IV: χ2 = 6.8, p = .55; for CIR: χ2 = 3.5, p = 0.89). Figure 1 demonstrates the discriminatory capacity of regression models for CD-V, CD-IV and CIR.

Conclusion: Preoperative albumin levels below 3.5 g/dL are a significant risk factor for serious short term-morbidity after primary bariatric surgery. Further research should focus on nutritional risk stratification and rehabilitation of patients prior to bariatric surgery.


The Utility of Routine Preoperative Upper Gastrointestinal Series for Laparoscopic Sleeve Gastrectomy

Warren Sun, MD 1, Jerry T Dang, MD1, Noah J Switzer, MD, MPH, FRCSC2, Daniel Birch, MD, MSc, FRCSC1, Shahzeer Karmali, MD, MPH, FRCSC11University of Alberta, 2Ohio State University Wexner Medical Center

Introduction: We aim to study the diagnostic utility of routine UGI series for preoperative evaluation of LSG in our center. Laparoscopic sleeve gastrectomy (LSG) has become the most commonly performed primary bariatric procedure for the treatment of severe obesity in North America. However, there is no consensus for the preoperative diagnostic evaluation for patients undergoing LSG. The role of preoperative upper gastrointestinal (UGI) series to evaluate candidates for LSG is debatable.

Methods and Procedures: A retrospective chart review for patients planning to undergo LSG with one surgeon at our hospital from May 2015 to April 2017 was completed. Primary outcomes included UGI findings and consequential changes in clinical management. Secondary outcomes included preoperative symptomology and postoperative complications.

Results: 36 patients were identified from billing records of a single surgeon and were originally scheduled to undergo LSG. Four patients were male and 32 (88.9%) were female. The average age was 43.2 ± 2.1 years and average preoperative BMI was 47.3 ± 1.2 kg/m2. 22 (61.1%) patients underwent a preoperative UGI series, of which, 8 (36.4%) patients had hiatal hernias, 9 (40.9%) had gastroesophageal reflux, and 2 (9.1%) had dysmotility. Additionally, four (18.2%) of the 22 patients had a change from LSG to laparoscopic Roux-en-Y gastric bypass (LRYGB) due to significant reflux or dysmotility found on UGI. Patients who did not receive preoperative UGI received preoperative esophagogastroduodenoscopy (EGD) for a variety of reasons. 18 (50.0%) patients underwent a preoperative EGD, of which 4 (22.2%) had esophagitis and 5 (27.8%) had gastritis. One additional patient required a change of surgical management to LRYGB due to reflux found on EGD. Overall, 31 (86.1%) patients had LSG and 5 (13.9%) patients had LRYGB. The average postoperative BMI was 38.7 ± 1.4 kg/m2, after an average follow-up period of 8.3 ± 0.8 months. Four (11.1%) patients had postoperative complications, including two LSG requiring revision to LRYGB for reflux esophagitis, one LSG with dysphagia, and one LRYGB with a marginal ulcer.

Conclusion: Our cohort demonstrated that preoperative UGI has the potential to screen for pathology that may affect outcomes after LSG, and changed clinical management in almost one-fifth of patients undergoing UGI. Overall, UGI is a relatively simple and inexpensive test for the preoperative evaluation of patients before LSG.


Risk Factors of Intraoperative Difficulties During Laparoscopic Sleeve Gastrectomy

Artur Kacprzyk 1, Magdalena Pisarska, MD2, Tomasz Stefura1, Piotr Malczak, MD2, Marcin Dembinski, MD, PhD2, Jakub Dros1, Katarzyna Chlopas1, Michal Wysocki, MD2, Michal Pedziwiatr, MD, PhD2, Andrzej Budzynski, MD, PhD2, Piotr Major, MD, PhD21Students’ Scientific Group at 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, 22nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland

Introduction: Laparoscopic Sleeve Gastrectomy (LSG) is one of the most frequently performed bariatric procedures worldwide. Preoperative knowledge concerning risk factors of potential intraoperative difficulties may help to predict outcomes and influence the operative approach.

Aim of the study: Our purpose was to identify potential risk factors of intraoperative difficulties during LSG.

Materials and methods: The analysis included consecutive patients who underwent LSG between December 2009 and April 2017. Patients with intraoperative difficulties were submitted to Group 1, patients without intraoperative difficulties to Group 2. Demographic parameters were assessed for potential risk factors of intraoperative difficulties. Length of stay (LOS) and complication rate were also analysed.

Results: Group 1 consisted of 37 (11.71%) and Group 2 of 279 (88.29%) patients. Besides rates of diabetes, pulmonary disease and sleep apnea, which were higher in group 1, there were no statistical differences between the groups based on demographic parameters. Univariate logistic regression found that risk factors affecting intraoperative difficulties included BMI > 45 kg/m2 (OR 2.15, 95% CI 1.05-4.39, p = 0.0362), experience of operating surgeon (OR 9.22, 95% CI 4.31-19.72, p = 0.0058), incidence of diabetes (OR 2.44, 95% CI 1.19-4.98, p = 0.0146) or pulmonary disease (OR 12.22, 95% CI 1.97-75.75, p < 0.0001). In the multivariate logistic regression model only experience of operating surgeon (OR 8.61, 95% CI 3.75-19.72, p < 0.0001) remained significant factor affecting intraoperative difficulties.

Conclusions: The only significant factor contributing to the incidence of intraoperative difficulties is the experience of the surgeon.

Keywords: sleeve gastrectomy, intraoperative difficulties, risk factors, postoperative complications


Endoluminal Revision of the Dilated Gastrojejunostomy: The State-of-the-art Cure of Dumping Syndrome After Gastric Bypass

Hamzeh Halawani, MD; Farah Medical Complex

Dumping syndrome is an underdiagnosed consequence after Roux en Y Gastric bypass. High osmolar food that passes rapidly due to accelerated pouch emptying and a dilated Gastro-Jejunal Anastomosis (GJA) results in osmotic overload and classical symptoms of hypoglycemia. New data links the presences of a dilated GJA and dumping syndrome to weight regain after gastric bypass. For those patients who suffer from intractable dumping syndrome, dietary changes, somatostatin analogues and surgical approaches are all well described. Endoluminal reduction of the GJA using a full thickness endoscopic suturing device is an attractive approach due to high success rate, safety and durability. Multiple recent reports concluded that a dilated > 10 mm GJA has been shown to be a major and an independent predictor or weight regain. Endoluminal solutions for patients who underwent a bariatric procedure is an exciting field for both the surgeon and the gastroenterologist. We present a case after a complete cure of intractable dumping syndrome using an endoscopic full-thickness suturing device.


Hormonal Response of Sleeve Gastrectomy. Does the Size of the Bougie Have an Influence?

Berta Gonzalo, Carlos Rodríguez-Otero, Meritxell Garay, Mercedes Camacho, Sonia Fernández, Inka Miñambres, Irene Gómez, Eulàlia Ballester, Carmen Balagué; Hospital Sant Pau

Background amb Aims: Laparoscopic vertical gastrectomy (LSG) is a growing technique in recent decades for the treatment of obesity. There are different theories about the influence of LSG on the hormones involved in glycolipid metabolism. The aim of this study is to analyze the influence of this technique on the levels of GIP, GLP-1, glucagon, ghrelin, insulin, leptin and PYY and the presence of differences according to the two bougie sizes used for gastrectomy.

Materials and methods: Prospective randomized study (Protocol IIBSP-RES-2012-178, EAES Research Project) that included patients undergoing vertical gastrectomy randomized into 4 groups according to distance to the pylorus at the beginning of gastrectomy (2 vs 5 cm) and size of the probe used for the gastrectomy (bougie size, 33 vs 42 Fr). A total of 33 patients (24 women and 9 men) who had completed the complete follow-up one year after the intervention were analyzed. The blood values ??of GIP, GLP-1, glucagon, ghrelin, insulin, leptin and PYY were determined preoperatively, postoperatively immediately (48 h post IQ), 2 months and 1 year postoperatively.

Results: The average decrease of the hormones studied, at in the immediate postoperative period, at 2 months and a year after sleeve gastrectomy were (pg/ml): GIP 48.65 ±  10.09/33.15 ± 11.97/37.84 ± 10.45, GLP-1 6.29 ± 6.85 (p = 0.36)/13.01 ± 5.07/17.71 ± 8.03, glucagon − 13.73   ±  7.28 (p = 0.06)/15.06 ± 6.14/21.78 ± 5.68, ghrelin 33.55 ± 6.73/30.36 ± 7.02/32.49 ± 6.76, Insulin 209.56 ± 108.98 (p = 0.06)/704.13 ± 124.32/788.91 ± 97.76, Leptin − 6964.24 ± 4757.32 (p = 0.15)/24143.03 ± 4744.26/24192.67 ± 5368.06 and PYY 14.51 ± 20.08 (p = 0.47)/8.19 ± 12.79 (p = 0.53)/1.29 ± 9.65 (p = 0.89). All results were statistically significant excepte those specified with the value of p.

Conclusion: Laparoscopic vertical gastrectomy has significant effects on the hormones involved in obesity, mainly at two months and one year after surgery. The size of the bougie is not an influential factor in the observed hormonal response.


Clinical Outcomes of Laparoscopic Greater Curvature Plication and Laparoscopic Sleeve Gastrectomy

Caleb J Ba Mendoza 1, Osamuyi Idubor1, Aisha Tabba1, Joel Miller1, Aliu Sanni, MD, FACS21Philadelphia College of Osteopathic Medicine, 2Eastside Bariatric and General Surgery LLC

Introduction: Laparoscopic greater curvature plication (LGCP) is an emerging restrictive bariatric procedure that successfully reduces the gastric volume by folding of the greater curvature of the stomach. Laparoscopic Sleeve Gastrectomy (LSG) and LGCP have been both successfully performed in recent years. The aim of this study is to compare the clinical outcomes of LSG vs. LGCP.

Methods and Procedures: A systematic review was conducted through PubMed to identify pertinent studies from 2009-2016 with comparative data on patients who underwent LGCP and LSG. The outcomes analyzed were  %EWL at 12 months, operative times and length of hospital stay. The results are expressed as standard difference in means with standard error. Statistical analysis was done using fixed-effects meta-analysis to compare the mean value of the two groups. (Comprehensive Meta-Analysis Version 3.3.070 software; Biostat Inc., Englewood, NJ).

Results: Five out of 215 studies were quantitatively assessed and included for meta-analysis. A total of 460 subjects underwent bariatric surgery; 221 had LGCP and 239 had LSG. The  % EWL (− 0.541 ± 0.095, p < 0.0001) was higher in the patients who underwent LSG when compared to LGCP. There was no difference in the mean operative times (0.073 ± 0.095, p = 0.441) or hospital length of stay (− 0.021 ± 0.094, p = 0.825) between both group of patients.

Conclusion: LSG results in higher weight loss at 12 months when compared to LGCP.


Outcomes Following Robotic-Assisted Compared to Conventional Laparoscopic Primary Bariatric Surgery: A Review of the MBSAQIP Database

Edwin Acevedo, MD 1, Huaqing Zhao, PhD, MS2, Xiaoning Lu, MS2, Rohit Soans, MD2, Michael A Edwards, MD, FACS, FASMBS21Temple University Hospital, 2Lewis Katz School of Medicine at Temple University

Introduction: Robotic-assisted bariatric surgery (RBS) is increasingly performed. The overall benefit of RBS compared to conventional laparoscopic bariatric surgery (LBS) remain controversial. In this study, we compare outcomes between RBS and LBS using a large risk-stratified clinical database. We hypothesize that LBS is safer and more cost-effective than RBS.

Methods: A retrospective analysis of the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed. Primary RBS and LBS were analyzed. 1:1 case–controlled matching was performed. Cases and controls were match by demographics (age, gender, race, BMI) and preoperative comorbidities. Outcomes measures included operative length (OL), length of stay (HLOS), 30-day outcomes and complications.

Results: 278,761 primary bariatric operations were identified (93% LBS, 7% RBS). 79% were female and 64.7% white. Mean age and BMI were 44.6 years and 45.5 kg/m2. 16,291 matched RBS and LBS cases and controls were identified, and outcomes compared (Table 1). Conversion rate was higher in RBS (0.53% vs 0.1%, p < 0.0001). RBS was associated with longer OL (118 min vs 85 min, p < 0.0001) and HLOS (1.83 days vs 1.7 days, p < 0.0001). Readmission, reintervention, reoperation and leak rates were higher in RBS. Bleeding, cardiac arrest and 30-day mortality rates were higher in LBS. There was no difference in mortality related to bariatric surgery (p 0.74).

Conclusion: Robotic-assisted bariatric surgery is associated with longer OL, HLOS and higher complication rates, likely contributing to less cost-effectiveness. Both approaches remain safe, but LBS is associated with a higher all-cause 30-day mortality.

Table 1. Matched cohort outcomes


Outcomes, N (%)

LBS (N = 16,291)

RBS (N = 16,291)


30-Day Readmission

604 (3.71)

715 (4.39)


30-Day Intervention

229 (1.41)

278 (1.71)


30-Day Reoperation

194 (1.19)

232 (1.42)


30-Day Mortality

18 (0.11)

8 (0.05)



12 (0.07)

3 (0.02)



96 (0.59)

66 (0.41)


Aggregate Bleeding

68 (0.42)

48 (0.29)


Organ Space SSI

35 (0.21)

62 (0.38)


30-Day Drain Present

27 (0.17)

70 (0.43)


Agregate Leak

36 (0.22)

66 (0.41)



Incidence of Perioperative Hypoglycemia in Bariatric Patients with Diabetes Mellitus Type II: A Single Institution Experience

Cristian Milla Matute, MD, Maria C Fonseca, MD, Camila Ortiz Gomez, MD, Francisco Ferri Abreu, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Raul Rosenthal; Cleveland Clinic Florida

Introduction: Bariatric surgery (BS) has shown to be an effective method to permanently reduce weight and improve comorbidities associated with obesity. The most common cause of hypoglycemia is medications used to treat diabetes mellitus such as insulin and sulfonylureas. The incidence of hypoglycemia after BS has been reported ranging from 0-4.5%, although most of the studies consist of small case series. The aim of this study is to analyze the incidence of hypoglycemia in bariatric patients with Diabetes type II at our institution.

Methods: After IRB approval, a retrospective chart review of all patients who underwent bariatric surgery at our institution between 2006 and 2017 was performed. Patients with Diabetes type II and older than 18 years of age that underwent BS were included in the analysis. Fasting hypoglycemia was defined as a measurement of blood glucose level of < 75 mg/ml, with or without symptoms. The perioperative period was defined as 30 days before and 30 days after the BS date. SPSS software was used to perform descriptive statistics and Chi Square for categorical values. A P value < 0.05 was considered significant.

Results: A total of 4,098 patient met the inclusion criteria. The predominant gender was female 67.7% (n = 2,818), the mean age was 55.2 ± 7, mean BMI 40.6 ± 8 and the most common ethnicity represented was Caucasian 73.9% (n = 3,032). Regarding the type of surgery, 60% (n = 2,465) of the patients had LSG (Longitudinal Sleeve Gastrectomy), 29% (n = 1,186) had RNYGB (Roux-en-Y-Gastric Bypass), 10% (n = 423) Gastric Banding (LAGB), and 0.5% (24) had revisions. The incidence of hypoglycemia pre-operatively was 2.9% (86), and 4.04% (56) in the post-operative period. When analyzing the impact demographics and each procedure on the incidence of hypoglycemia in both groups, none of the variables resulted in statistically significant differences (table 1).

Conclusions: This is the first study to analyze perioperative hypoglycemia in bariatric patients with Diabetes Mellitus type II. Our reported incidence of hypoglycemia is 3.4% (n = 142) in the perioperative period of Bariatric Surgery. There was no statistical significant associated with hypoglycemia and type of bariatric procedure.


Measure Twice, Cut Once: Anatomy-Based Sleeve Gastrectomy Associated with Dramatic Benefits Versus Suction Bougie in Sleeve Gastrectomy Pouch Creation

Jonathan R Thompson, MD 1, Vikrom K Dhar, MD1, Dennis J Hanseman, PhD2, Brad M Watkins, MD1, Tayyab S Diwan, MD1, Thomas Inge, MD, PhD3, John M Morton, MD, MPH41University of Cincinnati College of Medicine, 2SET Data Collaborative, 3Children’s Hospital Colorado and University of Colorado, Denver, 4Stanford School of Medicine

Introduction: Anatomic imperfections in the sleeve gastrectomy pouch have been implicated in increased gastroesophageal reflux disease (GERD) and food intolerance following LSG. Anatomy-based sleeve gastrectomy (ABS) has been developed to improve the shape, volume and anatomic consistency of the laparoscopic sleeve gastrectomy (LSG) pouch. We report our one-year results using an ABS technique.

Methods: A quality improvement data collaborative was initiated with custom fields added to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Determination of “not human subjects research” was obtained from our IRB. ABS was implemented beginning in 6/2016. ABS consists of planning a sleeve gastrectomy pouch by marking the stomach 1 cm from the gastroesophageal junction, 3 cm from the IA, and 6 cm from the pylorus. The marks are lined up beside a 25 cm clamp and a 60 mm endocutter is used to resect the stomach. 641 ABS cases were compared to 737 cases where a 40F suction bougie was used for pouch creation (1/2014-5/2016). No programmatic changes were made during this time. 30-day safety, 6-month and 1-year GERD and weight loss outcomes were compared. Students t test and Chi square tests were used as appropriate.

Results: No significant differences in gender, preoperative BMI, or operative time were identified between groups (all p > 0.05). Average age was 45 in the bougie group and 43.5 in ABS (p = 0.02). ABS was associated with shorter length of stay (1.2 vs 1.7, p < 0.01), 42% fewer readmissions (3.3% vs 5.7%, p = 0.03), 61% fewer readmissions due to nausea/vomiting (1.1% vs 2.9%, p = 0.02). ABS patients had a 48% lower 6-month GERD rate (21% vs 40%, p < 0.01), 86% higher 6-month GERD resolution rate (54% vs 29%, p < 0.01), 49% lower 1-year GERD rate (20% vs 39%, p < 0.01), 106% higher 1-year GERD resolution rate (72% vs 35%, p < 0.01). Both groups had similar 1-year  % total weight loss (26.3% vs 27.3%, p = 0.41).

Conclusion: Anatomy-based sleeve gastrectomy offers benefits over sleeve gastrectomy with suction bougie with regard to 30-day safety and dramatic improvement of GERD rates at 6 months and 1 year.


Rogue Staples: An Alarming Trend Observed Over the Past Two Years

Allan E Stolarski, MD, MS, Olga Beresneva, MD, Cullen Carter, MD, Luise Pernar, MD, Brian Carmine, MD, Donald Hess, MD; Boston University Medical Center

Introduction: Our objective is to raise awareness of complications arising from loose or improperly folded staples (“rogue staples”) that originated from a staple closure device that was appropriately fired. Linear staplers are frequently used instruments across all disciplines of surgery and are highly relied upon tools to effectively complete operations in a safe, efficient, and reliable manner.

Methods and Procedures: At a busy urban tertiary care center from August 1st. 2016 until August 31st 2018 we observed seven cases of rogue staples causing bowel obstruction after several gastric bypasses and one appendectomy performed by various surgeons. Demographic data collected include age, procedure, and identification of the involved staple loads. Outcomes of interest include the number of days between the index surgery and presentation with obstruction, length of stay after representation, and the morbidity of observed patients.

Results: Over a two-year period we have identified seven cases related to a rogue staple protruding beyond the staple line after correct closure technique was applied resulting in adhesion (3 patients; 43%) or hooking of nearby bowel (4 patients; 47%). All of these patients required return to the operating room, during which time six patients (86%) were found to have a small bowel obstruction, and one patient (14%) suffered from internal hernia. The average time to representation was 8.57 days (range: 2-17 days). The average length of stay after representation was 4.29 days (range: 1-9 days), indicating and increased use of hospital resources.

Conclusion: Over two years, we present a series of seven cases where an improperly formed staple from a linear stapler caused direct mechanical obstruction or adhesion formation. These cases resulted in bowel obstruction or internal hernia in the early postoperative period requiring reoperation. To our knowledge, this is the largest case series in the literature describing this early postoperative complication. Due to our recent experiences following gastric bypass or appendectomy, general and bariatric surgeons should be aware of these potentially significant consequences of linear staplers.


Reversal of RYGB and Revision to Single Anastomosis Duodenal Ileal Bypass with Sleeve Gastrectomy (SADI-S) Using a Two Stage Approach. Safety, and 30 Day Outcomes for Patients with Failed RYGB

Ryan Fairley, DO 1, Moataz Bashah, MD2, Danial Cottam, MD3, Helmuth T Billy11Community Memorial Hospital, Ventura California, 2Hamad Medical Center, Doha Qatar, 3Bariatric Medical Institute, Salt Lake City, Utah

Background: Failed Roux-Y Gastric Bypass (RYGB) is a difficult problem with few options for treatment. We report a series of ten consecutive morbidly obese patients with weight regain following RYGB who were converted to SADI-S using a 2 stage approach.

Methods: 10 patients with a history of laparoscopic RYGB and weight regain (BMI > 35) were evaluated for surgical revision. Each patient completed medical weight management consisting of monthly appointments with a dietician, psychological evaluation and follow up with the physician team. All patients failed to achieve any significant weight loss. Each patient underwent laparoscopic reversal of the RYGB as a first stage followed by revision to laparoscopic SADI-S as a second stage.

Results: 10 morbidly obese patients underwent revision following weight regain after RYGB. Average pre-operative BMI was 44.3 with a range of 37.6 to 54.1. All patients underwent EGD without evidence of abnormal pathology. EGD revealed an average gastric pouch length between 5 and 6 cm. There was no evidence of pouch dilation, fistula, anastomotic dilation or other abnormality that might have contributed to weight regain. Presenting weight ranged from 210.5 lb to 362.4 lb. Each patient underwent laparoscopic reversal of their gastric bypass to normal anatomy. The average time from primary RYGB to reversal of gastric bypass was 8 years. Average operative time to perform the reversal RYGB to normal anatomy was 170.9 min. Average length of stay was 2.5 days.

Time between reversal of RYGB to laparoscopic SADI-S ranged from 3 to 6 months. Preoperative weight at the time of SADI-S ranged from 215.5 lb to 353.8 lb. Average operating time to perform the laparoscopic SADI-S was 198.3 min. Average length of stay was 2.7 days. 30 day post operative weight ranged from 196.6 to 316.6 lb and the average weight lost per patient in the first 30 days was 19.85 lb.

In the 30 days following SADI-S, 2 patients were seen in the emergency department for reflux, both treated with proton pump inhibitors not requiring admission. There were no reoperations, there were no deaths and there were no readmissions

Conclusions: Our series of 10 patients undergoing a two stage approach to revise failed RYGB to SADI-S appears to be a promising and safe approach to the challenge of weight regain following RYGB. Further long term follow up and a larger series will be needed to demonstrate safety and efficacy,


Preoperative Use of Arepitant for Laparoscopic Sleeve Gastrectomy and its Impact on Hospital Length of Stay in a Community Hospital Setting

Kristin Mccoy, MD, Meaghan Broderick, MD, James Bonheur, MD, Phillip Bilderback, MD; Stamford Hospital

Introduction: Laparoscopic sleeve gastrectomy was first performed in 2000 as a component of the biliopancreatic diversion with duodenal switch. Today, it is gaining popularity in the bariatric field as a stand-alone procedure for weight loss. However, patients continue to complain of postoperative nausea, vomiting and dry heaving due to the new anatomical constriction. Nausea and vomiting can be harmful to the newly formed staple line. Several anti-emetics are utilized in the postoperative patients. We aim to investigate the use of arepitant which is a neurokinin-1 inhibitor as a prophylactic anti-emetic in laparoscopic sleeve gastrectomy patients.

Methods: 36 patients from a multicenter bariatric practice were studied prospectively between October 2017- Septmeber 2018. Patient data collected included age, gender, BMI, post-operative use of anti-emetic medicine, episodes of emesis, and length of stay. Statistical analysis was performed on post-operative episodes of emesis, and administered doses of antiemetic medicine.

Results: There were 18 patients in each of the cohorts. The population was predominantly female with only one male in each of the cohorts. The average age in the arepitant group was 41.6 vs. 43.2 in the control group. Average starting body mass index (BMI) in the arepitant group was 41.9 vs. 41.0 in the control group. There was no statistical difference in BMI or age. The arepitant group required less post-operative emetics with 7.6 mg of Zofran administered in the arepitant group and 9.6 mg in the control group. The length of stay was also shorter in the arepitant group as compared to the control group (1.55 days vs. 1.73 days). There was no significant difference in number of episodes of emesis between the arepitant and control arms.

Conclusion: The preoperative use of arepitant aids in reducing the postoperative nausea and vomiting patients experience. Our results show promise in decreasing the length of stay in laparoscopic sleeve gastrectomy patients, as well as the amount of post-operative anti-emetics required. Arepitant should be considered in the use of bariatric elective procedures.


Outcome of Laparoscopic Sleeve Gastrectomy in Morbidly Obese Thai Patients

Pakkavuth Chanswangphuvana 1, Ajjana Techagumpuch1, Karikarn Auksornchart2, Sanit Wichansawakun31Division of Gastrointestinal and Endoscopic Surgery, Department of Surgery, Thammasat University, Pathum Thani, Thailand, 2Division of Trauma and Critical Care, Department of Surgery, Thammasat University, Pathum Thani, Thailand, 3Division of Clinical Nutrition, Department of Medicine, Thammasat University, Pathum Thani, Thailand

Background: Because of technical simplicity and the relatively good outcome, Laparoscopic Sleeve Gastrectomy (LSG) as a standalone bariatric procedure has rapidly gained popularity worldwide. LSG was also the most common bariatric procedure in Thailand. In our hospital, obesity clinic was established in June 2015 and the first bariatric procedure was LSG that was performed in November 2015. The objective of this study was to evaluate the outcomes for LSG in morbidly obese Thai patients.

Methods: There were 64 morbidly obese Thai patients underwent bariatric procedure that 52 procedures (81.3%) were LSG as a standalone procedure. The mean age was 37.6 years (19-58 years). The mean preoperative body weight and body mass index (BMI) were 140.7 kg (85-195 kg) and 51.2 kg/m2 (33.2-71.1 kg/m2) respectively. Twenty four super morbidly obese patients (46.2%) that BMI was more than 50 kg/m2 were included. All patients were evaluated and managed under a strict multidisciplinary team approach.

Results: There were neither morbidity nor mortality. The mean BMI declined to 36.5 ± 9.1 kg/m2 at 1 year and 31.3 ± 7.3 kg/m2 at 2 years (p < 0.001). The mean percent total body weight loss (%TWL) and mean percent excess body weight loss was 32.0 ± 13.3% and 62.1 ± 25.1% at 1 year and 39.0 ± 13.2% and 78.5 ± 23.8% at 2 years. Complete remission of type 2 diabetes was achieved in 8 patients (36.4%). Super morbidly obese patients had a tendency to achieve less weight loss. Revision of LSG were required in eight patients (15.4%) due to insufficient weight loss.

Conclusion: LSG for Thai morbidly obese patients is effective with good short-term outcomes. For super morbidly obese patients, other surgical options may be required. The revision of LSG is possible and mainly for insufficient weight loss.


Validation of the Modified Frailty Index as a Predictor of Outcomes After Bariatric Surgery

Jakub Dros 1, Tomasz Stefura1, Artur Kacprzyk1, Katarzyna Chlopas1, Magdalena Pisarska, MD2, Michal Wysocki, MD2, Michal Pedziwiatr, MD, PhD2, Andrzej Budzynski, MD, PhD, Professor2, Piotr Major, MD, PhD21Students’ Scientific Group at 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, 22nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland

Introduction: Obesity and aging are associated with declines in organ functions and constitute a marker of frailty. A modified frailty index (MFI) is a confirmed tool predicting postoperative morbidity and mortality, but its usefulness in the field of bariatric surgery has not been sufficiently investigated. As the population ages and more elderly patients seek bariatric procedures, it is essential to evaluate the method which may potentially improve quality and efficacy of the treatment.

Objectives: To assess the usefulness of MFI as a predictor of short- and long-term outcomes of bariatric surgery.

Methods: The retrospective analysis was conducted among 731 patients who underwent laparoscopic bariatric surgery during eight-year period. MFI was calculated using 11 variables defined in the National Surgical Quality Improvement Program of the American College of Surgeons. Primary endpoints of the study include intra- and postoperative parameters, secondary endpoints – long-term effects of bariatric treatment after one-year follow-up. The correlations between MFI and surgical outcomes were assessed. Additionally, a cutoff MFI score of 0.18 and above classified patients as “frail”.

Results: Increasing MFI was not significantly associated with longer operative time (p = 0.41 for sleeve gastrectomy, p = 0.88 for Roux-and-Y gastric bypass), higher rates of intraoperative adverse events (p = 0.36), postoperative complications (p = 0.08), reoperations (p = 0.16), readmissions (p = 0.21) and longer hospital stay (p = 0.25). Multivariate logistic regression models adjusted for relevant intergroup baseline differences did not show increased risks of negative intra- and postoperative outcomes in “frail” patients. Increasing MFI was negatively correlated with effects of bariatric treatment in terms of percentage of weight loss (p = 0.02) and percentage of excessive weight loss (p < 0.01), but not percentage of excessive body-mass index loss (p = 0.09).

Conclusion: Estimation of MFI in bariatric patients does not constitute a method predicting intra- and postoperative outcomes of the surgery. However, high MFI is associated with inferior long-term effects of bariatric treatment in terms of weight loss.

Keywords: bariatric surgery, modified frailty index, postoperative complications


Evaluating the Safety of Bariatric Surgery for Weight Loss in Class I Obesity: A Propensity-Matched Analysis of North American data

Gary G Gamme, MD 1, Jerry Dang, MD2, Noah Switzer, MD3, Richdeep Gill, MD4, Daniel Birch, MD2, Shahzeer Karmali, MD21University of Ottawa, 2University of Alberta, 3Ohio State, 4University of Calgary

Background: Bariatric surgery is a safe and effective treatment for severe obesity. However, there has been an evolving role for bariatric surgery as a primary treatment in the management of Class I obesity. Objectives: We aimed to assess safety of surgery by comparing the surgical safety of LSG and LRYGB in Class I obesity to those with Class 2 obesity and higher with an analysis of a large-scale matched patient cohort analysis. Setting International database, USA and Canada.

Methods: We performed a retrospective analysis using the MBSAQIP database, which collects patient information from over 790 bariatric surgery centers in North America. Patients included in our analysis underwent surgery in the years 2015 and 2016 and had either LRYGB or LSG for weight loss. A propensity matched analysis was performed between patients with Class I obesity and Class II obesity and higher for factors predictive of major complications and mortality.

Results: Initial analysis revealed 274,091 patients. Propensity matching resulted in 9,104 patients for analysis in each arm. The overall major complication rate between the two matched groups was 3.9% for Class I and 3.5% for Class 2 and higher (p = 0.09). We did not find that Class I obesity was associated with an increased risk of 30-day complication or death.

Conclusions: In our analysis of propensity-matched patients undergoing LSG and LRYGB for weight loss, Class I obesity did not have statistically higher risk of postoperative complication rates compared to Class II and higher.


Feasibility of Laparoscopic Sleeve Gastrectomy for Morbidly Obese Patients with Cardiomyopathy

Fahad Ba Mehriz, Consultant Laparoscopic and Bariatric1Hassan Arishi, General Surgery Resident 2, Mohammed Alali, General Surgery Resident11King Khalid university hospital, 2King Abdulaziz Medical City, National guard health affair

Background: Morbidly obese patients with associated co-morbidities have high perioperative morbidity and mortality. Cardiomyopathy found to be a predictor for mortality in those undergoing bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) with its low complications rate could be safe option for those patients.

Methods: A retrospective study of morbidly obese patients with cardiomyopathy underwent LSG (2016-2018). Length of stay, 30-day morbidity, mortality, and emergency department visits were assessed. The aim is to assess the feasibility and safety of LSG in morbidly obese patients with cardiomyopathy.

Results: Elven patients (7 men) with mean age 41.27 ± 5.16 years, preoperative body mass index (BMI) 52.78 ± 4 kg/m2 (39-88), and mean ejection fraction 38.73% (20.3-73.9). Six patients (54.5%) were having American Society of Anesthesiologists (ASA) class III. The mean length of stay was 5.6 days. There was no 30-day mortality. One patient was re-admitted due to sever dehydration and acute kidney injury.

Conclusion: Our study showed that LSG is feasible and safe for morbidly obese patients with cardiomyopathy. Further researches are recommended to assess postoperative ventricular function and quality of life.


Safety of Laparoscopic Heller Myotomy with Concurrent Gastric Bypass Compared to Primary Gastric Bypass: A Case-Controlled Analysis

Semeret T Munie, MD, Melissa C Helm, MS, Jon C Gould, MD, Andrew Kastenmeier, MD, Tammy L Kindel, MD, PhD; Medical College of Wisconsin

Background: Achalasia in the setting of morbid obesity is a unique surgical challenge as use of standard surgical therapy with a laparoscopic Heller myotomy (HM) carries a high likelihood of further postoperative weight gain and worsening of obesity-associated comorbidities. Concomitant treatment of achalasia and morbid obesity is an attractive consideration but with limited evidence in the literature beyond case reports to suggest an acceptable safety profile regarding perioperative outcomes in this high-risk patient population. The aim of this study was to compare the 30-day postoperative complication rate in patients who underwent concurrent laparoscopic Roux-en-Y gastric bypass (RYGB) and HM to those who underwent RYGB alone.

Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 and 2016 datasets were queried for primary laparoscopic RYGB and concurrent RYGB with HM. A case–control matching was performed for age, BMI and ASA class to obtain a 1:2 matching ratio between concurrent RYGB-HM and RYBG alone patients, respectively. Analysis was performed comparing 30-day post-operative outcomes of the two groups.

Results: There were 65,504 primary laparoscopic RYGB procedures, with 62 RYGB patients matched to 31 RYGB-HM patients. Importantly, there were no reported mortalities and no significant differences in the rate of reoperation (1.60% vs 3.20%, p = 0.19), interventions (3.2% vs 3.2%, p = 1.00) or readmissions (3.20% vs 9.70%, p = 0.19) between RYGB vs. RYGB-HM groups. There was also no difference in the rate of post-operative pneumonias (1.60% vs 0%, p = 0.48), need for blood transfusion (1.60% vs 3.20%, p = 0.61) and no VTE occurrences in either group. Although the operative time was longer with concurrent RYGB-HM compared to RYGB alone by 58 min (p < 0.01), there was no difference in hospital length of stay (2 ± 1.3 vs 2.06 ± 0.9 days, p = 0.78).

Conclusion: In this matched case-control study utilizing the MBSQIP database, we found that concurrent RYGB-HM is as safe as primary RYGB. This is the largest reported study documenting the safety of concurrent RYGB-HM in patients with achalasia and morbid obesity suggesting both diseases can be treated simultaneously with exceptional 30-day safety in MBSAQIP accredited centers.


Non-internal Hernia Bowel Obstructions After Roux-en-y Gastric Bypass

Brandon W Vanderwel, MD, Kevin M Reavis, MD, Jan C Jay, MD, Valerie J Halpin, MD; Legacy Good Samaritan Medical Center

Background: Roux-en-y gastric bypass is a proven therapeutic treatment for metabolic diseases and morbid obesity. Internal hernias as a cause of bowel obstruction after roux-en-y have been extensively studied and surgical techniques have been developed to reduce their incidence. There is a paucity of data, however, about the incidence and etiology of non-internal hernia bowel obstructions (NIHBO).

Methods: A retrospective review of our institutional MBSAQIP database from 01/01/2015 – 08/01/2018 was used to identify NIHBO after roux-en-y gastric bypass. PHI was de-identified and data about patient characteristics, comorbidities, and clinical course were collected from the medical record.

Results: Twenty patients were identified as meeting the eligibility criteria for NIHBO after roux-en-y gastric bypass. Each patient that experienced a NIHBO was categorized by etiology: intraluminal hemorrhage (10%), technical (20%), unclear etiology (20%), food bezoar (20%), and adhesive disease (30%). Intraluminal hemorrhage as a source of obstruction presented within 1-2 days after surgery and were operatively managed to resolve the hemorrhage. All technical obstructions presented within 5 days of discharge (average post operative day 4) and were successfully treated with an operation, where a clear technical issue was identified and corrected. Patients with unclear etiology of obstruction presented within 2-7 days after surgery (average post operative day 4) and all were successfully managed with supportive care. All food bezoar obstructions presented within 30 days of discharge (average post operative day 8) and all were successfully treated with nonoperative management. Adhesive obstructions presented within a range of 3-75 days after discharge (average post operative day 26) and all were treated with an operation. There were no mortalities.

Conclusion: There are a variety of causes of post operative bowel obstruction after roux-en-y gastric bypass. Technical, bleeding, and adhesive disorders are successfully managed with surgery. Dietary causes can be managed nonoperatively.


Chronic Prescription Opioid Use Does Not Impact Outcomes after Bariatric Surgery

Nicole Shockcor, Sakib Adnan, Ariel Siegel, Sami Tannouri, Mark Kligman; University of Maryland

Introduction: Over the last decade, United States healthcare providers dispensed over 200 million opioid prescriptions annually for chronic pain. Here we aimed to determine the effect of prescription opioid use on weight loss post laparoscopic Roux-en-Y gastric bypass (LRYGB) as well as laparoscopic sleeve gastrectomy (LSG).

Methods: We completed a retrospective review of chronic prescription opioid use in 1177 consecutive patients undergoing primary bariatric surgery at a single institution. Patients were grouped into chronic prescription opioid users (OU), defined as ongoing opioid use for > 3 months at the time of surgery, and non-users (NU), defined as no opioid use prior to surgery. Patients undergoing remedial operations (conversions or revisions), and those lost to follow up were excluded.

Results: In the 1177 patients included in this analysis, 133 (11.3%) were identified as chronic prescription opioid users. 465 (39.5%) underwent LSG and 713 (60.6%) underwent LRYGB with similar rates in both groups. At 2 months OU patients lost on average 54.88 lb, similar to NU patients 56.8 lb (p-value 0.402). Similar outcomes persisted long-term at 1 year follow up with average weight loss in the OU group 93.46 lb vs NU 97.91 lb (p-value 0.458). Postoperative complications and rates of follow up were studied and similar between groups.

Conclusions: A significant proportion (11.3%) of bariatric patients have active narcotic prescriptions, and given the ongoing opioid epidemic, understanding the short and long-term effects on surgical patients is key. Initial analysis here supports similar weight loss outcomes in prescription opioid users as compared to non-users.


Reducing Readmission Following Bariatric Surgery: Is There an App for This?

Jordan Heuser, MD 1, Azusa Maeda, PhD2, Caterina Masino, MA2, Timothy Jackson, MD, MPH1, Allan Okrainec, MD, MHPE11Department of Surgery, Faculty of Medicine, University of Toronto, 2Division of General Surgery, University Health Network

Introduction: Despite efforts to improve recovery through the enhanced recovery after surgery (ERAS) pathway, visits to the emergency department (ED) and readmissions remain a critical issue in bariatric surgery patients. The purpose of this study is to determine the impact of a patient education mobile app on healthcare utilization and outcomes of patients undergoing bariatric surgery.

Methods: Bariatric surgery patients were recruited prospectively to use a mobile app that provides evidence-based surgical and dietary education, allows tracking of postoperative symptoms for 30 days, and alerts patients at risk of ED visits or readmission when necessary. The cohort was compared to the group of patients who did not enroll in the app for the same study period of September 2017 to April 2018. Data on 30-day readmissions, ED visits, and postoperative occurrences were collected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database to compare the healthcare utilization between the two groups. Data from the mobile app was additionally analyzed to evaluate user satisfaction and usage rates.

Results: There were 338 bariatric surgery patients included during the study period, with 104 patients who enrolled in the mobile application. There was an equal distribution based on age, gender, BMI and type of bariatric procedure performed between patients with and without the app. There was no difference in ED visits (7/104, 6.7% vs. 14/234, 6.0%) or readmissions (6/104, 5.8% vs. 7/234, 3.0%) between patients with and without the app, respectively. The mobile app surveys indicated that the overall ratings were high (37/50, 74%) and the usage rates were high (86% of patients used the app at least once and usage was over 50% for post-operative days 1 to 7). In addition, although the MBSAQIP data revealed no difference in ED visits, the survey from the mobile app showed that 12.6% of patients perceived that they had avoided at least one ED visit.

Conclusions: Overall, patient satisfaction and use of the mobile app were high, although a reduction in ED visits and readmissions was not found despite a significant percentage of patients that reported avoided ED visits because of the mobile app. Further investigation is warranted to evaluate reduction of other healthcare resources such as nurse educators, as well as to increase the proportion of patients that enroll in the mobile app and allow for transition to a paperless patient information pamphlet.


Text Mining Techniques for Bariatric Patient Personal Statements

Kristen M Saad, MS 1, Paige L Martinez, MS2, Larissa A Mcgarrity, PhD3, Ellen H Morrow, MD2, Eric T Volckmann, MD2, Juliana S Simonetti, MD4, Anna R Ibele, MD21University of Utah School of Medicine, 2University of Utah Department of Surgery, 3University Hospital Rehabilitation Psychology, 4University of Utah Department of Internal Medicine

Introduction: Bariatric surgery is one of the best-evidenced treatments for obesity, a complex medical condition with both physiologic and psychosocial contributors. As such, it’s become standard of care at some institutions to elicit pre-surgical written personal statements regarding patient motivation for seeking bariatric surgery. While these statements are often used as a “jumping-off point” for clinical discourse, they also represent a rich data source for text analytics.

This pilot study (n = 50) presents novel interdisciplinary methodological approaches and best practices for bariatric personal statement text mining to uncover and elucidate lexical and psychosocial patterns in presurgical patients.

Methods and Procedures: A proof-of-concept dataset of pre-surgical personal statements and associated demographic factors was constructed using an IRB-approved database, and subsequently analyzed with R. The dataset was cleansed, normalized, and descriptive statistical techniques applied to better understand the population of statements. The statements were then analyzed for word frequency, topic affiliations, and sentiment to better understand underlying patterns in patient motivation and psychological state.

Results: Word clouds, comparative graphs, and sentiment charts are used to effectively communicate the results of text mining studies using the pilot dataset. Methods, lessons learned, and best practices for database design, data cleansing, descriptive analytics, advanced computational techniques, and result integration and operationalization will be presented.

Conclusions: By combining a wide range of computational methods including word counts, lexical diversity, collaborative filtering, and sentiment analysis, underlying text patterns can be detected and analyzed for clinical use as well as potential association with post-surgical and long-term outcomes. While bariatric survey statements have been evaluated and subjectively scored by teams of researchers, this is the first known investigation utilizing computational text analytics to evaluate statements elicited as standard-of-care. This project represents a step forward in the field as it leverages a novel application of interdisciplinary techniques to enable clinicians to understand patient motivations and population patterns using patients’ own words.


Impact of Bariatric Surgery on Male Sex Hormones and Sperm Quality: A Systematic Review and Meta-Analysis

Yung Lee, BHSc 1, Jerry Dang, MD2, James Yu, BHSc1, Chunhong Tian, PhD2, Noah Switzer, MD, MPH2, Daniel W Birch, MD, MSc2, Shahzeer Karmali, MD, MPH21McMaster University, 2University of Alberta

Background: This systematic review and meta-analysis aims to establish the effects of bariatric surgery on male sex hormones, sperm parameters, and sexual function. Men with obesity experience lower testosterone levels, lower sexual satisfaction, and reduced fertility. The literature on the effect of bariatric surgery on male sex hormones and sperm quality is considerable and has not been comprehensively reviewed and meta-analyzed.

Methods: We searched the following databases covering the period from database inception through June 2018: MEDLINE, EMBASE, Web of Science, and Scopus. Articles were eligible for inclusion if the studies examined the effect of bariatric surgery on male sex hormones and sperm parameters in patients with obesity. Primary outcomes of interest were: (1) sex hormones (luteinizing hormone (LH), follicle stimulating hormone (FSH), total estradiol, free estradiol, total testosterone, free testosterone, dehydroepiandrosterone (DHEA), androstenedione, sex hormone binding globulin (SHBG), prolactin, inhibin B) and (2) sperm quality (sperm volume, sperm concentration,  % total motility,  % normal morphology,  % progressive motility. Secondary outcome was sexual function (International Index of Erectile Function (IIEF) score). Pooled estimates were calculated using random effects meta-analyses and heterogeneity was quantified using the inconsistency (I2) statistic.

Results: A total of 28 cohort studies with 1,022 patients were identified from 3,896 potentially relevant citations. Both free and calculated testosterone levels were significantly increased after bariatric surgery (Mean Difference (MD) -7.47 nM, 95% CI -8.62 to -6.31, p < 0.001 and MD -0.05 nM, 95% CI -0.07 to -0.02, p < 0.001 respectively). Consistent with the increase in testosterone levels, LH, FSH, and SHBG levels were also significantly increased after surgery. In contrast, free and total estradiol and prolactin levels were significantly decreased after bariatric surgery. From only five studies that reported the IIEF score, bariatric surgery led to a small, but statistically significant increase in erectile function after surgery (MD -0.46, 95% CI -0.89 to -0.02, p = 0.04). However, bariatric surgery did not affect any of the sperm parameters, DHEA, androstenedione, and inhibin B levels. Most of the sex hormone meta-analyses results had considerable heterogeneity (I2 > 50%).

Conclusions: Sustained weight-loss induced by bariatric surgery had an effect on male sex hormones and decreased female sex hormones in male patients with obesity. However, sperm quality and function were not improved after surgery. Long-term comparative studies or adequately powered randomized controlled trials are warranted to examine the impact of bariatric surgery on male sex hormones and sperm quality.


The Impact of Protein Malnourishment on Bariatric Surgery Outcomes: An Mbsaqip Analysis

Michael Mazzei, MD 1, Jeremy Van De Rijn2, Dominic Recco2, Rajiv Raghavan, MD1, Matthew Knouse, MD1, Michael Edwards, MD1, Eric Velazquez, MD11Temple University Hospital, 2Temple University Lewis Katz School of Medicine

Introduction: While morbidly obese patients have an excess of stored calories, this is not necessarily commensurate with adequate nourishment. Nutritional deficiencies are commonly identified in the bariatric population; in particular, hypoalbuminemia has been identified in up to 15% of patients prior to bariatric surgery. Protein malnutrition has been implicated as a risk factor for poor outcomes in a number of surgical populations, and may represent a potentially modifiable preoperative risk factor in the bariatric patient. In this study, we evaluate the effects of hypoalbuminemia on 30-day bariatric outcomes.

Methods: From the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) database, we identified patients with albumin levels recorded within 30 days prior to weight loss surgery in 2015-2016. An unmatched cohort analysis as well as a 1:1 propensity-matched cohort analysis was performed to assess the relationship between preoperative albumin levels and thirty-day postoperative outcomes and complication rates.

Results: Of the 195,407 patients with albumin levels recorded in the thirty days prior to weight loss surgery, 12,124 (6.2%) had protein malnutrition (albumin < 3.5 g/dl). At baseline, hypoalbuminemic patients had higher BMI (48.9 vs. 45.1, p < 0.001) with significantly increased rates of comorbid conditions, including heart disease, diabetes, and COPD. These patients had longer postoperative length of stay (2.1 vs 1.7 days, p < 0.001), and higher rates of readmission (6.1% vs. 4.3%, RR = 1.41, p = 0.001), unplanned ICU admission (1.4% vs. 0.8%, RR = 1.77, p < 0.001), re-intervention (2.5% vs. 1.5%, RR = 1.61, p < 0.001), and wound infections (1.4% vs. 0.8%, RR = 1.59, p < 0.001). On 1:1 propensity-matched analysis of 24,064 patients controlling for age, BMI, operation type, and major comorbidities, the findings of poorer outcomes among patients with preoperative protein malnutrition were preserved, including higher rates of readmission (6.1% vs. 5.1%, RR = 1.18, p = 0.004), re-intervention (2.4% vs. 1.8%, RR = 1.33, p = 0.002), and wound infections (1.3% vs. 1.0%, RR = 1.33, p = 0.019).

Conclusions: In this large database analysis, protein malnutrition independently increases the risk of 30-day adverse outcomes following primary bariatric surgery. This is especially true in the context of a higher prevalence of comorbid conditions in this patient population, which further increases the risk. Because hypoalbuminemia may be viewed as a modifiable comorbid condition, weight loss surgery should be deferred for patients with protein malnutrition until this condition is corrected preoperatively.


Resolution of Co-morbidities in Pediatric Patients Undergoing Bariatric Surgery

Aryan Meknat, MD, Gustavo Fernandez-Ranvier, MD, PhD, Vivienne Cabreza, MD, Kaitlyn E Billington, DNP, AGPCNPBC, Daniela E Guevara, MD, Daniel M Herron, MD, Matthew L Dong, MD, Abiba Salahou; Mount Sinai Hospital

Introduction: Adolescent obesity is currently an epidemic in the western world. With increased prevalence of obesity in the pediatric population, we are seeing a significantly younger onset of metabolic syndrome (1). This can potentially lead to a greater rise in premature morbidity and mortality from cardiovascular disease, as a result of prolonged exposure to modifiable risk factors (1,2). The objective of this study was to evaluate the effect of bariatric surgery on obese pediatric patients who had obesity-related co-morbidities.

Methods: We retrospectively reviewed our prospectively maintained database and included in the analysis pediatric patients (range; 15 to 21 years) who underwent a laparoscopic sleeve gastrectomy (LSG) or a laparoscopic roux-en-y gastric bypass (LRYGB) between 2011-2016, and those who subsequently followed up at one and two years. Attention was placed on those who had obesity-related co-morbidities (e.g. type 2 diabetes mellitus, dyslipidemia, and/or obstructive sleep apnea) and whether or not they were resolved after the bariatric procedure.

Results: The review yielded 70 patients; 12 (17.14%) had sleep apnea (necessitating the use of CPAP), 4 (4.28%) had type 2 DM, and 2 (2.85%) had dyslipidemia. Sixty eight percent of all co-morbidities were resolved at one-year follow-up with no recurrence at two years. These left three patients with sleep apnea, who all stated their need for CPAP was decreasing and one patient with type 2 DM after having undergone a LRYGB. There were fifty-two other pediatric patients who underwent either LSG or LRYGB that did not have an associated co-morbidity, and they did not develop one when seen on follow-up.

Conclusion: Our study showed 68% of patients had complete resolution of their pre-existing co-morbidities at one-year follow up. Evaluation at long-term follow up is necessary to determine if the rate of resolution improves or if there are recurrences. More studies are showing that obesity in the pediatric population is associated with mortality secondary to the associated co-morbidities. These same studies are showing safe and effective results of pediatric bariatric procedures with respect to weight loss and resolution of co-morbidities analogous to the adult population (1–3).


Gastrojejunostomy Stricture after Roux-en-Y Gastric Bypass, A 17 Year Experience

Brittany Nowak, MD, George Fielding, MD, Marina Kurian, MD, Bradley Schwack, MD, Andrea Bedrosian, MD, Christine Ren-Fielding, MD; New York University Langone Medical Center

Introduction: The gastrojejunostomy (GJ) during Roux-en-Y gastric bypass (RYGB) can be performed by stapled or hand-sewn techniques, and is at risk for anastomotic stricture, reported in the literature at rates from 0 to 33%. This study reviews a single center’s experience with anastomotic stricture and intervention required.

Methods and Procedures: A retrospective chart review was performed of 904 patients who underwent RYGB as primary or revisional surgery at a single institution from October 2000 through September 2017. There were 182 patients excluded for follow up duration of less than 1 year, 5 for an esophagojejunostomy rather than GJ, and 1 for gastroparesis as the surgical indication rather than morbid obesity. This left 716 patients to be included in the study. Demographic and operative data were collected including technique for GJ, post-operative follow up, and complications, with a focus on GJ stricture and subsequent interventions.

Results: Gastrojejunostomy (GJ) was performed with a 25 CEEA stapler in 674 (94.1%) patients, with a linear stapler in 25 (3.5%), was hand-sewn in 7 (1.3%), and the technique was unknown in the remaining 8 (1.1%). Roux-en-Y gastric bypass was performed as a primary surgery in 522 (72.9%) patients and as a revisional surgery in 194 (27.1%).

Stricture of the GJ was diagnosed in 29 (4.1%) patients. The average time to diagnosis of early strictures occurring prior to 3 months was 40.3 days, and for late strictures was 871 days. By technique, stricture was diagnosed in 26 (3.9%) patients in the 25 CEEA group, 1 (4%) in the linear stapler group, and 2 (22.2%) in the hand-sewn anastomosis group. In primary RYGB patients stricture was diagnosed in 20 (3.8%) patients, and in revisional RYGB in 9 (4.6%) patients (p = 0.626). Esophagogastroduodenoscopy (EGD) with dilation was performed at least once (1-9 times) in 26 patients, 2 with concomitant stenting, 2 required operative intervention, and 1 patient awaits operative intervention. Both patients who required surgery also had marginal ulcers, and possible gastro-gastric fistula at time of surgery.

Conclusion: The results of this study show that the 25 CEEA circular stapler is a reasonable technique for performance of the GJ anastomosis in RYGB, with a stricture rate of 3.9%. There is also a slightly increased stricture rate in revisional surgical patients, though not statistically significant.


A Systematic Review on the Use of Biochemical Markers as a Predictive Tool for Post-operative Complications After Bariatric Surgery

Siddharth Shinde, Gabriel Marcil, Juan Arminan, Artan Reso, Estifanos Debru, Neal Church, Richdeep Gill, Philip Mitchell; University of Calgary

Introduction: The aim of this study was to assess the use of acute phase reactants, specifically C-Reactive Protein (CRP), as a marker which may precede the onset of clinical manifestations of post-operative complications after bariatric surgery. Presently there are no systematic reviews/meta-analysis on validated biochemical markers for early prediction or identification of patients who are prone to post-operative complications. While early discharge under the Enhanced Recovery After Surgery (ERAS) protocol after bariatric surgery has its advantages, it can often mask post-operative complications until after the patient has been discharged. The current best diagnostic method for complications remains clinical suspicion, which can guide further biochemical and radiographic investigations.

Methods and procedures: A comprehensive literature search was conducted through Medline, Embase, Scopus, Web of Science, Dare, Cochrane library, and HTA database from January 2008 through October 2017. All human prospective or retrospective studies, non-randomized comparison studies, and case series involving more than ten patients were considered for inclusion. The target patients were adults (≥ 18 years) who have under gone surgical management of obesity. The primary outcome of interest was level of acute phase reactants in patients who develop complications following bariatric surgery. Secondary outcomes aimed to determine the association of acute phase reactants with complication stratified by the bariatric surgical procedure performed and type of complication.

Results: Thirteen studies were included in our analysis (n = 20,639 patients). The average patient age was 42.14 ± 2.62 years. The average pre-operative BMI was 45.49 ± 2.96 kg/m2. 79.0% of patients were female. 1403 patients had at least one post-operative complication of any type (leak, bleed, or abscess). The overall post-operative complication rate was 6.8%. From a limited analysis due to heterogeneity of our studies the mean Post-operative Day (POD) 2 CRP in patients with any complication was 197.04 ± 53.94 mg/L, while the mean POD 2 CRP in patients with no complication was 62.45 ± 33.36 mg/L

Conclusions: Timely diagnosis of post-operative complications after bariatric surgery remains challenging. Preliminary analysis demonstrates higher POD 2 CRP in patients who develop post-operative complications after bariatric surgery. CRP could provide a cost-effective option for screening for post-operative complications in conjunction with clinical suspicion. However, there is no clear consensus on timing of biomarker measurement and cut-off values that indicate the need for re-operation. Next steps in this study will be to stratify CRP for leaks, abscesses, and bleeds based on type of procedure performed.


Initial Outcomes of One Anastomosis Gastric Bypass at a Single Institution

Mohammad Zagzoog, MD 1, Wisam Jamal, MD2, Salma Sait3, Ashraf Maghrabi, MD31King Abdulaziz Medical city, 2University of Jeddah, 3King Abdullaziz University

Introduction: One anastomosis gastric bypass (OAGB) is an emerging bariatric procedure, which has been reported to be safe and effective. This study aims to evaluate the short-term outcome of OAGB and its mid-term effects on weight loss and remission of Type 2 Diabetes Mellitus (T2DM).

Methods: A retrospective review of patients who had undergone OAGB between January 2013 and January 2016 in King Abdulaziz University Hospital, Jeddah, Saudi Arabia is presented here. Patients; perioperative characteristics, biochemical profile (HbA1c and iron) and details on subsequent weight loss in terms of Body Mass Index (BMI) and Excess Weight Loss percentage (%EWL) along with early and late postoperative complications were evaluated.

Results: Out of the forty-three patients who underwent OAGB, 38 were included in this study and completed the 2-years follow up. Average operative time was 107.5 ± 21.8 min and average length of hospital stay was 2.5 ± 0.64 day. Mean preoperative BMI was 48.6 ± 9 kg/m2 and at 1 and 2 years of follow up was 30.6 ± 8.7 and 27.5 ± 6.3, respectively. No mortality, anastomotic leak or bleeding were reported. Most common mid-term complication was iron deficiency anemia (n = 7/38). Remission of T2DM at 6 month was 81.8%. Patients with preoperative T2DM for less than 10 years showed better remission (p = 0.024).

Conclusion: Our analysis suggests that OAGB is a safe and effective weight loss procedure that carries low perioperative risk and acceptable nutritional complications in the midterm, with a notable remission of T2DM. Preoperative duration of T2DM plays a major role in achieving remission after OAGB.


Short and Mid term Outcomes Comparing Morbidity and Weight Loss After Laparoscopic Sleeve Gastrectomy vs. Roux-En-Y Gastric Bypass in patients over 65 years of age and older

Joel S Frieder, MD, Camila Ortiz Gomez, MD, Rene Aleman, MD, Maria C Fonseca, MD, David Romero Funes, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Background: Bariatric surgery in the elderly population has been reported as feasible and safe. Laparoscopic Sleeve Gastrectomy (LSG) seems to have fewer complications than Laparoscopic Roux-En-Y Gastric Bypass (RYGB), even in the over 65 age group. We analyzed the difference in weight loss between LSG and RYGB in patients ≥ 65 years of age.

Methods: After IRB approval we retrospectively reviewed 2,486 patients, who underwent either LSG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative BMI and comorbidities were described. We identified all patients ≥ 65 years old and subsequently divided them in two groups depending on the type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were done. Post-operative BMI was reviewed at 6, 12 and 24 months and  %EBMIL was calculated accordingly. T-test and Chi2 analysis were performed for nominal and categorical variables, respectively.

Results: From 2,486 patients reviewed, 22.73%(n = 565) were ≥ 65 years old. From these, 43.19%(n = 244) underwent LSG and 56.81%(n = 321) RYGB (Table 1). Caucasians and females were predominant in both groups. Mean age was similar for both populations (LSG:71.10 ± 3.96, RYGB:71.67 ± 4.54). Pre-procedure mean BMI was similar in both groups (40.46 ± 5.48 for LSG vs. 43.68 ± 7.22 for RYGB). Postoperative follow-up rates were similar in both groups at 12 and 24 months (LSG:51.23% and 31.56%; RYGB:48.29% and 34.27%; p = 0.4883 and p = 0.4976). The  %EBMIL at 6, 12 and 24 months was higher for the RYGB group vs. the LSG group (59.27 ± 27.91, 72.10 ± 29.51, 77.35 ± 26.11 vs. 50.16 ± 21.85, 55.21 ± 25.58, 43.85 ± 32.23; p = 0.0006, p < 0.0001 and p < 0.0001; respectively). Complication rates were significantly higher in RYGB vs. LSG (27.73% vs 9.43%; p < 0.0001). We observed significantly higher anastomotic ulcer and stricture rates for RYGB vs. LSG (7.17% and 5.92% vs. 0% and 0%; p < 0.0001 and p = 0.0015, respectively). RYGB had a higher rate for GI obstruction requiring intervention (2.18% vs. 0.41%; p = 0.0776). A similar De Novo GERD rate was noted in both procedures (3.74% vs. 3.69%; p = 0.9753). No leaks were reported in either group (Table 2).

Conclusions: Both LSG and RYGB are effective weight loss procedures for patients ≥ 65 years of age. RYGB seems to have higher  %EBMIL at 1 and 2 years, however it has almost three times higher complication rate than LSG.


Outcomes of Bariatric Surgery in Super Super Morbidly Obese Patients

Raelina S Howell, MD, Harika Boinpally, MD, Elizabeth Carruthers, MSN, RN, Keneth Hall, MD, FACS, FASMBS, Jun Levine, MD, Armando Castro, MD, Patrizio Petrone, MD, Collin Em Brathwaite, MD, FACS, FASMBS; NYU Winthrop Hospital

Introduction: Increased body mass index (BMI) is associated with poor bariatric surgical outcomes. The risks of bariatric surgery in the super super morbidly obese (BMI ≥ 60 mg/kg2) merit further investigation. This study examines short-term outcomes of bariatric surgical procedures in this population.

Methods: Our prospectively-maintained database was retrospectively reviewed for patients with BMI ≥ 60 mg/kg2 who underwent bariatric surgery at our Center of Excellence over a 13-year period ending June 2018. Demographic data was summarized using descriptive statistics for quantitative variables, and frequencies and percentages for categorical variables. Statistical analyses were made using Chi Square.

Results: Two hundred fourteen procedures were performed on 207 patients over the 13-year period. Excluded were four aborted procedures, one internal hernia repair, and one lap band removal. Four laparoscopic sleeve gastrectomies (LSG) were aborted due to extensive adhesions (n = 3), and respiratory distress prior to incision (n = 1). Two hundred eight cases were eligible for inclusion. One hundred thirty-six patients were female (65.4%). Mean age was 43 years (range 17-68), BMI 65.9 mg/kg2 (60-95), and weight 411 lb (range 265-639). Co-morbidities included obstructive sleep apnea (n = 154; 74%), hypertension (n = 125; 60%), gastroesophageal reflux disease (n = 94; 45%), osteoarthritis (n = 91; 44%), and diabetes mellitus (n = 65; 31.3%). There were 97 roux-en-y gastric bypasses (46%), 88 LSG (42%) and 23 adjustable gastric bands (11%). These included primary (n = 181; 87%), conversion (n = 20; 9.6%), and revision (n = 7; 3.4%) procedures. Technique was primarily minimally-invasive (75% laparoscopic, 24% robotic, and 1% open). Complications were graded according to the Clavien-Dindo classification system: 1 grade I, 1 grade II, 3 grade IIIa, 3 grade IIIb, and 3 grade IVa. Thirty-day events included: 11 complications (5.3%; including 1 leak [0.5%] and 1 deep vein thrombosis [0.5%]), six readmissions (3%), and four reoperations (1.9%), which involved repair of staple-line leak (n = 1), repair of incisional hernias (n = 1), uterine dilation and curettage for vaginal bleeding (n = 1), and cholecystectomy for biliary colic (n = 1). There were no mortalities. Complications occurred in 14.8% of conversion/revision cases and 3.9% in primary cases (p = 0.0395) with no difference in complications between laparoscopic (4.5%) and robotic (6.1%) modalities (p = 0.7051).

Conclusion: Super super morbidly obese patients may undergo bariatric surgery safely, with no mortalities using minimally-invasive techniques. Revision procedures may increase the risk.


One Hundred Most Frequently Cited Studies on Sleeve Gastrectomy

Tomasz Stefura 1, Katarzyna Chlopas1, Jakub Dros1, Artur Kacprzyk1, Michal Wysocki, MD2, Magdalena Pisarska, MD2, Michal Pedziwiatr, MD, PhD2, Andrzej Budzynski, MD, PhD2, Piotr Major, MD, PhD21Students’ Scientific Group at 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, 22nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland

Introduction: Sleeve gastrectomy (SG) is currently one of the most popular bariatric operations and one of the most frequently and thoroughly studied areas in bariatric surgery. Multiple previous publications have focused on the 100 most frequently cited papers investigating various topics in surgery to underline which authors, centers, countries, or journals have most strongly influenced particular area. The aim of this study was to analyze and summarize the characteristics of the most frequently cited studies focusing on SG.

Materials and Methods: We used the Web of Science database (Thomson Reuters, Philadelphia, PA, USA) to identify all studies focused on SG published from 1945 to 2018. The term “sleeve gastrectomy” was used to reveal 100 most cited records.

Results: The most frequently cited publication had 471 citations. The highest mean number of citations per year was 65.2. Studies were frequently published in the year 2010 and 2013. Overall, 61 among included publications were observational studies. Articles were most commonly published in bariatric surgery oriented journals. The most frequent country of origin was United States of America. Usually articles were written by authors from academic departments, working in a surgical institution. Most of the studies focused on the short- and long-term clinical outcomes of SG.

Conclusion: Our study indicates an increase in medical researchers’ interest in the subject of SG and underlines the need to perform studies with a higher level of evidence, preferably randomized clinical trials, to further analyze the outcomes and basic science behind SG.


An Observational Study to Evaluate Metabolic Effects of Bariatric Surgery on Morbidly Obese Patients

Richa Jaiswal, Dr, Sumit Talwar, Dr, Bariatric Surgeon; Manipal Hospitals, Bengaluru

Introduction and Objective: Metabolic syndrome is a known association of obesity and is also associated with diabetes and increased cardiovascular risk. In this study we evaluated the metabolic effects of bariatric surgery on morbidly obese patients.

Materials & Methods: We recruited 40 morbidly obese patients; 26 underwent Laparoscopic sleeve gastrectomy (LSG) and 14 underwent Roux en Y gastric bypass (LYRGB) of which seven and nine were diabetic respectively. All patients were evaluated for weight, BMI, FBS, PPBS, HbA1c, C-Peptide, Lipid parameters, Mean Arterial Pressure at baseline and at two weeks and at six months post surgery.

Results: We achieved significant reduction in weight (p < 0.0001) by paired Friedman test was noted at and six months (mean = 94.3 kg) postoperative as compared to baseline (mean = 129.7 kg). A mean weight loss of 52% for  %Excess weight loss and  %Excess BMI loss. Fasting Blood Glucose was significantly reduced at two weeks (mean = 132.2 mg/dl; p = 0.04) and six months (mean = 96.7 mg/dl; p = 0.01) postoperatively. A total of 56.3% diabetic patients achieved an HbA1c levels < 5.5 at six months post surgery with or without the use of antidiabetic medications. Majority of diabetic patients (93.8%, 15/16 patients) were able to achieve an HbA1c = 6.5 at 6 months post surgery. C-Peptide levels showed significant difference as compared to baseline (mean = 6.3) to those at 6 months (mean = 3.8; p = 0.03) and also there was a significant difference in reduction of use of antidiabetic medications at six months postsurgery (mean = 0.3; p < 0.0001) when compared to baseline (mean = 1.4). Difference in improvement in deranged lipid parameters (p < 0.0001) and Mean Arterial Pressure (p < 0.0001) became quite significant at six months post surgery.

Conclusion: Bariatric surgery thus helps in reducing weight and also helps in treatment of diabetes, correction of deranged lipid profile and reduces Mean arterial blood pressure.

Keywords: BMI, Weight loss, FBS, HbA1c, Lipid parameters, Laparoscopic sleeve gastrectomy, Laparoscopic Roux en Y Gastric Bypass.


Bariatric Surgery in Patients with Body Mass Index < 35: a Systematic Review and Meta Analysis

Chris G Smith, Dr1, Fatima Haggar, Dr2, Joe Mamazza, Dr2, Bryan Curtis, Dr1, Michael Hogan, Dr1, Dave Pace, Dr1, Darrell Boone, Dr1Lisa Bacque, Dr 1, Dimitry Terterov, Dr1, Priscille Cyr, Dr1, Aryan Modasi, Dr1, Erin Mayo, Dr1, Vanessa Falk, Dr1, Hensley Mariathas, Dr11Memorial University of Newfoundland, 2University of Ottawa

Background: Bariatric surgery has been shown to be safe and effective for the treatment of morbid obesity and related comorbidities. The goal of the current study is to explore the role of surgery in patients with moderate obesity or body mass index (BMI) < 35.

Methods: Systematic review and Meta analysis was performed focusing solely on patients with BMI < 35 who underwent laparoscopic roux en y gastric bypass (REYGB), sleeve gastrectomy (LSG), or adjustable gastric banding (AGB). Data were limited to randomized controlled trials and prospective cohort studies. Primary outcome measure was fasting plasma glucose (FPG). Secondary outcome measures included hemoglobin A1c (HbA1c), and other obesity related comorbidities.

Results: 13 studies were included in the analysis. Surgery was associated with significantly improved FPG compared to medical therapy (WMD -3.24, 95% CI -4.45; -2.02). Surgery was also associated with improved HbA1c, body weight, BMI loss, waist circumference, and resolution of hypertension and dyslipidemia. Improvements were also seen with respect to obstructive sleep apnea, osteoarthritis, gastroesophageal reflux, infertility, urinary stress incontinence, and venous stasis. These results were consistent across each surgical procedure. 2 randomized controlled trials compared REYGB to LSG and subgroup analysis was performed which revealed no difference with respect to glucose metabolism however REYGB was associated with greater BMI loss and decreased waist circumference. Perioperative complications were comparable to morbidly obese subjects.

Conclusion: REYGB, LSG and AGB appear to be safe and effective in the treatment of obesity and related comorbidities in patients with BMI < 35. REYGB and LSG have similar effects on FPG and HbA1c however REYGB appears to have improved results with respect to waist circumference and BMI.


Hiatal Dissection in Conjunction with Sleeve Gastrectomy is Associated with Increased Rates of Readmission and Reoperation

Anna R Ibele, MD, Paige L Martinez, MS, Chelsea M Allen, PhD, Mark A Taylor, MD, Matthew Kingsbury, BS, Ellen H Morrow, MD, Robert E Glasgow, MD, Eric T Volckmann, MD; University of Utah

Introduction: Hiatal hernia repair at the time of bariatric surgery adds additional operative time and technical complexity to the operation. While early postoperative complications of conventional hiatal hernia repair and paraesophageal hernia repair performed with fundoplication are well described, the incidence of perioperative complications in patients undergoing hiatal dissection and closure in conjunction with sleeve gastrectomy has not been established.

We wished to determine whether performing a hiatal hernia repair in conjunction with sleeve gastrectomy was associated with increased risk of adverse perioperative outcomes.

Methods and Procedures: Registry data from the American College of Surgeons’ MBSAQIP database from January 2015 to December 2016 was reviewed to assess for the presence of a hiatal or paraesophageal hernia repair performed in conjunction with a sleeve gastrectomy. Patients were grouped into two cohorts depending on the presence or absence of hiatal dissection at the time of sleeve gastrectomy. Regression models were constructed to assess for incidence of postoperative nausea and vomiting with nutritional depletion, sepsis, stricture, anastomotic leak, need for therapeutic endoscopy, 30 day readmission and 30 day reoperation rates. Depending on the type of postoperative outcome variable, logistic regression (binary response) or Poisson regression (count response) was used, controlling for demographic covariates.

Results: In the two year period, 44,291 patients underwent sleeve gastrectomy with hiatal hernia repair and 155,477 underwent sleeve gastrectomy without hiatal dissection. The addition of a hiatal repair to a sleeve gastrectomy was associated with a 14% increase in the odds of diagnosis of postoperative nausea and vomiting with nutritional depletion (OR: 1.14; 95% CI: 1.03, 1.26/p = 0.010), a 10% increase in the odds of 30 day readmission (OR 1.10; 95% CI: 1.03, 1.17/p = 0.003) and a 17% increased odds of 30 day reoperation (OR 1.17; 95% CI: 1.04, 1.31/p = 0.010). There was no significant difference in rates of sepsis, stricture, anastomotic leak or need for therapeutic endoscopy.

Conclusion: Hiatal hernia repair performed in conjunction with sleeve gastrectomy imparts an increased risk of nausea and vomiting with nutritional depletion, 30 day readmission, and 30 day reoperation compared to patients having sleeve gastrectomy performed without hiatal hernia repair. In patients with a hiatal hernia, the decision to perform sleeve gastrectomy with hiatal repair should be undertaken with caution because of these increased perioperative risks.


Roux-en-Y Gastric Bypass vs. Vertical Sleeve Gastrectomy: Long Term Surgical Outcomes

Vanessa Boudreau, MD, Karen Barlow, HonsBSc, Scott Gmora, MD, Dennis Hong, MD, Mehran Anvari, MD, PhD; Center for Minimal Access Surgery, McMaster University, Ontario, Canada

Introduction: Vertical Sleeve Gastrectomy (VSG) is becoming an increasingly popular surgical treatment for morbid obesity compared to Roux-en-Y Gastric Bypass (RYGB) in North America.

Methods: Data collected in Ontario Bariatric Registry between 2010–2018 was used to compare long term outcomes of patients undergoing VSG or RYGB (currently the gold standard). Intention to treat analysis was performed. Results include conversions and revisions.

Results: Of the 18 431 patients that underwent surgical treatment, 15,379 (81.4%) had RYGB (baseline BMI 48.2; age 44.3 years; 84.3% female) and 2572 (13.6%) had VSG (baseline BMI 53.3, age 48.2 years; 75.4% female). Surgical complications were reported in 5.6% of RYGB patients and in 2.8% of VSG patients. There were 50 VSG patients that required a conversion due to weight regain/ineffective weight loss compared to 4 RYGB patients. The follow-up data were available for 2384 RUGB at 3 years and 569 at 5 years. For VSG, 236 patients had 3 year follow-up and 40 patients had 5 year follow-up.





3 year

5 year





< 0.05

< 0.05


3 year

5 year





< 0.05

< 0.05

Improvement in GERD

3 year

5 year



− 3.9%

− 6.0%

< 0.05

< 0.05

Improvement in Diabetes

3 year

5 year







Improvement in OSA

3 year

5 year





< 0.05

< 0.05

Improvement in musculoskeletal pain

3 year

5 year





< 0.05

< 0.05

Conclusion: RYGB results in more favorable weight loss and reduced weight regain as well as better resolution of GERD, musculoskeletal pain and OSA symptoms and has a significantly less likelihood for conversion due to weight regain or side effects at 5 years.


Early Experience with Endoscopic Gastrogastric Fistula Closure After Gastric Bypass

Matthew Tufts, Thadeus Trus, MD, Stuart R Gordon, MD; Dartmouth-Hitchock Medical Center

Background: Gastrogasrtic fistula (GGF) is a rare but serious complication of gastric bypass surgery. Overall incidence has been reported to be from 1.2% to as high as 12%. Pathogenesis is due to incomplete division of the stomach, staple line breakdown, or a leak/marginal ulcer leading to subsequent fistula formation. Symptoms included epigastric pain, reflux, lack of early satiety and weight gain Traditionally, fistula closure is achieved by open or laparoscopic revisional surgery. Recently, endoscopic closure has been reported with variable levels of success.

Methods: All Apollo Overstitch™ GGF closures at our institution were followed prospectively. Inclusion criteria were, history of gastric bypass surgery and endoscopic documentation of GGF. All patients underwent mucosal cauterization using argon plasma coagulation of the fistula tract prior to closure. In some cases closure was augmented by large over the scope clip placement. We examined, time from index operation to fistula diagnosis, fistula size, technique of bypass (open versus laparoscopic), symptoms of GGF, mechanism of fistula formation, number of endoscopic interventions, length of follow up and degree of fistula closure.

Results: 6 patients underwent endoscopic GGF closure. 5 patients had open gastric bypass, 1 had laparoscopic bypass. GGF diagnosis was made 13.3 years after index operation (range 8-20 years). GGF fistula was secondary to staple line breakdown in 4 patients, 2 were due to marginal ulceration/perforation. Average fistula size was 2 cm, (range .5-8 cm). The most common symptoms of fistula were weight gain and reflux Average follow up was 20.8 months, (range 1-51 months) An average of 2 endoscopic closure attempts were performed(range 2-5). 2 patients also underwent over the scope clip placement. 2 patients experienced weight loss after endoscopic closure. 4 patients have endoscopic documentation of persistent fistula, one was lost to follow up and 1 has yet to be endoscopically re-evaluated. 1 patient underwent operative revision after closure failure.

Discussion: GGF is a rare complication of gastric bypass. GGF should be suspected in bypass patients that have reflux or weight gain after bypass surgery.. These data suggest GGF fistula endoscopic closure has a high failure rate, particularly after staple line breakdown. Operative revision remains the optimal treatment. More studies are needed to elucidate which patients may respond to endoscopic fistula closer.


Longer Operative Times is an Independent Risk Factor for Increased Risk of Pulmonary Embolism in Laparoscopic Gastric Bypass Compared to Laparoscopic Sleeve Gastrectomy

Sahil Gambhir, MD, Reza F Alizadeh, MD, Colette S Inaba, MD, Megan T Smith, PhD, Jeffry Nahmias, MD, Brian R Smith, MD, Ninh T Nguyen, MD, Shaun Daly, MD; University of California Irvine Medical Center

Introduction/Objectives: Postoperative venous thromboembolism (VTE) is a leading cause of morbidity and mortality in bariatric surgery. There is limited data comparing VTE disease between various types of bariatric surgery. Operative time has been found to be an independent predictor of postoperative VTE. We hypothesized the incidence of VTE would be higher in Laparoscopic Gastric Bypass (LRYGB) compared to Laparoscopic Sleeve Gastrectomy (LSG) and operative time could be an independent predictor.

Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was queried to identify patients who underwent LSG or LRYGB between 2015- 2016. Perioperative data were compared using univariate analysis including t-tests and Fischer’s test. Adjusted odds ratios (AOR) for the risk of deep venous thrombosis and/or pulmonary embolus (PE) were determined using multivariable logistic regression analysis.

Results: During the study period 167,563 (71%) patients underwent LSG and 67,525 (29%) underwent LRYGB. Demographics were similar between both groups, including age, sex, body mass index, history of DVT (1.37% versus 1.78%), history of PE (1.02% vs. 1.18%) and history of smoking (8.91% vs. 8.72%) respectively. Patients diagnosed with perioperative PE have longer operative times in both LSG (86 min vs. 65 min) and LRYGB (135 min vs. 108 min) than patients without diagnosis of PE. LRYGB patients experience longer length of stay (2.06 days vs. 1.62 days). There was no significant difference in risk of postoperative DVT between LSG and LRYGB (OR 0.968, CI 0.767-1.220, p > 0.05). Compared to LRGYB, LSG was associated with decreased risk of pulmonary embolism (PE) (AOR 0.614, CI 0.462-0.816 p = 0.004). LRGYB patients with PEs had a statistically longer operative time compared to LSG patients with PEs (135 min vs. 86 min; p = 0.001).

Conclusion: Patients undergoing either LSG or LRYGB and have longer operative times, have a higher incidence of PE. However, LSG confers a lower risk of pulmonary embolism compared to LRYGB. After multivariate analysis, operative time is an independent risk factor for higher PE rates in LRYGB patients compared to LSG patients.


Our Initial experiance of Performing Laparoscopic Bariatric Surgery in a Public Teaching Hospital in a Middle Ecomic Country Like Pakistan

Danish Ali, Muhammad Adeel Kaiser, Muhammad Farooq Afzal; Lahore General hospital, Lahore

Introduction and Purpose: After establishing foothold in the west, pandemic of obesity now threatens the developing countries of Asia like Pakistan. Pakistan has witnessed unprecedented growth of obese individuals which is causing serious public health concern. Bariatric surgery is now established as the first line treatment for weight loss for morbidly obese patients. The treatment however is costly and carries its own risks and benefits. Although bariatric surgery has been practiced in Pakistan for more than 10 years now but its use is still only limited to private hospitals as a treatment option for the very few who can afford it. But things are changing now as we have started the first Bariatric Surgery Program for the public sector in Lahore. We would like to share our initial experience.

Methodology: In a period of 18 months from January 2017 to May 2018 a total of 18 cases have been performed. Demographics, gender, comorbidities, preop weight and BMI of all patients were recorded. Informed consent had been taken from all the patients. All the equipment and gadgets had been arranged and managed by hospital and department of surgery unit-I at LGH. Type of procedure and procedure related complications were recorded. All the patents had been planned to have follow up at 1st, 3rd, 6th, 12th and 24th months. Post op weight, excess weight loss and resolution of comorbidities were also recorded and analyzed in SPSS.

Results: Total 18 patients were included. Median age was 34 years and median BMI was 41. 16 sleeve gastrectomies and 2 minibypass was performed. Weight reduction of 11 kg at 1montg, 27.8 kg at 3 months, 52.8 kg at 6 months and 72 kg at 12 months. There was complete resolution of symptoms in patients.

Conclusion: Morbid obesity is serious health concern in developing countries like Pakistan. Bariatric surgery has proven itself the best modality to not just only treat the morbid obesity but also in significantly decreasing the obesity related comorbidities. The treatment is however costly and had never been practiced in a public sector hospital. According to results of our study, Bariatric surgery can be safely practiced in a Public Sector Teaching hospital in a developing countries like Pakistan Bariatric surgery in a public sector hospital in a lower middle income country is as safe and effective as in any private setup. We hope the government acknowledges our efforts and extends this program to other teaching hospitals across the country.


Liraglutide in a Tertiary Bariatric Clinic: A Case Series

Daniel Ta, BSc, Jerry T Dang, MD, Arya M Sharma, MD, PhD, Shahzeer Karmali, MD, MPH, Renuca Modi, MD; University of Alberta

Introduction: The objective of this study is to demonstrate the use of liraglutide in various patient scenarios in a tertiary bariatric clinic. Liraglutide is a glucagon-like peptide type 1 (GLP-1) analogue. Its efficacy for weight management has been demonstrated in various clinical trials, indicating its potential as a pharmacological option for patients with obesity.

Case Descriptions:

Case 1: A 26-year old female started liraglutide treatment to induce weight loss preoperatively. She sufficiently loss weight and successfully underwent laparoscopic sleeve gastrectomy.

Case 2: A 39-year old female was assessed for obesity. To become eligible for surgery, the patient needed to lose a substantial amount of weight. She began liraglutide treatment and was successfully bridged to laparoscopic Roux-en-Y gastric bypass (RYGB).

Case 3: A 31-year old male started liraglutide with plans to undergo bariatric surgery. However, after successful weight loss, the patient opted to cancel the procedure and remain on long-term liraglutide due to its flexibility in lifestyle and behavior.

Case 4: A 29-year old female started liraglutide and successfully lost weight. However, the patient was paying for liraglutide out of pocket, and was forced to discontinue. As a result, she experienced weight recidivism. The patient elected to go back on liraglutide on a lower dose to decrease cost and was subsequently able to lose weight. She successfully underwent laparoscopic RYGB.

Case 5: A 51-year old female underwent successfully laparoscopic RYGB. However, over the years, she began to experience weight recidivism. When she began liraglutide therapy, her weight recidivism reversed, and she lost weight.

Case 6: A 39-year old female had polycystic ovarian syndrome (PCOS) and infertility. The patient wished to pursue in vitro fertilization (IVF) but was advised to reduce her BMI prior to treatment. She was referred to a bariatric clinic and began liraglutide therapy. She was able to reduce her BMI and successfully underwent IVF shortly after.

Conclusion: This case series provides evidence that liraglutide may potentially be a useful pharmacological option in a bariatric clinic. Patients in our cases tolerated liraglutide well, however, liraglutide has been associated with nausea and vomiting, gastroparesis and esophageal dysmotility. Liraglutide is a useful adjunct in a multispecialty bariatric clinic for weight loss. Liraglutide can be used in various patient scenarios: as a bridge to bariatric surgery, for long-term weight loss or to pursue fertility treatment. Further research on liraglutide should be performed, especially in these various patient scenarios to determine its efficacy.


Management of Gastroesophageal Reflux in Patients with Laparsocopic Sleeve Gastrectomy: Hill Modified Technique

Ricardo Nassar, MD, Surgeon, Gastrointestinal Surgery, Juan David Hernandez, MD, Surgeon, FACS, Felipe Giron, MD, MSc, Alberto Ricaurte, MD, Surgeon, Juan David Linares, MD, Surgeon, Natan Zundel, MD, Surgeon; Fundación Santa fe de Bogota

Introduction: Obesity has become a worldwide public health problem, affecting rich and poor countries alike. Bariatric surgery is still the best treatment to achieve significant and long lasting weight loss and control of comorbidities. Laparoscopic Sleeve Gastrectomy (LSG) has become the most frequently practiced operation, even more than laparoscopic Roux-en –Y gastric bypass. GERD is a common disease among obese patients with prevalence between 39% and 61% before surgery. There is controversy in choosing the best approach to manage GERD whether if it was present before, worsens, or appears de novo in relation with bariatric surgery. It has been suggested that GERD can be either treated or prevented using a technique inspired in Hill’s posterior gastropexy. We present our experience with this procedure.

Objective: To describe both surgical technique and results of a treatment for GERD based in Hill technique, which can be carried out simultaneously in patients undergoing LSG, or in patients who already have been operated in the past.

Methods: Retrospective observational study based on a prospectively recorded database of patients with GERD who underwent a “Hill modified technique” either concomitantly with a LSG or who presented with GERD after a previous LSG. Patients were followed-up for at least 3 years since 2014, both for obesity control and GERD, this last based on the presence or absence of symptoms. All patients treated were included, and all of them had preoperative studies showing pathologic reflux. Surgical technique is based in obtaining an intra-abdominal esophageal length of minimum 3 cm, posterior closure of the hiatus, and posterior fixation of gastroesophageal junction to the crus, with at least two non-absorbable stitches.

Results: A total of 18 consecutive patients underwent closure of the hiatus and posterior gastropexy. 5 patients had the procedure alone to treat post-LSG symptomatic GERD. 13 had the procedure simultaneously with LSG. There were no complications associated to the procedure and none of the patients needed reintervention or medication out of the standard protocol. Postoperative controls were at 1, 3, 6, 12, 18, 24 and 36 months. All patients have shown satisfactory results in the control and management of both obesity and GERD, remaining asymptomatic during the study period.

Conclusion: “Hill modified technique” has shown adequate control of GERD symptoms in patients with LSG with no complications. Longer series and comparison with other strategies will allow to determine protocols for GERD treatment in patients undergoing bariatric surgery.


Longer Biliopancreatic Limb Length in Roux-en-Y Gastric Bypass Does Not Promote Greater Weight Loss

Chetna Bakshi, MD 1, Julio Teixeira, MD21Zucker School of Medicine at Hofstra/Northwell, 2Lenox Hill Hospital, Northwell Health

Background: Roux-en-y gastric bypass promotes weight loss by restrictive and malabsorptive means. The malabsorptive effects are due to bypassing a portion of jejunum as well as hormonal pathways that are not fully understood1. There is variation in the lengths of the biliopancreatic limb (BPL) and alimentary limb (AL) lengths among different centers. Whereas some studies have shown increased weight loss with increased BPL and AL lengths2, others have shown no difference3. The aim of our study was to compare weight loss with a BPL length of 100 cm versus 150 cm, and a stable AL (100 cm).

Methods: Single center retrospective review of 50 patients, 25 patients with a BPL length of 100 cm (group 1) versus 25 with a BPL length of 150 cm (group 2), between 2015-2016 at our Bariatric Center of Excellence. Weights were measured preoperatively and at varying times of follow up from 20 days to over 2 years.

Results: We calculated and compared the average decrease in weight change from surgery to follow-up weigh-in between the two groups. There was no significant difference in average weight decrease between the groups; group 1 vs 2 [27.69 kg s ± 14.79 kg vs 28.87 kg ± 13.77 kg, p = 0.77]. There was also no significant difference in average days to follow up weigh-in between group 1 vs group 2 [285.28 days vs 281.32 days, p = 0.93].

Conclusions: It is theorized that a longer BPL length provides more malabsorption, and therefore should provide greater weight loss. However, in our study, no weight loss difference was seen in patients with a BPL length of 100 cm versus 150 cm, with a stable AL of 100 cm. Even after controlling for differences in surgical technique between surgeons and different centers, no added advantage to lengthening the BPL was seen in terms of weight loss. Further research is needed to determine other effects of lengthening the BPL, such as effects on comorbidities, hormonal changes, and deleterious effects.


A Comparison of the Effects Of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy on Body Mass Composition as Measured by Air Displacement Plethysmography

Rhys Kavanagh, MD, Smith Jessica, MD, Debra Allan, RN, MSN, Peter Nau, MD, MS; University of Iowa Hospitals and Clinics

Introduction: The roux-en-y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most commonly performed bariatric surgeries worldwide. Evidence suggests that the malabsorptive component of the RYGB leads to disparate changes in fat and lean mass when compared to that which is seen with restrictive-centric efforts. This can impart deleterious effects on the patient such as an inability to complete activities of daily living, decreased bone mineral density and basal metabolic rate. The SG omits the intestinal bypass and is thought to lack the malabsorptive qualities seen with the RYGB. Little evidence exists on the effects of SG on body composition. This study seeks to compare patients who received a RYGB to SG with regards to change in excess body weight and body composition using Air Displacement Plethysmography (BodPodTM). It is hypothesized that patients who undergo RYGB will experience more profound loss in lean body mass than with SG.

Methods: Patients were selected according to NIH guidelines for bariatric surgery and completed a full multidisciplinary evaluation and monitored weight loss preoperatively. Patients underwent SG or RYGB based on surgeon recommendation, patient preference and medical comorbidities. Body composition was calculated using whole body densitometery (BodPodTM, Cosmed Chicago, IL). Patients underwent testing pre-operatively, six months and 12 months post-operatively. Measurements of change in total body mass, fat mass and lean mass as well as calculation of change in percent excess body weight were performed. Statistical analysis was completed using SPSS.

Results: 63 patients were enrolled. 33 patients underwent SG and 30 had a RYGB. Mean  %EBW loss for SG and RYGB was 47.2% and 53.4% respectively (P value = 0.17 95%CI -14.8 to 2.6). Mean  % change in fat mass for the SG and RYGB groups was 9.2% and 10.51% respectively (P value = 0.25 95%CI -0.86 to 3.22). The mean  % change in lean mass for the SG group and RYGB group was 9.4% and 10.49% respectively (P value = 0.38 95%CI -2.8 to 1.13).

Conclusions: Both the SG and RYGB provide equivalent, clinically significant loss in excess body weight. Despite the malabsorptive component of the RYGB, a greater degree of lean body mass loss was not observed when compared to the SG. This data can be used in patient counselling and patient selection when discussing the pros and cons of each procedure.


Predictors and Outcomes of Bleeding After Sleeve Gastrectomy: An Analysis of the MBSAQIP Data Registry

Valentin Mocanu1, Jerry Dang 1, Daniel Skubleny1, Noah Switzer2, Daniel Birch1, Shahzeer Karmali11University of Alberta, 2The Ohio State University

Background: The purpose of this study is to examine predictors of and outcomes associated with postoperative bleeding in patients undergoing laparoscopic sleeve gastrectomy (SG) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement (MBSAQIP) data registry.

Bleeding following SG is a common complication associated with significant morbidity and a drastic increase in healthcare resources. Multiple strategies have been developed to minimize bleeding including varying bougie size, staple line reinforcement, and intra-operative tranexamic acid. These techniques, however, have been implemented without a clear understanding of the pre-, intra-, and post-operative predictors of bleeding in patients undergoing sleeve gastrectomy.

Methods and Procedures: We identified all MBSAQIP patients who underwent SG in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of bleeding in SG patients. Our secondary outcomes of interest include characterizing overall complication rates in SG patients. Univariate analysis of pre-, intra-, and post-operative variables was performed using Chi squared tests for categorical data and independent sample t-test for continuous data. A non-parsimonious multivariable logistic regression model was then developed to determine predictive factors for development of postoperative bleed.

Results: A total of 175353 patients underwent laparoscopic SG from 2015 to 2016. The majority of patients were female (79.0%), with a mean age of 44.4 (SD 12.0) years and a mean BMI of 45.2 kg/m2 (SD 7.9 kg/m2). A total of 4366 (2.5%) patients had a postoperative bleed associated with a mortality of 1.0%. The mean operative time was 74.0 min (SD 36.6 min) with a mean bougie size of 36.9 F (SD 2.9F), and a mean pylorus distance of 4.80 cm (SD 1.1 cm). Staple line reinforcement was used in 67.8% of patients while 22.4% were oversewn. Bleeds were associated with a statistically significant increase in all complication rates. Multivariable logistic regression analysis revealed the following independent predictors of leak: bougie size, BMI, female, chronic steroids, dialysis, prior history MI, ASA, GERD, prior cardiac surgery, hypertension, prior DVT, renal insufficiency, therapeutic anticoagulation, diabetes, functional status, COPD, sleep apnea, and operating time.

Conclusion: Overall bleed rate following SG was 2.5% with bleed significantly increasing all other complications, readmission and reoperation rates and mortality at 30 days. Despite adoption of novel operative techniques to minimize bleed rates, none were protective after adjusting for confounders. Preoperative optimization of patient comorbidities prior to surgery may therefore have the greatest role in reduce bleeding after SG.


Geriatric Robotic-assisted Bariatric Surgery: How do Sleeve Gastrectomy and Roux-en-Y Gastric Bypass Compare in Terms of Short-term Morbidity

Amlish B Gondal, MD, Matthew E Mobily, MD, MPH, Iman Ghaderi, MD, MSc, MHPE; University of Arizona

Introduction: In the United States, more than 10% of bariatric procedures in academic centers are performed in elderly patients. Higher morbidity and mortality rates have been described in patients above 65 years old. However, there is limited data about the relative safety of robotic assisted sleeve gastrectomy (RA-SG) and Roux-en-Y gastric bypass (RA-RYGB) in this subset of patients. We aimed to compare 30-day safety of these procedures in geriatric patients.

Methods: Using current procedural terminology codes, RA-SG and robotic assisted RA-RYGB procedures performed on patients greater than 65 years of age were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participant use file 2016. Demographic data, baseline comorbidities, perioperative data and 30-day outcomes were examined. Outcomes of interest were summarized with descriptive statistics and two tailed analyses were performed using Chi squares for categorical variables (reported as proportions) and t-tests for continuous variables (reported as mean ± SD).

Results: A total of 698 patients were identified; 61.9% patients underwent RA-SG whereas 38.1% underwent RA-RYGB. Mean age was 68.4 ± 2.83, mean body mass index was 42.7 ± 7.44, 71.8% were female, 85% were white, and 82.5% patients were classified as ASA class III.

Both the RA-SG group and RA-RYGB group were similar in baseline characteristics except patients who underwent were RA-RYGB had higher prevalence of gastroesophageal reflux disease (54% vs. 43%, p = 0.002) and patients who underwent RA-SG had higher prevalence of hypertension (21% vs. 14%, p = .02).

Patients who underwent RA-RYGB had a longer length of hospital stay, operative time, reoperation and readmission rates within 30 days after surgery (Table 1). Major organ system morbidity was similar in both groups. There were no deaths in either group.

Conclusion: Robotic assisted bariatric surgery in patients 65 years and older appears safe. However, robotic assisted gastric bypass is associated with higher rates of reoperation and readmission. Prospective data is needed to evaluate long-term efficacy of these procedures in the elderly.


Predictors and Outcomes of Leak After RYGB : An Analysis of the MBSAQIP Data Registry

Valentin Mocanu1, Jerry Dang 1, Farah Ladak1, Noah Switzer2, Daniel Birch1, Shahzeer Karmali11University of Alberta, 2The Ohio State University

Background: The purpose of this study is to examine gastrointestinal leak in patients undergoing Roux-en-Y gastric bypass (RYGB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement (MBSAQIP) data registry.

Gastrointestinal leak is one of the most severe postoperative complications following RYGB, occurring in up to 2% of all patients. This has led to adoption of simpler procedures, such as sleeve gastrectomy (SG), which have improved safety profiles but potentially less effective long-term metabolic outcomes. Yet, in contrast to SG, a paucity of modern literature exists regarding predictors of leak for RYGB.

Methods And Procedures: We identified all MBSAQIP patients who underwent RYGB in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of leak in RYGB patients. Our secondary outcomes of interest include characterizing overall complication rates in RYGB patients. Univariate analysis of pre-, intra-, and post-operative variables was performed using Chi squared tests for categorical data and independent sample t-test for continuous data. A non-parsimonious multivariable logistic regression model was then developed to determine predictive factors for development of leak.

Results: A total of 77596 patients underwent RYGB from 2015 to 2016. The majority of patients were female (79.8%), white (75.9%), and underwent laparoscopic RYGB (89.7%). The mean age of patients was 45.2 years (SD 11.9) with a mean BMI of 46.3 kg/m2 (SD 8.17). Complication rates for RYGB were low with a mortality of 0.2% and a total complication rate of 7.5%. A total of 476 leaks were identified with an overall leak rate of 0.6% and a mortality of 1.5%. Leak was associated with a statistically significant increase in all complication rates. Multivariable logistic regression analysis revealed the following statistically significant independent predictors of leak: BMI, age, ASA score > 3, prior PE, and partially dependent functional status. Albumin and increased operative time were the only independent protective variables after adjusting for confounders and interactions.

Conclusion: Using the robust MBSAQIP database, we found RYGB to be a safe procedure with low morbidity and mortality. The overall leak rate was 0.6% with leak significantly increasing all other complications, readmission and reoperation rates at 30 days. Logistic regression identified prior PE and partially dependent functional status as the two largest predictors of leak while increased albumin was the only protective factor. Optimizing pre-operative nutrition and strength in these patients through structured multidisciplinary programs may therefore have a role in the ongoing improvement of outcomes following RYGB.


Incidence of Gastroesophageal Reflux in Morbidly Obese Patients Taken to Laparoscopic Sleeve Gastrectomy: 2 Years of follow-up

Carlos Luna, MD, Ruben Luna, MD, Luis F Cabrera, General Surgeon, Laura Quintero; Bosque University

Introduction: Gastroesophageal reflux disease are one of the most common disorders in morbidly obese patients. Despite the positive effect of laparoscopic sleeve gastrectomy regarding weight loss and improvement in obesity co-morbidities, there are concerns about the development of de novo gastroesophageal reflux disease. Several published follow-up studies report an increased rate of gastroesophageal reflux after a laparoscopic sleeve gastrectomy. However, the literature on this topic is ambivalent.

Objetives: Identify the incidence of gastroesophageal reflux in morbidly obese patients brought to laparoscopic sleeve gastrectomy in 2 years of follow-up.

Materials and Methods: Prospective observational study. Laparoscopic sleeve gastrectomy patients were studied before and at 2 years follow-up. Demographics, anthropometrics, status of comorbidities, perioperative data, gastroesophageal refluxsymptoms with de GerdQ score were evaluated.

Results: 129 morbidly obese patients without gastroesophageal refluxwere treated with laparoscopic sleeve gastrectomy and follow for 2 years with the GerdQ score every 6 months, with a incidence of de novo gastroesophageal reflux, with a GerdQ score of 8 or more was the 12%.

Conclusions: The incidence of de novo gastroesophageal reflux in laparoscopic sleeve gastrectomy patients can be reduced by performing a standardized and high-quality technique by a group of experienced and certified bariatric surgery.


Medical Complications in 166,601 Surgical Patients with Morbid Obesity Varying Directly with Increasing Age Independent of Bmi

Luke Perry, DO, Kevin Engledow, DO, Gus Slotman, MD; Inspira Medical Center Vineland New Jersey

Introduction: In today’s overweight society, every surgeon must operate on medically high-risk morbidly obese patients. In this milieu of toxic obesity, every clinical insight helps. Although we have reported increased obesity co-morbidities in Medicare patients, some of whom are younger on disability, the specific risks of weight-related peri-operative problems by age are unknown. Objective: To identify the incidence of obesity co-morbidities by decades of age in pre-operative bariatric surgery patients.

Methods: Pre-operative data on 166,601 patients from the Surgical Review Corporation’s BOLD database was analyzed by age: < 30 (n = 18,119), 30-40 (n = 41,879), 40-50 (n = 46,911), 50-60 (n = 40,788), 60-70 (n = 17,475, > 70 (n = 1,429) years. Data included demographics, BMI, and  % incidence of 33 obesity co-morbid conditions. Statistics: ANOVA for continuous variables; Dichotomous variables by general linear models modified for binomial distribution.

Results: BMI varied inversely by age (48 + -8 < 30 to 44 + -8 > 70), as did female/male percent (84/16 < 30 to 64/36 > 70) (p < 0.0001). African-American/Caucasian/Hispanic race percent varied from 12.4/67.5/12.6 in the < 30 group to 7.0/86.6/2.2 among patients > 70 years of age (p < 0.0001). Variations by age of obesity co-morbidities are displayed in the Table. The incidence of hernia, abdominal panniculitis, angina, cholelithiasis, CHF, DVT/PE, fibromyalgia, impaired function, GERD, diabetes, gout, hypertension, ischemic heart disease, dyslipidemia, leg edema, back pain, musculoskeletal pain, obesity hypoventilation, PVD, pulmonary hypertension, stress incontinence, and unemployment increased directly with increasing age, peaking in the > 70 group (12) and the 60-70 years cohort (10) (p < 0.0001). Asthma, depression, psychological impairment, and liver disease were highest in the 40-60 decades, but lower < 30 and > 70 (p < 0.0001). Alcohol/tobacco/substance use, PCOS, mental health diagnosis, and pseudotumor cerebri (n-6) were inversely proportional to increasing age < 30 to 60-70, > 70 (p < 0.0001).

Conclusion: Among adult surgical patients with obesity, the incidences of weight-related medical conditions vary by age. Younger patients are heavier, more frequently female, African-American or Hispanic, and have more psychological/behavioral issues. The major cardiopulmonary, abdominal/hepatobiliary, endocrine/metabolic, and weight-induced somatic issues increase in prevalence directly with increasing age. This severe age variation in morbid obesity suggests exaggerated adverse effects the longer one has obesity. Although BOLD did not capture the length of time each patient was morbidly obese, these result suggest the concept of obesity years, with entrenched co-morbidities accumulating the longer patients carry excess weight. These results may not be perfectly representative of all obese surgical patients. Nevertheless, applying this advance knowledge clinically may facilitate presumptive management of obese surgical patients, reduced peri-operative adverse events, and improving outcomes.


Metabolic Outcomes After Bariatric Surgery for Indigenous Patients in Ontario

Olivia Lovrics, BSc, MScA 1, Aristithes G Doumouras, MD, MPH1, Scott Gmora, MD2, Mehran Anvari, MB, BS, PhD, MD2, Dennis Hong, MSc, MD21St Joseph’s Healthcare, Hamilton, Ontario, Canada, 2McMaster University, Hamilton, Ontario, Canada

Introduction: In 2013, over 18% of Canada’s general adult population was considered obese (BMI > 30 kg/m2), compared to 25.7% of Canada’s First Nations, Inuit, and Metis (collectively, Indigenous) peoples. Obesity-related comorbidities affect indigenous Canadians more than non-indigenous, contributing to a lower life-expectancy in indigenous Canadians than non-indigenous. Bariatric surgery has been demonstrated to be an effective treatment for obesity, but this treatment has not been studied in Canadian indigenous populations. Accordingly, the purpose of this study is to determine the effect of bariatric surgery on metabolic outcomes for indigenous populations.

Methods and Procedures: Prospectively collected data from the Ontario Bariatric Registry was used in this study. All individuals who underwent bariatric surgery between March 2010 and February 2018 were included in initial analysis. Post-operative outcomes in the database include diabetes, hypertension, GERD, and medication requirements. Demographics, baseline characteristics, and univariate outcomes were assessed using either the Pearson Chi Squared test or t-test. A multivariable regression model for BMI change at 6 months and 1 year was utilized with both a complete case analysis and multiple imputation.

Results: Overall, 16,629 patients were identified of which 338 self-identified as indigenous, 13,502 as non-indigenous, and 2,789 did not enter a designation and were excluded. Overall follow-up rates were 67.5% at 6-months and 52.0% at 1-year. Baseline demographics were not statistically different between indigenous and non-indigenous patients; however, rates of hypertension (p = 0.03) and diabetes (< 0.001) were higher in indigenous populations. Indigenous patients utilized pre-surgical medical and allied healthcare specialists, investigations and procedures at rates similar to non-Indigenous patients, except in the cases of physiotherapists, psychologists, nurse practitioners and diabetes nurses, who were more likely to be seen by indigenous patients. In univariable analysis, at 1 year, change in BMI was similar between groups (Indigenous: 15.8 ± 6.0 kg/m2; Non-indigenous: 16.1 ± 5.6 kg/m2, p = 0.362). After adjustment, BMI change for indigenous patients, compared to non-indigenous, was not different at 6-months (Effect Size = 0.07, 95%CI -0.45 to 0.58, p = 0.803) and 1-year (Effect Size = -0.24, 95%CI -0.93 to 0.45, p = 0.489), respectively. Rates of diabetes, hypertension, GERD, and medication use were similar at 1-year between the two populations despite differences at baseline.

Conclusions: Indigenous Ontarians appear to respond as well as non-indigenous Ontarians to bariatric surgery in terms of weight loss and resolution of relevant comorbidities. Accordingly, this treatment, and the standard outcomes associated with it, should be considered for all indigenous patients who qualify.


Learning Curve for Robotic Sleeve Gastrectomy, Roux-en-Y & One-Anastomosis Gastric Bypass

Jackly M Juprasert, MD1, Lauren Tufts1, Katherine D Gray, MD1, Omar Bellorin, MD2, Gregory Dakin, MD1, Alfons Pomp, MD1, Cheguevara Afaneh, MD1Francesca M Dimou, MD 11NewYork-Presbyterian Hospital/Weill Cornell Medicine, 2The Valley Hospital/Valley Health System

Introduction: The safety and efficacy of robotic bariatric surgery has been established. However, the learning curve has been variably documented and assessed. In this study, we describe our experience with the learning curve in robotic sleeve gastrectomy (RSG), robotic one-anastomosis bypass (ROAB), and robotic Roux-en-Y gastric bypass (RRYGB).

Methods: Consecutive patients undergoing primary robotic bariatric surgery from October 2015 to July 2018 by a minimally invasive fellowship (MIF)-trained surgeon (Surgeon 1) during his first three years of attending practice were included. Demographic and perioperative data were collected via retrospective chart review. The primary outcome was the learning curve in RSG, RRYGB, and ROAB, represented as the change in operative time over the course of this study and calculated by linear regression fit lines over the number of procedures performed. Secondary outcomes were estimated blood loss (EBL), length of stay (LOS), 90-day readmission, and morbidity. To externally validate our single-surgeon results, we compared our data to Surgeon 2 who trained under Surgeon 1. We report on Surgeon 2’s learning curve and outcomes during his first year in practice in 2017. Resident and fellow participation did not change significantly throughout the study period.

Results: A total of 241 patients undergoing RSG (n = 162), RRYGB (n = 53), and ROAB (n = 26) by Surgeon 1 were included. Median age was 42 ± 12.5 years (range 18-72). 75% were female. 67% of patients had ASA scores ≥ 3. Mean pre-operative BMI was 45.9 ± 8.9 (23.3-92.5). Mean operative time for RSG for 2015-2016, 2016-2017, and 2017-2018 were 110 ± 26 (73-185), 98.3 ± 25 (60-211), and 90.8 ± 24 (54-211) respectively. Mean operative time for RRYGB for 2015-2016, 2016-2017, and 2017-2018 were 200 ± 36 (141-268), 178 ± 44 (117-278), and 142 ± 37 (87-278) respectively. Mean operative time for ROAB for 2016-2017 and 2017-2018 were 104 ± 21 (72-142) and 98.2 ± 19 (71-142) respectively. Operative time decreased over time for all three procedures (Figure 1). There were no conversions to open. Mean EBL was 33.2 ± 37 mL (0-250). Mean LOS was 2.18 ± 1.83 days (1-26). 90-day readmission rate was 6%. Overall morbidity rate was 5.8%. Mortality was zero. The RSG learning curve was shorter for Surgeon 2 with a comparable complication rate of 4% (Figure 1); Surgeon 2 did not perform enough RRYGB or ROAB cases to construct learning curves.

Conclusions: RSG, RRYGB, and ROAB operative time consistently and rapidly decreased while morbidity and readmission rates remained low, suggesting that the learning curve for robotic bariatric surgery is quick without compromising patient safety or increased morbidity.


Critical Role of the Postoperative Visits to a Hospital Following Laparoscopic Adjustable Gastric Banding (LAGB)

Minyoung Cho, MD, PhD 1, Jung-Eun Kim, MD, PhD1, Bodri Son, MD, PhD1, Gyu-Hee Chae, MD, PhD1, Jae-Yong So, MD, PhD1, Sun-Ho Lee, MD, PhD2, Ha-Jin Kim, MD, PhD3, Kyungnam Eoh, MD1, Yun-Chan Park, MD4, Nam-Chul Kim, MD, PhD41365mc Obesity Clinic LAMS Center, 2Global 365mc Hospital, 3Seoul 365mc Hospital, 4Busan 365mc Hospital

Background: Chronic illness including hypertension and diabetes means treatment is necessary throughout life. Obesity has declared a chronic disease. Many patients believe that the bariatric surgery is not a start to weight loss but a last resort. Patients tend to ignore the importance of visiting hospitals when they reach appropriate adjustment levels of the laparoscopic gastric banding (LAGB). This study evaluated what happens in that case.

Methods: The data were recorded by patients’ hospital visits who undertook the same day LAGB using LAP® APs for 8 years. The loss to follow-up (LTFU) is defined as the case where no visit has been made to a hospital for more than six months since LAGB.

Results: Only 497 out of 1,086 patients were followed up during the study (45.8%). Mean preoperative BMI was 35 kg/m2 and age was 32 years-old. 90.9% of the patients showed more than one LTFU (n = 452, p < 0.0001). The first LTFU started at 14.7 (0.2 - 52.8) months after LAGB. 78.7% of the LTFU patients occurred more than 1-year LTFU duration.  %EBMIL at the first LTFU was 54.3% (-61.3 ~ + 253). The gap time from the first LTFU to hospital revisit was 20.1 months (3 ~ 72.8).  %EBMIL at the revisit was 50.1% (-381.9 ~ + 306.3). 51% of the LTFU patients showed weight gain (+7.3 kg) and the rest was lost (-8.8 kg). 80.5% of the LTFU patients complained and developed adverse symptoms and signs such as solid food intolerance (40.3%), esophageal dilatation (16.2%), esophageal barium stasis (12.8%), liquid intolerance (5.1%), pouch dilatation (3.5%), slippage (2.4%), and erosion (0.2%) (p < 0.0001).  %EBMIL of the LTFU patients vs. Non-LTFU patients was 21.9% vs. 25.9%, 60.9% vs. 70.8, 59.3% vs. 76.5%, 60% vs. 95.6%, 49.6% vs. 88.3%, 45.6% vs. 106.3% at post-LAGB 1, 12, 24, 36, 48, and 60 months, respectively (p < 0.05). Pseudoachalasia was more frequently developed in the LTFU (27.7% vs. 11.1%, p < 0.05). Among the study participants, 39.2 percent (n = 195) of the bands were removed and there was no difference between the two groups. Up to this series, the total explantation rate was 18%.

Conclusion: It is usually difficult to follow up regularly after bariatric surgery because patients mistake obesity as a treatment for weight loss through simple restrictive dietary control. To ensure a safe and good weight loss through the LAGB, proper diet and lifestyle changes must be made through regular hospital visits.


The Role of Statins and Post Bariatric Surgery Pericardial Fat Reduction in Preventing Coronary Artery Disease

Mauricio Sarmiento-Cobos, MD, Lisandro Montorfano, MD, Carlos Rivera, MD, Camila Ortiz Gomez, Elliot Wasser, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Background: Pericardial fat is a type of visceral adipose tissue (VAT) with multiple endocrine and inflammatory functions, which may play an important role in the pathogenesis of coronary artery disease. Due to its anatomical location, it has been associated with vulnerability of the atherosclerotic plaque. Lipid-lowering therapy has been shown to halt the progression of atherosclerotic plaques and to induce regression of cardiac adipose tissue. The aim of this study is to report the statin effect on pericardial fat after bariatric surgery.

Methods: A linear measurement of the pericardial fat thickness (PFt) was recorded before and after Bariatric Surgery (BS), from the chest and abdominal CT scans. We divide the patients into two groups; patients using statins (Group 1), and patients not using statins (Group 2). PFt was measured in both groups at the right ventricular wall, perpendicular to the myocardium, at the level of the sternum. We compared the measurements before and after BS, and the risk of developing CAD by Framingham heart study. Common demographics and comorbidities were collected along with lipid profile preoperative and postoperative and were analyzed between the groups.

Results: From our bariatric population, 82 patients met inclusion criteria. We identified 31 patients in Group 1 and 51 patients in Group 2. In group one 41.93% (n = 13) and in group 2 70.58% (n = 36) were females. The average age for group one was 61.35 + 11.14 years and 57.27 + 9.001 years for group two (p = 0.091). The percentage of estimated BMI loss (EBMIL) % at 12 months in group one was 57.32 + 31.08 (N = 28) versus 73.30 + 31.16 (N = 42) in group two (p = 0.04). Pericardial fat thickness loss was 17.07 + 10.86% in group one versus 11.78 + 6.35% in group 2. The risk of CAD one year after BS was 12.22 + 6.57 (n = 9), and in group two was 6.78 + 2.38 (n = 9) p = 0.04.

Conclusion: Obese patients have higher VAT deposits. Pericardial adipose tissue is highly associated with the risk of developing CAD. Pericardial fat can be a target by pharmaceutical agents like statins. In our population, the use of statins combined with bariatric surgery is linked to a significant decrease in pericardial fat thickness and to a lower risk of CAD. Further studies may be needed to better assess these findings.

Table 1. Variables and Demographics.


Weight Loss After Bariatric Surgery Predicts an Improvement in the Non-Alcoholic Fatty Liver Disease (NAFLD) Fibrosis Score

Charleen Yeo, Marc Ong, Anton Cheng, Chun Hai Tan; Khoo Teck Puat Hospital, Singapore

Introduction: Non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases worldwide, and has been shown to be present in up to 90% of bariatric surgery patients. Bariatric surgery has grown to be an internationally accepted option for the treatment of obesity and type II diabetes mellitus. Previous literature has demonstrated improvement in liver steatosis, inflammation and fibrosis in patients undergoing bariatric surgery. Our study aims to investigate if bariatric surgery results in an improvement in NAFLD fibrosis scores, and if there is a correlation with weight loss.

Materials and Methods: A retrospective study was conducted on all patients who underwent bariatric surgery from 2010 to 2016 in our institution, using a prospectively collected bariatric surgery database. Patients who had a redo bariatric surgery, or other concomitant gastric pathologies requiring surgical intervention were excluded. Indications for bariatric surgery followed the guidelines of the Asia–Pacific Metabolic and Bariatric Surgery Society. Patient demographics, clinical characteristics, operative details, and surgical outcomes were collected. All patients were followed up for at least one year post-operatively. Statistical analysis was performed using SPSS Version 21, with p-value of less than 0.05 considered statistically significant.

Results: There were a total of 304 patients in this study, of which the majority were females (n = 178, 59%). Data are represented in mean ± 2 standard deviation unless stated otherwise. Mean age was 40 ± 8 years old. Pre-operative mean weight and body mass index (BMI) was 116 ± 24 kilograms, and 42 ± 3.6 kg/m2 respectively. The mean pre-operative NAFLD fibrosis score was − 1.42. 1-year and 2-year follow up post bariatric surgery demonstrated a decrease in mean weight from 116 to 86 to 82 kilograms, and a decrease in in mean BMI from 42 to 31 to 30 kg/m2. There was also an improvement in mean NAFLD scores from − 1.42 to − 1.99 to − 1.84. The correlation between weight loss and the improvement in NAFLD fibrosis scores was statistically significant at both the 1st and 2nd post-operative year, with a r-coefficient of 0.36 and 0.463 respectively, and p-values of < 0.001.

Conclusion: Bariatric surgery results in weight reduction as well as an improvement in the NAFLD fibrosis score. The degree of weight loss predicts the extent of improvement in NAFLD fibrosis scores. More long term studies need to be conducted to assess if this effect is permanent.


Implementation of an ERAS Pathway for Gastric Bypass Results in Reduced Costs and Length of Stay

Anne P Ehlers, MD, MPH, Judy Y Chen-Meekin, MD, Andrew S Wright, Saurabh Khandelwal, MD; University of Washington

Background: Enhanced Recovery After Surgery (ERAS) pathways are well studied in colorectal surgery patients and are increasingly applied to other surgical populations. The effectiveness of ERAS pathways on outcomes and costs for patients undergoing Roux-en-Y gastric bypass (RYGB) remains to be determined.

Methods: Single-institution retrospective study of prospectively collected administrative data for patients undergoing RYGB from July 2015-August 2018. The ERAS pathway was implemented in June 2016 and consisted of standardized pre-operative teaching; multimodal analgesia and anti-emetics in the perioperative period; early oral intake; and standardized discharge instructions. We compared outcomes for patients treated prior to ERAS implementation (July 2015-May 2016) to those treated after ERAS implementation (July 2016-August 2018). The primary outcomes were length of stay (LOS), mean direct hospital costs, and 30-day readmission rates.

Results: Of the 311 patients undergoing RYGB, 116 had surgery before ERAS implementation and 195 did after. Patients treated after ERAS implementation had a 0.8 day shorter hospital LOS (1.9 versus 2.7 days) and direct hospital costs that were $1,096 lower ($10,796 versus $11,892). The 30-day readmission rate was similar (6.2% versus 6.0%).

Conclusion: Implementation of an ERAS pathway was associated with hospital LOS that was nearly one day shorter, and cost savings of more than $1000 per patient. This resulted in 156 fewer inpatient days and more than $200,000 in direct cost savings. Despite this, there was no appreciable change in the rate of 30-day readmission. This suggests that for patients undergoing elective RYGB, ERAS pathways can increase efficiency without negatively impacting patient outcomes. In an era when patient outcomes are increasingly scrutinized while reimbursement is declining, an ERAS pathway may help streamline patient care and maximize hospital resources.


Survey of Perceptions and Educational Needs of Primary Care Providers in Ontario, Canada Regarding Management of Patients with Morbid Obesity

Boris Zevin, MD, PhD, FRCSC, FACS 1, Nancy Dalgarno, PhD2, Mary Martin, MSc3, Colleen Grady, DBA3, Linda Chan, MPH2, Robyn Houlden, MD, FRCPC4, Richard Birtwhistle, MD, MSc, FCFP3, Karen Smith, MD, FRCPC5, Rachel Morkem, MSc3, David Barber, MD, CCFP31Department of Surgery, Queen’s University, 2Office of Professional Development and Educational Scholarship, Queen’s University, 3Department of Family Medicine, Queen’s University, 4Department of Medicine, Queen’s University, 5Department of Physical Medicine and Rehabilitation, Queen’s University

Introduction: Five percent of the Canadian population has morbid obesity; however, access to surgical and medical weight loss interventions for these patients remains limited. This study explored the knowledge, experience, perceptions, and educational needs of Primary Care Providers (PCP) in managing patients with morbid obesity and obesity-related comorbidities in primary care settings.

Methods: We surveyed practicing PCPs, including primary care physicians and nurse practitioners, in the South East Local Health Integration Network in Southeast Ontario, Canada using a 24-question survey. The survey was circulated via mail, fax, email or in-person at events to 591 PCPs. Data was collected between October 2017 and June 2018, and analyzed with SPSS using descriptive statistics.

Results: One hundred and three participants responded to the survey (17.4%). The majority were primary care physicians (91.8%), followed by nurse practitioners (6.2%) and other primary health care providers (2.0%). Overall, PCPs reported that, on average, 11.6% of their patient population qualifies for bariatric surgery, though the majority (77.0%) reported that they refer fewer than 20% of these patients for weight loss interventions. In terms of satisfaction with the outcome of recommending treatments for patients with morbid obesity, bariatric surgery had the highest reported level of satisfaction (71.9% were satisfied/very satisfied), while the outcome of recommending weight loss diets was among the lowest (18.7% were satisfied/very satisfied). Twenty-two percent of PCPs agreed/strongly agreed that they are hesitant to refer patients for bariatric surgery, and 43.5% and 53.5% agreed/strongly agreed that they were concerned with the risks associated with bariatric surgery and with postoperative surgical complications, respectively. Nearly half (43.4%) strongly agreed/agreed that future treatment of patients with morbid obesity must be based primarily on bariatric surgery with appropriate behavioral and dietary modifications. Nearly all respondents (88.5%) believe there is a need for education of PCPs on bariatric surgery.

Conclusions: Despite an overall perception that bariatric surgery is successful in the treatment of patients with morbid obesity, PCPs continue to under-refer their patients for surgical weight loss interventions. This appears to be due to a lack of knowledge about and experience with bariatric surgery among PCPs. Our results can inform the development of continuing professional development programs that support PCP education in management of patients with morbid obesity.


A Comparison of Surgical Outcomes Before and After Implementation of a Bariatric Surgery Program

Elizabeth M Carr 1, Samaad Malik, BSc, MSc, MD, FRCSC21University of Victoria, 2Unit of British Columbia, Island Medical Program Victoria General Hospital

Introduction: Laparoscopic sleeve gastrectomy has become the most common procedure for patients with morbid obesity worldwide. Dedicated bariatric surgery programs have become the central intake for patients; however, there is limited evidence to show improved outcomes with this approach. This study aims to evaluate surgical outcomes following laparoscopic sleeve gastrectomy (LSG) procedures pre- and post- implementation of a formal bariatric surgery program (BSP).

Methods and Procedures: A retrospective analysis of surgical outcomes for patients undergoing LSG pre-BSP implementation from December 20, 2011 to December 31, 2014 to post-BSP implementation January 01, 2015 to May 14, 2018 was conducted. Data was analyzed from the Plexia EMR system from patients that had undergone LSGs performed by a same single surgeon in Victoria, BC, CANADA. Patients who were considered for revisional bariatric surgery were excluded from analysis. Patient demographics, operative time, complications, and length of postoperative stay (LOS) were statistically analyzed utilizing an unpaired two sample t-test.

Results: A total of 381 patients were included in the study, 309 (81.1%) patients were female and 72 (18.9%) patients were male. Mean age was 47.1 ± 10.4 years, with a mean pre-operative BMI of 44.9 ± 6.1 kg/m2. Pre-BSP mean OR time was 55.8 ± 10.0 min, and the post-BSP mean OP time was 57.3 ± 27.8 min. There were no sleeve leaks nor deaths in our study. Three (0.9%) patients returned to hospital postoperatively, for dehydration and pain. The average length of postoperative stay was reduced from 2.3 ± 0.75 days pre-institution to 1.3 ± 0.65 days post-institution (P < 0.001).

Conclusion(s): Implementation of a formal bariatric institution may correlate with reduced postoperative length of stay for LSG procedures. More studies are required to ensure BSPs are improving surgical and patient outcomes.


Efficacy of Sleeve Gastrectomy vs. Roux-en-y Gastric Bypass Amongst Obese Pediatric Patients

Aryan Meknat, MD, Gustavo Fernandez-Ranvier, MD, PhD, Vivienne Cabreza, MD, Daniela E Guevara, MD, Kaitlyn E Billington, DNP, AGPCNPBC, Daniel M Herron, MD, Matthew L Dong, MD, Abiba Salahou; Mount Sinai Hospital

Background: Despite the fact that childhood obesity has become an epidemic in the western world with lifestyle changes having a limited success in sustaining weight loss; algorithms that incorporate bariatric surgery for adolescent weight management programs are lacking (1). Data comparing the efficacy of different bariatric procedures among pediatric patients is sparse. The safety and efficacy of the laparoscopic sleeve gastrectomy (LSG) and the laparoscopic roux-en-y gastric bypass (LRYGB), in the pediatric population, have been independently demonstrated (2). When comparing LSG with LRYGB in the adult population, there is no significant difference in short or mid-term weight loss (3). The objective of this study was to determine whether one bariatric surgery was more effective at lowering short-term (at one follow-up) BMI than another.

Methods: We retrospectively analyzed our series of pediatric patients (range; 15 to 21 years) who underwent either a LSG or LRYGB between 2011-2016, and those who subsequently followed up in one year.

Results: A total of 63 patients followed up at one year after having one of the two bariatric procedures done. 56 underwent LSG, while 7 underwent LRYGB. The mean pre- and post-operative BMIs for those who underwent LSG were 46.212 ± 6.29 and 33.192 ± 6.066, respectively. The mean pre- and post-operative BMIs for those who underwent LRYGB were 46.124 ± 4.413 and 32.052 ± 6.955, respectively. A t-test was used to measure the difference between the post-operative BMIs and a p-value of 0.646 was discovered.

Conclusion: Much like the adult population, there was no clinical or statistically significant difference in post-operative BMIs when comparing LSG vs. LRYGB at one year follow up. LRYGB, amongst the adults, produced better long-term weight loss (3). Therefore, the long-term efficacy and morbidity between these two bariatric procedures still needs to be determined.


Incidentaloma of Duodenal Pancreatic Heterotopia in Laparoscopic Sleeve Gastrectomy : A Case Report and Literature Review

Mohammed N Alali, MD 1, Fahad Bamehriz, MD1, Hassan Arishi, MD2, Waad Y Yaseen, MD31King Khalid University Hospital,college of medicine,KSU, Riyadh,KSA, 2King Abdulaziz Medical City, National Guard health affair, Riyadh,KSA, 3AlNoor hospital, Ministry of health, Makkah

Introduction: Pancreatic heterotopia or Heterotopic pancreas (HP) is the presence of pancreatic tissue outside the normal anatomical boundaries. It is usually found in the upper gastrointestinal tract - specifically, the stomach, duodenum, and proximal jejunum. The incidence of HP is 0.25-1.2%.

HP is usually asymptomatic and diagnosed during histopathological examinations with extremely rare malignant transformation.

We are reporting the first case report of incidentaloma of duodenal HP in obese patients during laparoscopic sleeve gastrectomy (LSG).

Case Report: A 15 year-old male obese patient (body mass index: 39.49 kg/m2), otherwise medically and surgically free, admitted electively for LSG. Intraoperatively, after a standard LSG was done a 2–3 cm doudenal nodule was noted incidentally to be attached to the mesenteric surface of the first part of duodenum. The decision was to do a wedge resection of the mass followed by closing the opening using 3 interrupted stitches. Post-operative course was uneventful and patient was discharged after less than 24 h. The histopathological examination of the duodenal nodule showed HP tissue.

Later during follow up, patient was doing well and tolerating oral intake.

Conclusion: Incidental pathology during bariatric surgery found to be around 2%, most commonly gastrointestinal stromal tumors (GISTs). We are reporting first case of incidental duodenal HP which was removed safely during LSG, further researches are recommended to look for the safety of excision of such lesion at the time of LSG .


The Use Of Non-steroidal Anti-inflammatory Drugs After Sleeve Gastrectomy

Alan Begian, BS, Jamil Samaan, BS, Evan Alicuben, MD, Angelica Hernandez, MD, Kulmeet Sandhu, MD, Adrian Dobrowolsky, MD, John Lipham, MD, Kamran Samakar, MD; University of Southern California

Introduction: Non-steroidal anti-inflammatory drugs (NSAID) are one of the most commonly used drugs for symptomatic relief of pain. More than 30 million Americans use NSAIDs daily and studies have demonstrated that those in higher BMI categories are more likely to be regular NSAID users compared to those in the lowest BMI categories. Nonetheless, NSAID use in the bariatric surgery population is strongly discouraged with some centers adopting a zero-use policy. The recommendations against NSAID use are based on low level evidence (Grade C) as published in the Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient. These recommendations were primarily aimed at preventing complications of NSAID use in gastric bypass patients but have been adopted to patients undergoing sleeve gastrectomy. The effects of NSAID use on sleeve gastrectomy patients has not been adequately studied to determine brest practice guidelines.

Methods and Procedures: A retrospective review of patients who underwent laparoscopic sleeve gastrectomy (LSG) at a single institution, multi-surgeon, academic tertiary hospital between January 1, 2014 and November 1, 2017 was performed. A phone interview and chart review were completed on the identified patient population.

Results: 423 LSG patients were identified for inclusion in the study. 76.7% of patients were female, average age was 48.5 years old, average preoperative BMI was 44.9, and average follow up was 28.7 months. There were zero identified cases of sleeve complications secondary to NSAID use including gastritis, bleeding, ulceration, perforation, or leak. 116 phone surveys were completed with 62.9% (n = 73) of respondents reporting some NSAID use after LSG. Of the respondents who reported using NSAIDs after surgery, 41.1% reported that they used them often(> once/week or daily), 28.8% reported occasional use (> 1/month but < 1/week), and 30.1% reported rare use (< 1/month). Nearly 27% of respondents reported regular NSAID use after LSG.

Conclusion: NSAID use in our bariatric surgery population is high despite an institutional policy to prohibit their use among all bariatric patients. Despite the high incidence of NSAID use in our study population, we could not identify a single case of NSAID induced gastrointestinal complications in our retrospective review. NSAID use after LSG may be a safe and viable pain management strategy that needs further evaluation.


Influence of HbA1c on Postoperative Outcomes of Bariatric Surgery

Michal Wysocki, MD 1, Piotr Major, MD, PhD1, Tomasz Stefura1, Jakub Dros1, Artur Kacprzyk1, Katarzyna Chlopas1, Katarzyna Major2, Piotr Malczak1, Magdalena Pisarska1, Michal Pedziwiatr1, Andrzej Budzynski112nd Department of General Surgery, Jagiellonian University Medical College, 2Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland

Introduction: The aim of this study was to investigate the influence of baseline glycated hemoglobin level (HbA1c) level in bariatric patients on postoperative outcomes. Studies investigating the association of HbA1c with surgical outcomes have shown conflicting results. We found scarce of clinical data regarding influence of baseline HbA1c on bariatric surgeries postoperative morbidity and readmission what was inspiration to conduct this multicenter retrospective study.

Methods and Procedures: Retrospective cohort study analyzed patients who underwent laparoscopic sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) or mini-gastric bypass (MGB) for morbid obesity in seven referral bariatric centers. Patients were divided into groups depending on preoperative HbA1c: HbA1c < 5.7%; 5.7-6.4% and ≥ 6.5%. Primary endpoints: influence of HbA1c level on perioperative (30-days) and postoperative (12-months) morbidity rates, operation time, length of hospital stay (LOS) and readmission rate.

Results: (32%). Median age was 43 (35-52) years. Median HbA1c was 5.7 (5.3-6.1). HbA1c < 5.7% was present in 1044 patients (49%), HbA1c5.7-6.4% in 734 (35%), and HbA1c ≥ 6.5% in 347 (16%). Percentage of male patients increased in groups from 26% in HbA1C < 5.7% to 47% in HbA1C ≥ 6.5% significantly. Same tendency through groups we observed in case of BMI and age. Uncontrolled diabetes (HbA1C ≥ 6.5%) was present in 185 (8.7%) patients, while 162 (7.62%) patients were not on antidiabetic medications despite having HbA1C ≥ 6.5%. Median operative time in patients with HbA1C ≥ 6.5% was significantly longer than in HbA1C < 5.7% and HbA1C 5.7-6.4%. 30-days morbidity rate was 5.27% (112 patients) and did not differ groups significantly, as 12-months morbidity rate (excl. 30-days) of 2.02% (43 patients). LOS did not differ groups significantly. 44 patients were readmitted in observation period (2.07%) in general. Patients having HbA1C in range of 5.7-6.4% and with HbA1C ≥ 6.5% did not have significantly increased odds for perioperative morbidity, 12-months postoperative morbidity as compared with those with HbA1C < 5.7%. Patients with HbA1c ≥ 6.5% had increased OR for prolonged LOS as compared to those with HbA1C < 5.7% (OR: 1.45; 95%CI: 1.07-1.97). HbA1c did not influence OR for readmissions. Patients with baseline HbA1c ≥ 8% had significantly increased chances for hospital readmission (OR 3.53, 95%CI: 1.35-9.21).

Conclusion: Baseline level of glycated hemoglobin did not influence chance for perioperative morbidity, 12-months postoperative morbidity and prolonged LOS. Patients with HbA1c ≥ 8% have increased chance for hospital readmissions.


Bariatric Surgery in Elderly Patients: 3-Year Outcomes

Vanessa Boudreau, MD, Scott Gmora, MD, Dennis Hong, MD, Mehran Anvari, MD, PhD, Karen Barlow, Hons, BSc, Olivia Lovrics, MsC; Center for Minimal Access Surgery, McMaster University, Ontario, Canada

Introduction: Only a few studies have studied bariatric surgery in the elderly population.

Methods: Data from the Ontario Bariatric Registry between 2010-2015 was used for this retrospective study to determine outcomes of bariatric surgery in the elderly population, compared with the population under 65 years old, with 3-year follow-up.

Results: 6420 patients underwent RYGB or SG, and completed at least 1-year follow-up. Of these, 140 patients (2%) were in the elderly cohort (BMI 48.4, age 66 years old, 70% female), with 101 patients undergoing RYGB (72.1%) and 39 undergoing SG (27.9%). At baseline, the elderly group had more hypertension (80.0% vs 44.9%), diabetes (86.0% vs 31.1%) and hyperlipidemia (86.6% vs 32.7%) than the younger group (BMI 49.5, age 45 years old, 84% female). Outcomes at 3-year follow-up are as follows:

Under 65 

65 and over


Decrease in BMI

 1 year

16.4 (5.6)

17.1 (5.7)


 3 years

16.1 (5.8)

16.5 (6.1)


Complications n (%)

 Mortality 30-day




 Overall complications

523 (8.3)

11 (7.9)



4 (0.1)

0 (0)



3 (0.1)

1 (0.7)



199 (3.2)

4 (2.9)


 Revisional Surgery

25 (0.4)



Comorbidities improvement (%, from baseline)



  1 year



< 0.05

  3 years



< 0.05



  1 year



< 0.05

  3 years



< 0.05



  1 year




  3 years




Conclusions: Gastric bypass and sleeve gastrectomy have similar overall mortality and morbidity rates for elderly patients, when compared to the younger patients. The elderly group may have an increased thromboembolic risk. Further study is needed to evaluate this finding.


Repair of Paraesophageal Hernia at the Time of Bariatric Surgery: A Propensity Matched Analysis of the Mbsaqip Database

Joshua Hefler, MD 1, Jerry Dang, MD1, Noah Switzer, MD, MPH2, Valentin Mocanu, MD1, Daniel W Birch, MD, MSc, FRCSC1, Shazheer Karmali, MD, MPH, FRCSC11University of Alberta, 2Ohio State University

Introduction: The purpose of this study is to examine short-term outcomes of patients undergoing bariatric surgery with concurrent paraesophageal hernia (PEH) repair versus bariatric surgery alone. PEHs are relatively common amongst obese patients. They must be repaired either before or concurrently with bariatric surgery. However, there remains debate on whether this is best done prior, in a separate operation, or at the time of bariatric surgery.

Methods & Procedures: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry was used to identify patients who had undergone bariatric surgery with concurrent PEH repair. Patients undergoing primary bariatric surgery at an accredited institution between 2015 and 2016 were included. Bariatric surgery procedures included laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). A propensity-score matching algorithm, accounting for patient age, sex, body mass index (BMI) and comorbidities, was used to match these patients to a cohort of patients who underwent bariatric surgery alone. Overall 30-day incidence of major complications was the primary outcome. Secondary outcomes included mortality, length of operation, length of stay, readmission and reoperation.

Results: The MBSAQIP database identified 222,320 bariatric procedures without PEH and 42,732 procedures with concurrent PEH repair (16.12% of the total). Baseline age, BMI, and comorbidities were significantly different between cohorts. With one-to-one propensity score matching, 42,379 pairs were selected. Background characteristics, including age, sex, preoperative BMI and preoperative comorbidities did not differ statistically between matched cohorts. There was no statistically significant difference in 30-day major complications (PEH 3.48% vs no PEH 3.36%, p = 0.317) or mortality (PEH 0.06% vs no PEH 0.08%, p = 0.189) after surgery. Reoperation within 30 days (PEH 1.24% vs no PEH 1.11%, p = 0.08) were also similar. Rates of readmission were higher with concurrent PEH repair (3.99 vs 3.59%, p = 0.002) and length of stay was longer without PEH repair (1.74 vs 1.63 days, p < 0.001). The cohort including PEH repair did have slightly longer operative times (87.09 vs. 81.19 min, p < 0.001).

Conclusions: With a total of 42,732 concurrent PEH repair procedures, this is the largest retrospective study to date. Our analysis indicates that the incidence of major complications for bariatric surgery with concurrent PEH repair is similar to bariatric surgery alone. However, rates of readmission and operative time are higher with concurrent PEH repair. Overall, this study demonstrates the safety of concurrent bariatric surgery and PEH repair.


ROUX-en-Y Gastric by Pass Impact on Obese Patients Erosive Esophagitis and Barret’s Esophagous

Franco J Signorini, MD1, German R Viscido, MD1Veronica Gorodner, MD 2, Lucio R Obeide1, Federico Moser11Hospital Privado Universitario de Córdoba, 2Unidades Bariatricas, Buenos Aires

Introduction: The incidence of erosive esophagitis (EE) and Barret´s esophagus (BE) is as high as 26% and 6% respectively in bariatric patients. Although the benefits of Roux-en-Y gastric by pass (RYGB) regarding gastroesophageal reflux disease (GERD) have been well documented, the reports of the effects of this procedure among EE and BE are scarce. The aim of this study is to evaluate the postoperative evolution of EE and BE after RYGB.

Methods and Procedures: A retrospective study from a prospective database was performed. Patients who had EE or BE and RYGB in our institution between 2013 and 2017 were included. Demographics, BMI and  %EWL evolution were analysed. Upper endoscopy pre and post operative and their biopsies results were assesed. Post operative data was collected at 24 months after surgery. EE was classified following the Los Angeles criteria.

Results: 64 patients were included, 55 had EE and 9 BE. Mean age, BMI and %EWL were 46.9 years, 44.29 kg/m2 ± 3.5 and 78.5 ± 5.8% respectively. Patients with EE were distributed as follows: A: 54.5% (n = 30), B: 34.5% (n = 19), C: 10% (n = 5) and D: 2%. 87% and 84% of patients with grade A and B resolved their condition respectively (p < 0.001 for both cases). 20% of patients with grade C resolved while 80% improved to grade A. The only patient with grade D resolved his esophagitis.

Nine patients had histological diagnosis of BE preoperatively. 4 (45%) were short segment Barret´s esophagus (SSBE) and 5 (55%) were long (LSBE). 75% of SSBE (p = 0.1429) and 40% of LSBE (p = 0.1667) had endoscopic and histopathological resolution. One patient (25%) with SSBE and 2 patients (40%) with LSBE remained the same. 1 patient (20%) with LSBE improved to SSBE.

Conclusion: In our experience, RYGB promoted the improvement and even resolution of EE and BE in a significant number of patients, without observing disease progression in any case. Long term studies should be perform in order to establish EE and BE definite behaviour after RYGB.


Intragastric Balloon Outcomes in Mexican Population of the General Hospital “Dr. Manuel Gea González” in the Last 5 Years

Luis A Topete, MD, Luz S Romero, MD, Rodrigo Aceves, MD, Martin E Rojano, Roberto Delano, MD, José De Jesus Herrera, MD; Hospital General “Dr. Manuel Gea González”

Introduction: In 1985, Garren-Edwards introduce the intragastric balloon. It was removed from market after several complications such as deflation and migration of the balloon. Outcomes in the usage of intragastric balloon published in other countries show a percentage of excess weight loss of 60%, and a weight regain of 35% after retrieval of balloon. Intragastric balloon therapy has been use as first option therapy for patient with obesity type I and also as bridge therapy in patients with morbid obesity, Nonetheless, there are none clinical trials publish in Mexico of the outcomes of usage of intragastric balloon.

Objective: Main purpose of the study is to report the percentage of excess weight loss and weight regain after retrieval of intragastric balloon in the General Hospital “Dr. Manuel Gea González” in the last 5 years.

Materials and methods: We conducted a research from database at the Clinic of Obesity of the General Hospital “Dr. Manuel Gea González” in search of patients who underwent an endoscopic intragastric balloon placement as therapy of weight loss from January 2012 to November 2017. We analyze demographics characteristics of patients, weight before intragastric balloon therapy, type of intragastric balloon, time of intragastric balloon therapy, symptoms after intragastric balloon placement. Follow up of patient with weight was recorded at 1, 3, 6, 9, 12 and 18 months. Additionally, it was specifying if the patient underwent a bariatric surgery after retrieval of intragastric balloon.

Outcomes: From January 2012 to November 2017, we found 22 patients who underwent intragastric balloon therapy. The average age of patient was 41.6 years, average Body Mass Index was 41.4 kg/m2, 6 patients were male and 16 were women. Percentage of excess weight loss was 34.9% with a weight regain after retrieval of intragastric balloon at 1 year of follow up. We had the same outcomes in terms of percentage of excess weight loss with the two different types of intragastric balloon. We included patients undergoing interval therapy and also as first option therapy. Five patients underwent bariatric surgery after balloon retrieval reaching a percentage of excess weight loss of 45.6% six months after removal. In terms of symptoms, none of the patients underwent early removal of the balloon and only 7 patients suffer from mild symptoms after placement of the balloon.

Conclusions: Our study shows similar outcomes as previous reports regarding weight regain and percentage of excess weight loss.


Comparing Mini-gastric Bypass and ROUX-en-Y Gastric Bypass for Bariatric Surgery Using the Metabolic and Bariatric Surgery Accreditaion and Quality Improvement (MBSAQIP) Database

Conrad Moher, MD, Daniel Skubleny, MD, Jerry T Dang, MD, Daniel W Birch, MD, FRCSC, Shahzeer Karmali, MD, FRCSC; University of Alberta

Introduction: The aim of this study is to determine whether MGB may be a reasonable alternative to RYGB by comparing post-operative complication rates. Mini-gastric bypass (MGB) is continuing to gain evidence as a viable bariatric procedure. Compared to the two-anastomosis laparoscopic Roux-en-Y gastric bypass (RYGB), the MGB is performed with a single gastrojejunal anastomosis and is arguably a simpler and faster procedure in experienced hands. Significant criticism surrounds the MGB, including complications related to bile-acid reflux and the potential risk of future gastro-esophageal cancer.

Systematic reviews from Europe and Asia have established MGB as a safe and effective procedure. North American comparisons of MGB and RYGB are currently limited. This is the first study using the MBSAQIP database to compare MGB and RYGB.

Methods and Procedures: This is a retrospective study using the MBSAQIP database. Univariate and multivariable analyses on multiple outcome measures for all primary MGB and RYGB procedures was performed. Revisional procedures were excluded. Data analyzed included demographic information, operative time, perioperative outcomes, and complication rates. Measured 30-day outcomes included: death, venous thromboembolism (VTE), bleed, leak, re-operation, re-admission, length of stay, and re-intervention.

Results: From 2015-2016, a total of 112 MGB and 78,883 RYGB were performed. There was no difference in patient demographics except: mean body mass index (BMI) (MGB = 44.0, RYGB = 46.3; p = 0.059), dialysis dependence (MGB = 0.9%, RYGB = 0.2%; p = 0.064), history of DVT (MGB = 4.5%, RYGB = 1.9%; p = 0.040), and therapeutic anticoagulant use (MGB = 8.9%, RYGB = 2.6%; p = 0.000). Mean operative time was longer for MGB (MGB = 135.6 min, RYGB = 119.6 min; p = 0.002). 30-day complication rates showed no significant difference in mortality, leak, bleed, re-operation and re-intervention. Significant differences were found in rates of VTE (MGB = 1.8%, RYGB = 0.4%, p = 0.025), readmission (MGB = 9.8%, RYGB = 6.1%; p = 0.099), length of stay lasting greater than 7 days (MGB = 3.6%, RYGB = 1.0%; p = 0.007), and acute renal failure (MGB = 0.9%, RYGB = 0.1%; p = 0.026).

Conclusions: Our analysis of the MBSAQIP database found that MGB had longer operative times and increased complications in several categories. Significant discrepancy in data volume between MGB and RYGB within the MBSAQIP database limits the ability to establish robust conclusions. Surgical volume and differences in geographical procedural preferences likely contributes to the increased complications found for MGB. The need for additional MGB data within the MBSAQIP database must be balanced with the notion that surgeons should continue to perform procedures in which they maintain large volumes in order to mitigate procedural complications.


Re-emergence of Diabetes After Sleeve Gastrectomy in Patients with Long Term Follow-up

Franco J Signorini, MD1, German R Viscido, MD1Veronica Gorodner, MD 2, Luciano Arocena, MD1, Lucio R Obeide, MD1, Federico Moser, MD11Hospital Privado Universitario de Córdoba, 2Unidades Bariatricas, Buenos Aires

Introduction: Diabetes (DBT) improvement or remission associated to bariatric surgery have been shown by several studies. Data about the recurrence of DBT after surgery remains scarce and very little information can be collected regarding sleeve gastrectomy (SG). The main goal of our study was to determine the incidence of durable remission of DBT after sleeve gastrectomy and factors associated with DBT recurrence.

Methods and Procedures: A retrospective study of all patients (n = 47) with DBT who had undergone primary LSG at a single institution and had more than eight years of follow-up with complete laboratory data available was perfomed. Patients with inadequate weight loss were compared with patients with adequate weight loss. Patients with long time of diabetes evolution were also compared with those with less than 10 years of evolution. Finally, patients that needed insulin for glycemic control were analyzed separately.

Results: After SG, all patients had rapid improvement of their DBT. 83% achieved complete resolution and 17% registered an improvement in their metabolic control within the first year. The average follow-up time was 8.8 years. At this point, the mean post-operative  %EWL was 51 ± 19.39%, HbA1c 6.45 ± 1.28% and FG 118.7 ± 27.75 mg/dl. 31% of the patients with initial resolution after surgery experienced recurrence. 6 out of the 8 (75%) patients who registered an initial improvement worsened their metabolic control. Those who recurred or worsened had an inadequate mean  %EWL (46%) and 67% needed more than one drug preoperatively for their DBT control. The results of a comparison of patients with adequate weight loss (n = 25) versus inadequate weight loss (n = 22) reported a  %EWL of 66,44% (± 11.38) and 34,04% (± 11.25) respectively (p?0.001). Statistical difference was obtained when the number of patients with remission or improvement was compared with those with recurrence or worsening among this groups (p?0.0255). Patients with long time DBT evolution (n = 14) were compared with those with short time DBT evolution (n = 33): 50% vs 37% of patients recurred respectively (p?0.704). All the patients who required insulin (n = 5), had initial remission or improvement. 60% recurrence or worsening was registered in the long term, none of them required insulin and their DBT could be managed with drugs and even without medication.

Conclusion: Sleeve gastrectomy significantly improves diabetes control and appear to alter the trajectory of the disease without resulting in a permanent cure. The result seems to be assosiated to weight loss and insulin requierements.


Laparoscopic Sleeve Gastrectomy with Hiatal Hernia Repair in a Morbidly Obese Patient with Gastroesophageal Reflux Disease

Krista Angeli P Delos Santos-Belen, MD, Miguel C Mendoza, MD, Judy Carissa M Atazan, MD; Asian Hospital and Medical Center

Introduction: Laparoscopic sleeve gastrectomy (LSG) has increasingly become one of the most commonly performed bariatric procedures in the past decade, with proven excellent outcomes in achieving excess weight loss, resolution of comorbidities, and low perioperative morbidity. Preoperative gastroesophageal reflux disease (GERD) in obesity is considered a relative contraindication due to the possibility of having worse reflux symptoms postoperatively. In general, developing GERD symptoms is also recognized as a late complication after LSG. For those with known preoperative GERD secondary to a hiatal hernia, newer techniques have been recently implemented such as performing a concomitant hiatal hernia repair, for GERD treatment and prevention as well. This case report aims to show the key steps in performing LSG with hiatal hernia repair (LSG + HHR) as a single stage procedure.

Methods: This is a case of a 30 year-old male with morbid obesity (BMI = 37.2 kg/m2), Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, and GERD. Preoperative gastroscopy, esophagogram, and abdominal CT showed a hiatal hernia type I. Patient was referred to the following services for multidisciplinary perioperative management and clearance prior to surgery: Gastroenterology, Endocrinology, Cardiology, Pulmonology, Psychiatry, and Nutrition. The patient underwent LSG + HHR as a single stage procedure.

Results: On the 1st postoperative day, an esophagogram was done showing smooth flow and no leak of contrast ingested. Patient was able to tolerate general liquids and was discharged on 2nd day after surgery. Short term outcomes evaluated included postoperative bleeding, anastomotic leakage, surgical site infection, and reflux symptoms - none of which were reported in the immediate postoperative period and on followup consults on 1st and 4th weeks after discharge.

Conclusions: LSG + HHR is an effective and feasible option in morbidly obese patients with GERD. Further studies are recommended to evaluate the outcomes as compared to conventional two-staged or bypass procedures.


Neural Mechanisms of Taste Preference Changes following Roux-en Y Gastric Bypass and Vertical Sleeve Gastrectomy

Kimberly Smith, PhD 1, Afroditi Papantoni, BS1, Marga Veldhuizen, PhD2, Timothy Moran, PhD1, Susan Carnell, PhD1, Kimberley E Steele, MD, PhD11The Johns Hopkins University School of Medicine, 2Yale University, The John B Pierce Laboratory, Inc

Background: Changes in taste preferences have been reported following bariatric surgery. To investigate neural mechanisms for such changes and differentiation by surgery type, we measured behavioral and neural responsiveness to varying concentrations of sugar and fat-containing tastants in patients before and 2 weeks after vertical sleeve gastrectomy (VSG) or Roux-en Y gastric bypass (RYGB).

Methods: Prior to surgery, patients were presented with 12 taste stimuli varying in sugar and fat content and asked each patient to rate each stimulus on a visual analog scale and select the stimulus they preferred most. Patients then underwent a functional magnetic resonance imaging (fMRI) brain scan in which they were orally presented with the following stimuli in a randomized order across multiple trials: high fat (cream, 0% added sugar), high sugar (skim milk, 20% added sugar), the patient’s most preferred tastant, and a tasteless solution. Two weeks following bariatric surgery, patients repeated the taste preference test and fMRI.

Results: A total of 34 patients (VSG; N = 17 and RYGB; N = 17) participated prior to and two weeks following bariatric surgery. The mean pre-surgical BMI for VSG (42.36, SD 4.43) and RYGB (43.52, SD 3.68); 2 weeks mean post surgery BMI VSG (39.77, SD 3.89) and RYGB (40.64, SD 3.90). Initial whole-brain analyses indicate increased blood-oxygen-level dependent (BOLD) responses in the insula and amygdala to the high fat and high sugar solutions, respectively, in RYGB patients relative to VSG patients 2 weeks following surgery. Greater post-surgical decreases in BOLD responses in the insula and striatum to the patients’ pre-surgical most preferred solution were seen in RYGB patients relative to VSG patients.

Conclusion: Our preliminary data suggest that bariatric surgery may decrease preferences for high energy-dense foods by modulating brain reward responses to combined tastes of sugar and fat, and that the extent of changes in taste-responsive neural activation may differ by surgery type (supported by 1K23DK100559).


A Novel Gastrointestinal Sealant for Use on Gastric Staple Lines: A Pilot Study

Tovah Z Moss, MD 1, Nathan Gasek2, Weiss Dan1, Patrick Forgione, MD11UVM, 2University of Connecticut

Introduction: Leakage of gastric/intestinal contents from disrupted gastrointestinal staple or suture lines is a significant cause of morbidity and mortality for surgical patients undergoing many gastrointestinal surgeries. For example, the incidence of gastric leak after sleeve gastrectomy from staple line disruption is approximately 2.2% and thus affects 2,329 patients annually (Parikh et al., 2013). We have developed multiple materials that show promising qualities for use as GI sealants. These materials are biological polymers that can be tailored and functionalized to harness qualities such as tissue-adhesiveness and increased tensile strength. This pilot study aimed to systematically assess one promising compound, methacrylated gelatin (GELMA) in ex vivo rat stomach models.

Methods and Procedures: Rat stomachs were harvested, the esophagus was cannulated using 18-gauge cannulas and sealed with 0 silk or Ethilon suture. The stomachs were then lavaged to remove excess stomach contents before stapling across the body of the stomach, excluding the pylorus, with vascular staple loads (Medtronic Endo GIA Gray Articulating Reload 30 mm Extra Thin/Vascular). The stomach was then tested using our burst pressure device until an air leak was detected. The max pressure was then recorded. 25% (w/v) GELMA sealant (200uL) was then applied to the previously-tested bare staple line (for paired analysis) and re-tested for burst pressure once again. These results were then compared to an equal number (n = 5) of rat stomachs that were stapled with buttressed staple loads (Medtronic Endo GIA Reinfored Medium/Thick staple loads).

Results: The mean burst pressure was higher in the GELMA 25% group compared to the bare staple lines, despite these stomachs being tested a second time (202.251 cmH2O vs 483.306 cmH2O, p = 0.134). The GELMA-enforced staples had significantly higher mean burst pressures than the commercially-available buttressed staple group (483.306 cmH2O vs 165.844 cmH2O, p = 0.036).

Conclusions: These are encouraging preliminary results in evaluating this novel material for use as a gastric staple line reinforcement in bariatric surgery. These results show that GELMA may provide a safe, effective, and practical tool as a gastrointestinal sealant and staple/suture line reinforcement.

Resources: PARIKH, M., ISSA, R., MCCRILLIS, A., SAUNDERS, J.K., UDE-WELCOME, A. & GAGNER, M. 2013. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg, 257, 231-7.


Outcomes from Explantation of Laparoscopic Adjustable Gastric Band: an Institutional Analysis from a Canadian Bariatric Centre of Excellence

Shannon E Stogryn, MBBS, MSc, FRCSC 1, Azusa Maeda, PhD1, Steve J Maclellan, MD, FRCSC1, Ashley Vergis, MMEd, MD, FRCSC, FACS2, Allan Okrainec, MD, MHPE, FRCSC1, Timothy Jackson, MD, MPH, FRCSC, FACS11University of Toronto, 2University of Manitoba

Introduction: Laparoscopic Adjustable Gastric Banding (LAGB) is a common bariatric procedure that has experienced a significant decline. This is primarily due to poor sustained weight loss and high revision rates compared to its contemporary bariatric procedures. Explantation of LAGB is commonly performed at our institution and often concurrently converted to other bariatric procedures. Previously reported adverse event rates for LAGB removal alone was 6.8%. The objective of this study is to evaluate the outcomes after LAGB removals at our institution including conversions to other bariatric procedures.

Methods: Patients were identified using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from the Toronto Western Hospital site, filtered by LAGB removal based on the principal procedure code and concurrent procedural terminology (CPT) codes (43773, 43774). Patients undergoing simultaneous conversion to other bariatric procedures were included. Outcomes were evaluated for 30-day morbidity, mortality, and readmission.

Results: Between 2011-2018, 93 patients met our inclusion criteria. The majority of patients were female (84.95%) with a mean body mass index (BMI) of 42.31 (± SD 9.48) and mean age of 49.12 years (± SD 10.77 years). All LAGB removals were performed laparoscopically with only 1 conversion to open (1.08%). The majority were elective procedures (96.77%) with only 3 emergency cases (3.23%). Mean length of stay was 2.19 days (± SD 2.29 days). Post-operative complications at 30 days occurred in 11.83% of patients with a 4.30% readmission rate. There were no deaths. Surgical site infections (SSI) accounted for 81.82% of complications (54.55% superficial SSI, 27.27% deep SSI). Thirty-day adverse event rate for LAGB removal alone was 15.00%. Emergent LAGB explantation had a 33.33% complication rate. LAGB was converted to another bariatric procedure in 56.99% of cases (48.39% Laparoscopic Roux-en-Y Gastric Bypass (LRYGB), 8.6% Sleeve Gastrectomy (LSG)). Conversion to LSG was associated with the highest 30-day post-operative complication rate (37.50%) compared to conversion to LRYGB at 2.22% (p = 0.375).

Conclusion: Thirty-day complication rates for removal of LAGB and conversion to other bariatric procedures is significant and may be higher than rates previously reported for LAGB removal alone. This case series suggests that conversion to sleeve gastrectomy may have the highest post-operative complication rate.


Mental Health and Bariatric Surgery

Jamil S Samaan, BS, Evan T Alicuben, MD, Elaine Qian, BS, Kulmeet Sandhu, MD, Adrian Dobrowolsky, MD, Kamran Samakar, MD; University of Southern California

Introduction: The relationship between mental health and bariatric surgery has not been well established. We aim to investigate how subjective measurement of depression and anxiety responded to bariatric surgery in our patient population and examine changes in mental health as a function of bariatric surgery outcomes.

Methods and Procedures: A retrospective chart review was conducted on patients who underwent laparoscopic sleeve gastrectomy (LSG) and roux-en-y gastric bypass (RYGB) from August 2002 to November 2017 at a single institution, multi-surgeon, academic hospital. Preoperative surveys and a telephone questionnaire were utilized for gathering data regarding personal characteristics and mental health. The telephone survey utilized a leikert scale to assess patient postoperative satisfaction and quality of life. Inclusion criteria included patients who completed a telephone interview. Exclusion criteria included patients who did not complete the telephone interview or preoperative questionnaires. Fisher’s exact test was used for statistical analysis.

Results: There were a total of 514 patients, 76% female, 71% underwent RYGB and 29% LSG with a median age of 47.0 (95% Cl 45.6-48.8). Median preoperative BMI was 42.6, range 29.95-80.24 (95% Cl 41.8-43.2). Median postoperative BMI points lost was 10.6 (95% CI 10.0-11.0). Average follow up was 6.99 years (SD = 4.30). Surgery success was defined as excess weight loss (EWL) of > 50%.

*Use of diuretics and laxatives, binging and purging, vomiting, binging followed by food restriction

Conclusion: Depression and anxiety symptoms improved significantly after bariatric surgery in our study. Those who improved also demonstrated higher improvement in quality of life and postoperative satisfaction. Interestingly, surgery success was statistically correlated with improvement in symptoms. Interpretation of the relationship between symptom improvement and mental health is difficult to ascertain and objective prospective trials are needed to further understand these relationships.


Balloons Gone Wild: Spontaneous Hyperinflation of Orbera Intragastric Balloon Causing Gastric Outlet Obstruction

Ransford Commey, MD, Ryan Lehmann, DO, FACS, FASMBS, Norbert Richardson, MD, FACS, FASMBS; St Alexius Hospital

Background: Several endoscopic bariatric therapies have been approved for use in the treatment of obesity and metabolic syndrome. The Orbera Intragastric balloon is one of the first devices to be approved in the United States. It is a single saline-filled balloon (400 – 700 mL) that is endoscopically inserted into the stomach for a period of 6 months. Rare complications of intragastric balloons include hyperinflation, deflation, gastric outlet obstruction, and pancreatitis. Spontaneous hyperinflation with resultant gastric outlet obstruction requires balloon removal.

Methods: We present the case of a 44-year-old female, BMI 37.6, who underwent placement of Orbera Intragastric balloon. She presented 2-1/2 months later with complaints of worsening nausea, vomiting and increasing fullness in the left upper quadrant. A computed tomography scan showed the balloon in position within the stomach but significantly enlarged at 15.6 × 14.2 × 12.4 cm with an air-fluid level. The spontaneously hyperinflated balloon was causing a gastric outlet obstruction. She was taken to the operating room and the balloon was endoscopically removed.

Results: The patient lost approximately 40Lbs from time of balloon insertion to removal. During endoscopy, the balloon was visualized in the gastric antrum. It appeared maximally inflated and tense with an air-fluid level. Attempt at the normal aspiration procedure resulted in balloon rupture and spillage of the saline content which was then suctioned. The deflated balloon was removed endoscopically in its entirety. The patient was discharged home the same day.

Conclusion: Spontaneous hyperinflation of the Orbera Intragastric balloon is a possible complication of the procedure. Clinicians must maintain a high index of suspicion in patients who present with symptoms of increasing left upper quadrant fullness and gastric outlet obstruction following balloon insertion. Endoscopic treatment of this complication with balloon removal is feasible and should be carried out following clinical and radiographic diagnosis.


Attending Specialization and 30-Day Outcomes following Laparoscopic Bariatric Surgery

Ivy N Haskins, MD, Sheena W Chen, MD, Ada Graham, MD, Andrew D Sparks, MS, Paul P Lin, MD, FACS, Hope T Jackson, MD, Khashayar Vaziri, MD; George Washington University

Introduction: Surgeon and hospital volume are two factors that have been shown to impact outcomes following bariatric surgery. However, there is a paucity of literature investigating surgeon training on bariatric surgery outcomes. The purpose of this study was to determine if bariatric specialty training leads to improved short-term outcomes following laparoscopic bariatric surgery.

Methods: All patients undergoing first-time, elective, laparoscopic bariatric surgery from 2015-2016 were identified within the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. These patients were divided into two groups based on surgeon training, including general surgery training only or metabolic and bariatric surgery training. Thirty-day outcomes following laparoscopic bariatric surgery were compared between the two groups using multivariate logistical regression analysis.

Results: A total of 140,340 patients met inclusion criteria; 4,598 (3.3%) patients underwent bariatric surgery by a general surgeon. These patients were lower risk as evidenced by their overall functional status and American Society of Anesthesia (ASA) classification. Despite being lower risk, patients who underwent surgery by a general surgeon were significantly more likely to be discharged to a facility (OR: 3.6, CI: 2.56-5.13, p < 0.0001) while patients who underwent surgery by a metabolic and bariatric surgeon were significantly less likely to be readmitted to the hospital within 30-days of their index bariatric surgery (OR: 0.81, CI: 0.67-0.97, p = 0.02).

Conclusion: Patients who undergo bariatric surgery by a general surgeon are more likely to be discharged to a facility and to be readmitted within 30-days of surgery. These differences in 30-day outcomes could be related to differences in postoperative support provided by the surgeon types and the institutions where they perform bariatric surgery. Additional information is needed with regards to the type of postoperative support provided following bariatric surgery and to determine if general surgeons are more or less likely to perform bariatric procedures at designated centers of excellence.


Pre-operative Risk Factors for 30-Day Mortality After Primary Laparoscopic Bariatric Procedures

Samantha Warwar 1, Noah J Switzer1, Jerry Dang2, Megan Delisle3, Carla Holcomb1, Shahzeer Karmali2, Susan Maurer1, Bradley Needleman1, Sabrena Noria11The Ohio State University, 2University of Alberta, 3University of Manitoba

Introduction: The purpose of this study was to identify predictors of 30-day mortality after bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.. With improvements in perioperative care, 30-day mortality rates after bariatric surgery are < 0.1%; a rate similar to elective laparoscopic cholecystectomy. With such low mortality rates, identifying patients at increased risk becomes difficult. Given the emphasis on shared decision-making and informed consent, predictive tools have become increasingly useful to guide physician–patient discussions.

Methods and Procedures: This is a retrospective review of prospectively collected data from the MBSAQIP database for the years 2015 and 2016. Patients > 18 yo, who underwent a primary laparoscopic gastric bypass (RYGB) or sleeve gastrectomy (LSG) were included in the analysis. The outcome of interest was 30-day mortality. Multivariable logistic regression analysis selected by univariable screen was performed. A derivation was created using the 2015 dataset and validated using the 2016 data. Variables with p value < 0.05 in univariate analysis were included in the predictive model. A forward selection algorithm with an entry p value of < 0.01 was used to build a logistic regression model predicting probability of death within 30 days using the derivation data set. The area under the receiver operating characteristic curve was calculated for the derivation and validation dataset. The accuracy of the predictions was assessed with the Brier score

Results: A total of 248, 286 patients were included in the analysis. Mean age was 44.64 + 11.93 years, with the majority of subjects being female (80%). Overall 30-day mortality rate was 0.1%, with 249 reported events. In the multivariable model, age (OR-1.04, 95% CI 1.02-1.05), gender(OR-0.56, 95% CI 0.42-0.73), BMI(OR-1.05, 95% CI 1.04-1.06), COPD (OR-1.82, 95% CI 1.09-3.04), operation length (OR-1.29, 95% CI 1.13-1.49), and therapeutic anticoagulation (OR-2.51, 95% CI 1.67-3.77) were all risk factors for 30 day mortality. The following prediction model was created.

Risk of Death = (13* therapeutic_anticoagulation) + (0.5*BMI) + (0.5*Age) + (3* Operationlength) + (-10* Female) + (8*Blackrace) + (3* Diabetes)

Subjects were stratified into high (> 5%), medium (1- 5%), and low risk groups (< 1%) for mortality at 30-days, based on points received from the model. The discrimination of the model was 0.80.

Conclusion: While death following bariatric surgery is rare, approximately 0.1%, a cohort of patients exist who are at increased risk. Identifying these patients before surgery may allow for proper informed consent and preoperative optimization.


Cannabis Use May Affect Early Outcome Weight Loss Post Bariatric Surgery

Nicole Shockcor, Sakib Adnan, Ariel Siegel, Eric Wise, Nabeel Zafar, Mark Kligman; University of Maryland

Introduction: With the decriminalization of marijuana, it is imperative that we understand how cannabis use can affect surgical outcomes. Previous studies in transplantation have indicated no difference in morbidity or mortality after receiving a kidney allograft, but the affect on bariatric patient outcomes remains to be uncovered. Here we aimed to determine the effect of marijuana use on weight loss post laparoscopic Roux-en-Y gastric bypass (LRYGB) as well as laparoscopic sleeve gastrectomy (LSG).

Methods: 1177 patients who underwent bariatric surgery from 2012-2017 at a single institution were identified. Patients who underwent LRYGB revisions, conversions to LRYGB, laparoscopic band removal with conversion, and lost to follow up were excluded. Patients were followed two years post procedure. SPSS software was utilized to determine covariate effects.

Results: In the 1177 patients included in this retrospective analysis, 73 (6.2%) patients were identified as cannabis users. This was defined by a positive toxicology screen and/or reported use. LSG was performed in 465 patients (39.5%) while LRYGB was performed in 712 (60.5%). Postoperative complications were no different between groups, including all cause complications, infection, venothrombolic events, and reoperation. Early 2 month average weight loss was greater in cannabis users (68.02 vs. 55.83 lb) than non-users, with the cannabis group having lost a larger percentage of excess body weight. Long-term BMI results showed no difference in excess BMI between cannabis users and non-users at 6 months (10.55 vs 10.07 kg/m2) and 1 year (6.48 vs 6.91 kg/m2) post procedure.

Conclusions: With nationwide changes in cannabis use and regulation, it is important to note that its use may have no effect on morbidity or mortality after bariatric surgery. With this preliminary retrospective analysis, a trend was seen towards greater initial excess weight loss in cannabis users; however, further investigation is warranted to fully characterize attributing factors.


One Anastomosis Gastric Bypass (OAGB) and Esophageal Reflux. A Cross Sectional Study

Luciano J Deluca, MD, Patrcio J Cal, MD, Tomas C Jakob, MD, Martin Pruss, MD, Ezequiel O Fernandez, MD; CMPFA Churruca Visca

Introduction: Obesity is associated with multiple metabolic disorders and is a risk factor for several upper gastrointestinal tract diseases. GERD’s prevalence can rise to 49.6% in the obese population.

Controversy has arisen regarding the severity of esophageal reflux after the one anastomosis gastric bypass (OAGB).

The objective of this study was to evaluate GERD following SAGB.

Methods: Between April 2015 and March 2018, 66 OAGBs were performed either laparoscopically or with robotic assistance.

Patients with at least 1 year follow up were evaluated via a standardized reflux questionnaire (GERDq), upper GI endoscopy and 24 h pH-impedanciometry performed and interpreted by surgical team to assess acid and non-acid esophageal reflux.

Results were shown as means ± standard deviations or as percentage of the total.

Results: A total of 51 patients achieved 1 year follow-up. Mean age was 45.4 ± 8.1 years, BMI 46.7 ± 7 kg/m2; 59,1% were women. GERD q was obtained in 33 patients, with a mean score of 1.43 ± 2.8. Only one patient showed a result higher than 8.

Upper GI endoscopy was performed on 31. Compared to preoperative study, 1 patient showed resolution of esophagitis, and de novo esophagitis was assesed in 2. No other erosive changes were recorded.

19 patients underwent ph-impedanciometry. Average Demeester score was 6.7 ± 1.8. 5 patients presented a score between 14.7 and 18,7. All of them showed a GERDq of 0 and non erosive upper GI endoscopy.

Average total time with acid reflux was 1.84%, all patients were below 6%. Four patients showed higher than normal number of weakly alkaline episodes, although percentage of total time in alkaline reflux was normal in all studies (0,36% ± 0,9). All of them presented a GERDq of 0 and a normal upper GI endoscopy. Only one patient showed a positive symptomatic index (SI).

Conclusion: OAGB seems to result in a low incidence of GERD. Even though 6,45% showed to have de novo esophagitis, pH-impedanciometry and questionnaires showed promising results.


Outcomes Following Revision and Conversion Robotic-Assisted Compared to Conventional Laparoscopic Bariatric Surgery: A Review of the 2015 and 2016 MBSAQIP Participant User Files Database

Edwin Acevedo Jr, MD 1, Huaqing Zhao, PhD, MS2, Xiaoning Lu, MS2, Michael A Edwards, MD, FACS, FASMBS21Temple University Hospital, 2Lewis Katz School of Medicine at Temple University

Introduction: Revisional bariatric surgery is being increasingly performed and is associated with higher operative risks. Optimal technique to minimize complications remains controversial. Here, we report a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Files (PUF) database, comparing outcomes between for revision/conversion bariatric surgery using conventional laparoscopic (LBS) and robotic-assisted (RBS) approaches.

Methods: Revisional/conversion cases were identified in the 2015 and 2016 MBSAQIP PUF database. Selected cases were characterized into two groups (RBS; LBS). Case-controlled matching (1:1) was performed of the RBS and LBS cohorts. Cases and controls were match by demographics (age, gender, race, BMI) and preoperative comorbidities. Outcomes measures included operative length (OL), length of stay (HLOS), 30-day outcomes, and complications.

Results: 26,404 revision/conversion cases were identified (93.3% LBS, 6.7% RBS). 85.6% were female and 67% white. Mean age and BMI were 48 years and 40.9 kg/m2. 1,144 matched RBS and LBS cases and controls were identified and outcomes compared (Table 1). 30-day follow-up was less for LBS (93.2% vs 95.5%, p = 0.024). RBS was associated with significantly longer operative times (p < 0.0001) and hospital length of stay (p = 0.0002). Unplanned ICU admission (1.31% vs 0.52%, p = 0.049), aggregate bleeding (p = 0.069) and aggregate leak (p = 0.087) were higher in RBS. 30-day mortality, reoperation, readmission, intervention and all other complications were similar.

Conclusion: In this matched cohort analysis of revision/conversion bariatric surgery, robotic-assisted and conventional laparoscopic approaches seem to be equally safe, but RBS is likely less cost-effective due to longer operative times and hospital length of stay.

Outcomes in case-controlled matched cohorts

Surgical Approach


Conventional laparoscopic [n = 1,144]

Robotic-assisted [n = 1,144]

p value

OL_Minutes (mean ± SD)

121.71 ± 67.45

177.42 ± 79.40

< 0.0001*

HOS_Days (mean ± SD)

2.19 ± 3.09

2.38 ± 3.07


Outcome, no. (%)

 Conversion rate

11 (0.96)

13 (1.14)


 30-day unplanned ICU admission

6 (0.52)

15 (1.31)


 30-day reoperation

32 (2.8)

42 (3.67)


 30-day mortality

2 (0.17)

3 (0.26


 Death related

2 (0.17)

2 (0.17)


 Aggregate leak

7 (0.61)

15 (1.31)


 Aggregate bleeding

4 (0.35)

11 (0.96)



Google Trends and Bariatric Surgery; A Google Search Data Analysis from 2004 to 2018

Aimal Khan, MD 1, Thaer Obeid, MD2, Renee Tholey, MD2, Alfred Trang, MD2, Ramsey Dallal, MD21University of Alabama at Birmingham, 2Einstein Healthcare Network

Introduction: Despite being a reliable and effective long-term tool in combatting obesity, the percentage of people undergoing bariatric surgery has remained stagnant over the last decade. Public interest in bariatric surgery is one of the main drivers of its utilization, however measuring it using traditional methods is challenging.

Materials and Methods: Google Trends is a useful internet tool that can be used for quantifying public’s interest in a particular topic. It reports internet searches about a particular term as search volume indexes (SVIs). SVIs are normalized values based on total searches during a specified period for a given region. We queried Google trends for “bariatric surgery”, “gastric bypass”, “gastric sleeve”, and “lap band” from January 2004- April 2018 and analyzed their results.

Results: The results of this study show that the public’s interest in bariatric surgery has been steadily increasing since 2004 after falling to its lowest point in December 2010. We also show that the interest in lap band and gastric bypass has been gradually declining, with sleeve gastrectomy (SG) taking over the most searched bariatric procedure in 2018. State and city wise analysis show Michigan and New York City to have the highest proportion of Google searches for “bariatric surgery” respectively.

Discussion: Our study provides insight into the interest levels of US population in bariatric surgery. These findings can aid in the development of awareness campaigns via Internet, aimed at surgeons and the general public by helping better understand the US population’s interest and means of accessing information regarding bariatric surgery.


Risk Factors and Outcomes for Bleeding Following Bariatric Surgery: Results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)

Aimal Khan, MD, Katey Feng, MPH, Richard D Stahl, MD, Abhishek D Parmar, MD, MS, Jayleen M Grams, MD, PhD; University of Alabama at Birmingham

Introduction: Bleeding following bariatric surgery can be a life-threatening complication. Here, we aimed to evaluate risk factors and outcomes of patients with postoperative bleeding using a national database from accredited bariatric centers.

Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) databases for 2015–2016 were used to identify patients with postoperative bleeding following laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Patients undergoing emergency or revisional surgery or had their approach converted intraoperatively were excluded. Multivariate logistic regression was used to identify the risk factors for postoperative bleeding.

Results: A total of 326,841 patients underwent either SG (70%) or RYGB (30%). Of these, 1,592 (0.5%) had postsurgical bleeding. RYGB were more likely to have a bleeding complication than SG (AOR 2.7, 95% CI = 2.375-2.982, p < 0001). Other factors associated with increased risk of postoperative bleeding included preoperative therapeutic anticoagulation (AOR 3.6, 95% CI = 3.017-4.338, p < 0.0001), history of pulmonary thromboembolism (AOR 1.4, 95% CI = 1.047-1.849, p = 0.0227) or deep venous thrombosis (AOR 1.3, 95% CI = 1.002-1.670, p = 0.0479), renal insufficiency (AOR 2.8, 95% CI = 2.030-3.801, p < 0.0001), hypertension (AOR 1.2, 95% CI = 1.028-1.287, p = 0.0147), diabetes (AOR 1.2, 95% CI = 1.086-1.355, p = 0.0006), gastroesophageal reflux disease (AOR 1.1, 95% CI = 1.028-1.265, p = 0.0130), obstructive sleep apnea (AOR 1.3, 95% CI = 1.028-1.272, p = 0.0132), and male sex (AOR 1.6, 95% CI = 1.429-1.789, p < 0.0001). ASA class, anastomotic or staple line provocative testing, and placement of a surgical drain were not associated with postoperative bleeding. On subgroup analysis of SG patients, use of staple line reinforcement material (AOR 0.722, 95% CI = 0.612-0.852, p = 0.0001), over-sewing of the staple line (AOR 0.791, 95% CI = 0.646-0.969, p = 0.0234), and increased distance of the staple line from the pylorus (AOR 0.933, 95% CI = 0.878-0.991, p = 0.0232) were all associated with decreased risk of postoperative bleeding. Larger sleeve bougie sizes were associated with increased risk of postoperative bleeding (AOR 1.031, 95% CI = 1.010-1.052, p = 0.0037). Patients with postoperative bleeding had significantly higher rates of unplanned admission to the ICU (25.25% vs 0.82%, p < 0.0001), increased length of stay (4.15 days vs 1.82 days, p < 0.0001) and mortality (1.82% vs 0.11%, p < 0.0001).

Conclusions: The overall rate of bleeding following index bariatric surgery is lower than previously thought. Numerous patient- and operation-specific risk factors for postoperative bleeding are identified and may be useful for improving risk stratification, patient counseling, and development of processes to reduce the risk of postoperative bleeding.


“Intraoperative Leak Test (ILT) is Not Associated with Improvement in 30-day Outcomes After Primary Laparoscopic Sleeve Gastrectomy (LSG): MBSAQIP PUF, 2015-2016.”

Ghaith Khair, MD, FACS, Anne Sill, MSHS, Andrew Averbach, MD, FACS, FASMBS; Saint Agnes Healthcare

Background: According to ASMBS estimate for 2017, LSG constituted over 60% of all bariatric procedures. Between 2011 and 2017 the leak rate has decreased from 2% and currently stabilized at 0.3%. A variety of ILT is used, in order to prevent the most serious complications of this procedure. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data indicate that ILT is performed in three quarters of LSG cases. However, at present the effectiveness of ILT in improving outcomes is still unclear.

Methods: MBSAQIP 2015-2016 Participant Use File (PUF) data were used to select only primary LSG cases. Two study groups were based on the use of ILT, and multiple primary outcomes were compared using Chi square tests and T-tests. Leak rate was calculated based on several reported outcomes. Data set reflected only the fact that ILT was performed without definition of the particular variant.

Results: A total number of 185,867 primary LSG were performed; 143,400 patients (77.2%) had ILT and 42,467 patients (22.8%) did not. The post-operative leak rate was similar (0.3% - with ILT and 0.2% - with no ILT; P = 0.367). There were no statistical differences between study groups in rates of mortality, overall morbidity, re-operation, reintervention and hospital readmission. In cases with no ILT, bougie size of Fr 40 or higher were used more frequently with average size of 37.1 + 8.1 Fr compared to 36.8 + 8.4 Fr in ILT group. OR time was significantly increased in ILT group (76.7 + 32.7 min vs 68.6 + 32 min; P < 0.001).

Table 1: Analysis of MBSAQIP 2015-2016 PUF, primary LSG



ILT performed

P value

Number of patients

42,467 (22.8%)

143,400 (77.2%)


Bougie size < 40 Fr



< 0.001

Bougie size > 40 Fr




Average bougie size Fr

37.1 + 8.1

36.8 + 8.4

< 0.001

OR time min.

68.6 + 32

76.7 + 32.7

< 0.001

Hospital LOS days

1.62 + 1.4

1.64 + 1.5






Overall morbidity




Leak postop
















Conclusion: The routine use of ILT in LSG is not associated with reduced leak rates or with improved 30-day outcomes.


Dual Academic Institutional Experience of Secondary Operations after Sleeve Gastrectomy

Victoria Lyo, MD 1, Ryan Macht2, Yalini Vigneswaran1, Andrew Posselt2, Jonathan Carter2, Stanley Rogers2, Andrea Stroud1, Stephanie Wood1, Farah Husain11OHSU, 2UCSF

Introduction: Although laparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed, patients can experience severe GERD, strictures, insufficient weight loss, and leaks. The incidence, indications, and patient outcomes of a secondary operation or conversion to bypass are not well understood.

Methods and Procedures: We reviewed institutional MBSAQIP data from two academic, tertiary referral centers for bariatric operations between 2014-2018. We identified patients who underwent secondary operations after LSG and evaluated their demographics and early postoperative outcomes.

Results: Of the 1713 bariatric operations performed, 316 (18.4%) were secondary after prior bariatric surgery: 165 after gastric banding, 82 after bypass, and 55 after LSG. We identified 49 operations after LSG in 42 patients, excluding six port-site hernia repairs. Seven of the 49 cases were washouts or tube placements in duplicate patients. Most LSGs (32/49, 65.3%) were performed outside of our institutions. Mean time to revisions was 2.7 years (range: 0.23-9.1 years).

Among the 42 reoperative LSG patients, 32 (76.2%) had conversions from sleeve to bypass. Of these conversions, three had concurrent HH repairs and one had a concurrent Heller myotomy. The remaining 10 patients had: four HH repairs, two gastroplasties, one incisural seromyotomy, one sleeve fundal revision, one conversion to esophago-jejunostomy for a chronic GC fistula, and one gastrobronchial fistula takedown.

Most patients had multiple indications for reoperation. Grouped by primary indication, the most frequent reason for surgery after LSG was GERD in 17 patients, four of whom had esophagitis, four HHs, and three inadequate weight loss. Of all patients with GERD (26 patients), 84.6% had their symptoms resolve with reoperation. Two of the four without resolution of GERD had a sleeve revision or HH repair alone.

Of the nine patients who had incisural strictures, six had resolution of oral intolerance after revision; three patients had persistent nausea with no strictures on EGD. All eight patients undergoing conversions for inadequate weight loss (baseline BMI 56.7 kg/m2 to post-LSG BMI 48.8, EBWL 21.1%) had successful weight loss to an average BMI of 44.7 and EBWL to 40.2%. One of seven reoperations for fistulas or leaks failed leak closure. Among all reoperative 42 patients, 14 patients (33.3%) had complications requiring further procedures.

Conclusion: Symptoms and complications after LSG can persist and these patients may need secondary operations. At our tertiary bariatric centers, secondary operations successfully treated the primary indications for reoperation and should be offered, but can be challenging with higher complication rates.


Patient Therapeutic Education: Smartphone-based Applications for the Bariatric Surgery Patient

Rene Aleman, MD, Cristian Milla Matute, MD, Maria Fonseca Mora, MD, Joel S Frieder, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Background: Patient therapeutic education (PTE) encourages patient involvement and it has demonstrated efficacy in treating various chronic conditions. With the ever-growing smartphone ownership in the U.S., packaged software applications <’apps’>, have become widely popular for the access of health-related information, including bariatric surgery. The aim of this study is to review currently available apps in terms of PTE for bariatric surgery.

Methods: The search for smartphone apps was conducted using three U.S. web stores: Apple’s App Store, Google Play (Android) and Blackberry World. The keyword ‘bariatric surgery’ was used in order to retrieve the available related apps. The content quality and quantity of the apps was determined in accordance to PTE definition by the World Health Organization (WHO) as: “helping the patient and his family to acquire knowledge and competencies about the disease and its treatment, in order to better collaborate with the caregivers, and to improve his quality of life”. Data was collected and posteriorly analyzed from the app overview description provided by the developer.

Results: Overall, a total of 306 apps were identified in the web stores used for the search (Google Play = 249, Apple App Store = 41, and BlackBerry World = 16). Of the entire query, 14.71% (N = 45) of the apps classified as PTE apps, 4.25% (N = 13) were targeted for surgeons, 1.31% (N = 4) targeted sales related to bariatric surgery, and 1.63% (N = 5) were literature reference apps. None of the apps reviewed required payment for download. Seven percent (N = 22) of the apps had customer review with an overall average of 4.01/5. Nineteen apps were duplicated in the Google Play and the Apple App stores. Furthermore, 77.77% of the PTE apps had some sort of medical professional involvement.

Conclusions: There are currently 45 apps available for patients specifically directed to PTE on bariatric surgery. With the current trend on smartphone/app patient education, further studies are needed to determine the impact of mobile-based information in current bariatric clinical practice. Additionally, although apps are a way to educate potential bariatric surgery candidates, expert professional follow up should be emphasized to guarantee satisfactory outcomes.


Incidence of Gallstone Formation After Bariatric Surgery. A Prospective Study and Follow up

Juan E Contreras, Professor, Jorge Bravo, MD, Ismael Court, MD; Clinica Santa Maria

Background: Chilean prevalence of cholelithiasis is 13.1% in men and 36.7% women and 70% of population has overweight or obesity.

Objective: The aim is to evaluate the incidence of cholelithiasis after bariatric surgery.

Methods: It is a prospective one year study of 444 patient operated by obesity, of which 86% Sleeve Gastrectomy and 14% Gastric Bypass.

Follow up until 5 years. Average age 38 years, weight preop average 100 Kgs and average BMI 36.27

A total of 345 cases were included after exclusion criterion

(previous and concomitant chlolecisthectomy and revision surgery)

All patients have ultrasound study at third month after de bariatric surgery. 163 patients lost the follow up and were discarded.Total included was 182 (155 sleeve and 27 Bypass)

Results: 86 patients developed Cholelithiasis (47%) after bariatric procedure. Women than men ratio of 2,2: 1.

Presentation with 73% with asyntomatic cholelitiasis and 21% with acute cholecistitis or pain

75 cases of 155 (48%) in Sleeve Gastrectomy and Bypass with 11 cases of 27(40%).

65% of patients under 40 years developed cholelithiasis, and older than 40 years it was 35%.

In 65% Cholelithiasis were detected at first year of F.U. Obesity grade I and II it was associated with higher prevalence of cholelithiasis compared to III–IV. 86% and 14% respectively.

Fast and effective EWL were associated with increased incidence of cholelithiasis.

Conclusion: patients undergoing bariatric surgery suffer a significant incidence of cholelithiasis during the first year.


The Impact of ADHD on Outcomes Following Bariatric Surgery: A Systematic Review and Meta-analysis

Valentin Mocanu1Iran Tavakoli 1, Jerry Dang1, Noah Switzer2, Daniel Birch1, Shahzeer Karmali11University of Alberta, 2The Ohio State University

Introduction: The objective our study was to carry out a systematic review and meta-analysis to examine the impact of attention deficit and hyperactivity disorder (ADHD) on bariatric surgery outcomes.

Despite the effectiveness of bariatric surgery, about 10 to 20% of patients continue to regain weight after the procedure. New evidence supports that ADHD may be directly associated with obesity and may affect outcomes following bariatric surgery. However, certain psychiatric illnesses, such as ADHD are rarely screened for, leading to a continued lack of data on the interaction between ADHD and bariatric surgery.

Methods and Procedures: A comprehensive literature search for both published and unpublished studies of ADHD and bariatric surgery from 1946 to August 2018 was performed. The search was conducted using the Medline, EMBASE, Scopus, the Cochrane Library, and Web of Science databases as well as conference abstracts. Our search strategy terms included “(ADHD OR attention deficit hyperactivity disorder) AND (bariatrics OR obesity surgery OR gastric bypass OR gastric sleeve OR Roux-en-Y OR RYGB OR sleeve gastrectomy)” and was limited to human studies in the English language. Preliminary database search of the literature yielded 104 articles after 70 duplicates were removed

Results: A total of five studies with 492 patients were included. The overall ADHD rate was 20.9% with reported rates ranging from 7% to 38%. The weighted mean age was 44.0 ± 10.2 years, the weighted sex was 83.6% female, and the weighted mean follow-up was 22.2 months. Preoperative weighted mean BMI was 43.7 versus a postoperative weighted mean BMI of 34.7. No statistical significance was observed for mean BMI difference between non-ADHD vs. ADHD patients undergoing bariatric surgery (Figure 1) (3 studies; MD -2.66; CI -7.54 to 2.13; p = 0.28). Statistical significance was, however, observed for postoperative follow-up between patients with ADHD vs. non-ADHD subjects (3 studies; MD -7.28; -13.83 to -0.73; p = 0.03).

Conclusion: Patients with ADHD do not have a statistically significant mean BMI difference following bariatric surgery but have a statistically significant reduction in postoperative follow-up versus non-ADHD patients. Targeted strategies aimed at improving clinic attendance for this at-risk ADHD population may improve bariatric outcomes and minimize recidivism rates.


Gastric Plication as a Component in a Comprehensive Weight Loss Program in Egyptian Patients

Ashraf A Bakr, Professor, Dr, Mohamed Y Selim, Professor, Dr; Faculty of Medicine, Cairo University

Introduction: Obesity in Egypt soared to a high 40%. Consequently, the rate of bariatric surgery increased fourfold, including laparoscopic greater curvature plication (LGCP). Illiteracy and poor patient compliance affect the outcome of surgical procedures, including bariatric procedures.

The aim of this study was to evaluate the impact of intensive patient education and strict postoperative care and monitoring on the outcome of LGCP.

Patients and Methods: This study included 53 patients, presenting with morbid obesity with Body Mass Index (BMI) < 40 kg/m2. The study was conducted from June 2016 till February 2018. All patients were enrolled in a comprehensive program. The complements of the program included preoperative orientation about
  • Obesity

  • Nutrition (pre and postoperative)

  • Weight loss surgery

  • How to maintain weight loss after surgery

  • Changes expected in co-morbidities

The patients then underwent LGCP by a standardized technique.

The patients were followed postoperatively using a strict program that included clinic visits, phone calls and social media communication. The main components of the follow up were
  • Morbidity

  • Weight loss

  • Changes in co-morbid disease

  • Patient satisfaction

Results: The participants were mostly females (42/53), with mean BMI 39.1 ± 0.19 kg/m2, mean age 33.7.4 ± 1.29 years. Postoperative follow up was complete in 45 patients and partial in 8 patients. Seven patients suffered from transient nausea and vomiting that lasted for one week and managed conservatively. Six patients complained from hair loss. The mean total body weight loss was 25% ± 4.5 after 6 month. No revisions and no re-operations were needed in this series. Patient satisfaction was in the range of 94%. Improvement in the management of co morbidities occurred in 7 patients (14.8%).

Disucssion: LGCP is a bariatric procedure that requires no resection or bypass of the gastrointestinal tract. No staplers are needed, therefore the cost of the procdrure is significantly reduced. The procedure takes a longer time to perfom and needs special skills, yet for BMI belwow 4o kg/m2 the excess body weight loss postoperatiely is satisfactory. Patients do not require extensive dietary supplements postoperatively. The down side is that the changes in comorbidities are not as high as other bariatric procedures.

Conclusion: LGCP is good option for morbidly obese patients with BMI below 40 with close postoperative monitoring. The low cost is an added advantage, especially in low-income countries.


Surgical Technique for Sleeve Gastrectomy: Comparison Between Medial Versus Lateral Approach at 3 Years

Vanessa Boudreau, MD, Scott Gmora, MD, Dennis Hong, MD, Mehran Anvari, MD, PhD, Karen Barlow, Hons, BSc, Olivia Lovrics, MSc; Center for Minimal Access Surgery, McMaster University, Ontario, Canada

Introduction: No consensus exists in the literature for the best surgical technique when performing a sleeve gastrectomy. Medial and lateral approaches have been described, but no study could identify if one technique is better in terms of clinical outcomes. This study aims to compare the medial and lateral approach for sleeve gastrectomy (SG) in terms of intraoperative and postoperative complications, and weight loss, and to determine if both techniques are equivalent.

Methods: Data from the Ontario Bariatric Registry was used for this retrospective study to compare the effectiveness and safety of sleeve gastrectomy using the medial approach versus the lateral approach, during a 3-year follow-up after SG.

Results: Between January 2010 and June 2015, 564 patients underwent a sleeve gastrectomy surgery at St Joseph’s Healthcare Hamilton. 229 patients underwent a medial approach (72.9% female, age 46.9, BMI 54.4) and 335 underwent a lateral approach (73.1% female, age 48.8, BMI 56.3). Both groups were comparable in terms of baseline comorbidities. Weight loss and rate of complications at 3-year follow-up are as follows:

Medial approach

Lateral approach


Weight loss

 Decrease in BMI (SD)

  1 year

15.9 (7.0)

15.0 (7.6)


  3 years

14.5 (6.7)

13.7 (8.3)


 OR time minutes (SD)

70.4 (15.8)

95.3 (31.3)


 Complications n (%)

  Mortality 30 days




  Overall complications

10 (4.4)

11 (3.3)


  Wound infection

1 (0.4)

2 (0.6)


  Stenosis and stricture

2 (0.9)

1 (0.3)



4 (1.7)

6 (1.8)


  Revisional surgery

3 (1.3)

4 (1.2)


Conclusions: Both the lateral and the medial approach are effective and safe for performing the sleeve gastrectomy. No significant differences were seen in weight loss and rate of complications at 3 years. The medial approach may decrease operative time. Further study is needed to evaluate this finding.


Trends in Drain Utilization in Bariatric Surgery: An Analysis of the MBSAQIP Database 2015-2016

Robert Cullen, BS, Ira L Swinney, MS, Alan Tyroch, MD, Ellen Wicker, DO, Ginger Coleman, MD, Calvin Mcnelly, BS, Babak Sadri, BS, Carlos Lodeiro, BS, Chris Dodoo, MS; Texas Tech HSC Paul Foster School of Medicine

Introduction: Laparoscopic gastric bypasses (GB) and sleeve gastrectomies (SG) are the two most common bariatric operations. There have been changes in surgical technique and surgical norms over time. The main advance has been moving towards laparoscopic surgery. With the implementation of enhanced recovery protocols, surgeons tend to use less invasive methods of perioperative management. This includes decrease in foley catheterization, the use of nasogastric tubes and drains. There is still controversy about the use of drains and indications for drain placement. As practice patterns change and enhanced recovery protocols are adopted, the use of drains should decrease.

Methods: The MBSAQIP database was queried for the years 2015 and 2016. Our inclusion criteria included all patients undergoing a primary GB or SG. Revisions were excluded. We examined demographics, operative characteristics, the use of drains, and post operative complications. Continuous variables were summarized using mean and standard deviations (SD). Categorical variables were summarized using frequencies and proportions. Students T- test (Wilcoxon sum rank test in the case of skewed data) and Chi squared analysis was used to assess the baseline differences in drain utilization. To assess the factors that predict drainage usage, the generalized linear models with family Poisson and link log was used obtain the relative risk measures. P values < 5% were considered statistically significant. All analyses were carried out using STATA V15.

Results: In 2015-2016 there were 240,462 bariatric cases performed without drains and 70,292 with drains. 31.4% of GB patients had a drain placed but only 18.5% of SG patients. The percentage of GB that had a drain dropped from 33.1% to 29.7% during the study period and SG dropped from 20.3% to 17.0%. For GB and SG, there was no difference in provocative testing, swallow studies, operative length, reoperations, readmissions or death. Patients that had drains placed were more likely to have a provocative test at the time of surgery (relative risk (RR) 1.9) and to have a postoperative swallow study (RR 2.67).

Conclusions: Drains are still commonly used in bariatric patients. Over the study period, there was a slight decrease in the use of drains in both bypass and sleeve patients. Patients with a drain were more likely to have had a provocative test and a swallow study. Drain placement was not associated with higher complications.


Revisional Surgery Results After Sleeve Gastrectomy. A Retrospective Cohort Study Surveying 2nd Stage BPD/DS

Zvi H Perry, MD, PhD, Mohammed Al Abri, MD, Olivier Court, MD, Amin Andalib, MD, MPH, Sebastian Demyttenaere, MD; Center for Bariatric Surgery, Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec

Introduction: Sleeve gastrectomy is becoming the most popular bariatric procedure in the world. However, there is ongoing debate as to the appropriate surgical procedure after failed sleeve gastrectomy. In this study, we aimed to evaluate patients who underwent prior sleeve surgery who subsequently underwent biliopancreatic diversion with duodenal switch (BPD/DS).

Methods: A retrospective analysis of a prospectively maintained database of laparoscopic sleeve gastrectomies (LSG) was performed between January 2006 and March 2018. Data analyzed included age, weight loss, postoperative complications and long-term outcomes.

Results: 173 patients were enlisted in our database as having lap BPD/DS. Of these patients, 91 subsequently had revisional surgery to (BPD/DS). Of the 91 patients 56 (61.5%) were female. Mean follow up time was 5.5 (± 2.7) years. Mean time between the sleeve and the revisional surgery was 21.5 (± 16) months. The mean age upon the sleeve procedure was 41.8 (± 10.5), while the mean age upon the revisional duodenal switch was 43.7 (± 10.6). Pre-sleeve mean body mass index (BMI) was 63.5 (± 9.7) kg/m2. Pre-BPD mean BMI was 46.3 (± 7.7) kg/m2 and at the end of the follow up period the mean BMI was 39.5 (± 7.8) kg/m2. Differences between pre-op BMI and pre-revision, pre-revision and end of follow-up BMI, as well as between pre-op BMI and end of the follow-up were all significant (p < 0.001). 20 patients suffered from a complication (22%), with the most common being leak (9 patients, 9.9%), and infection (6 patients, 6.6%). No death occurred.

Discussion and Conclusions: Controversy exists regarding technical aspects of revisional LSG. In our study, we have seen that post-sleeve duodenal switch had substantial weight loss, with a satisfactory complication profile. Longer follow up is needed to determine if this improvement in weight loss remains in the long term.


Risks of Bariatric Surgery Among Patients with End-Stage Renal Disease

John R Montgomery, MD 1, Seth A Waits, MD1, Justin B Dimick, MD, MPH2, Dana A Telem, MD, MPH21University of Michigan, Dept Transplant Surgery, 2University of Michigan, Center for Healthcare Outcomes & Policy

Objective: The association between bariatric surgery and long-term weight loss and comorbidity improvement among obese patients with end-stage renal disease (ESRD) is well established. Moreover, for patients who subsequently undergo kidney transplantation, it is associated with improved patient and graft survival. However, the perioperative risks of bariatric surgery among obese ESRD patients are poorly characterized as data are limited to single-center studies that lack generalizability and may not detect rare events. In this context, we performed an analysis of perioperative safety of bariatric surgery in obese patients with ESRD using a national registry capturing > 95% of bariatric operations.

Methods: Patients who underwent primary, laparoscopic sleeve gastrectomy or gastric bypass between 2015-2016 were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use file. The primary outcome was a composite variable of death and severe, life-threatening complications within 30 days of operation. Logistic regression was used to compare adverse outcomes between ESRD patients (defined as dialysis-dependent) and those with normal renal function.

Results: During the study period, 299,373 bariatric operations were performed; of these, 836 (0.3%) patients had ESRD. ESRD patients were more likely to be older (48.6 ± 10.4 vs 44.8 ± 11.9 years, p < 0.001), male (43.7 vs 20.2%, p < 0.001), hypertensive (88.4 vs 72.2%, p < 0.001), diabetic (55.0 vs 25.7%, p < 0.001), and have poorer functional status (5.9 vs 1.0% partially-or-fully dependent, p < 0.001). After adjusting for patient age, smoking status, hypertension, diabetes, and functional status, ESRD was associated with increased chance of death or severe, life-threatening complications (4.8 vs 1.9%, aOR 2.61[1.93-3.52], p < 0.001). This difference was primarily driven by higher incidence of reoperation (3.6 vs 1.3%, p < 0.001), transfusion ≥ 3 units (0.8 vs 0.2%, p < 0.001), and death (1.0 vs 0.1%, p < 0.001) among ESRD patients.

Conclusion: ESRD is associated with increased risk of death and severe, life-threatening complications after bariatric surgery when compared to patients with normal renal function. However, the absolute risk is low and largely driven by increased reoperation rates; it should not be prohibitive for operative consideration. Given the established long-term benefits of bariatric surgery in obese ESRD patients and improved post-transplantation patient and graft survival, this supports consideration of CMS-mandated referral for comprehensive weight-loss management with availability of surgical options in all obese ESRD patients, and especially among patients being considered for renal transplantation.


The Role of Sleeve Gastrectomy in Glycemic Control in Patients with Morbid Obesity and Type 2 Diabetes

Taryel Omerov, PhD 1, Gulay Mamedova, Md2, Nadir Zeynalov, PhD1, Nuru Bayramov, Professor11Azerbaijan Medical University, 2Modern hospital

Key words: Obesity, sleeve gastrectomy, type II diabetes, bariatric surgery.

Aim of the study: Study of the results of sleeve gastrectomy in patients with type II diabetes with excessive obesity in the postoperative period.

Materials and Methods: 84 obese patients have undergone a sleeve gastrectomy procedure in Azerbaijan Medical University and Modern Hospital clinic 2012 through 2018 years. A 59 (70,2%) of patients were females, 25 (29,8%) were males, mean age was 37.9 (15-59) years. Preoperative weight of patients ranged from 102 to 220 kg, BMI 35.7-80.5 kg/m2. The current trials have shown the growing burden of obesity incidence among population. Above all, the proportion of the patients with type 2 diabetes among morbid obese patients is significantly high. Taking in accounts above mentioned, we decided to investigate the correlation between glycemic control and rate of weight decrease among patients with morbid obesity, underwent stomach bariatric surgery. We followed the 84 patients with morbid obesity and prediabetes and diabetes type 2, who underwent bariatric surgery and observed their glycemic level. The 30 patients (35/7%) had the history of diabetes type 2 for 2 year, in 27 patients (32.1%) the history of diabetes was for 10 years, whereas 12 patients (14.3%) had diabetes for more than 10 years. The 15 patients (17.9%) had prediabetes.

Results: The dynamic of anthropometric parameters showed significant decrease of weight in comparison with initial level (38%), the BMI decreased from 46.8 kg/m2 (42.3-54.3) to 27.6 kg/m2 (25.4-30.9), (p < 0.001). In two years following operation weight parameters were decreased in comparison with initial level for 42%, the BMI was decreased up to 26.8 kg/m2 (23.1-28.4). The remission of type 2 diabetes was observed in 98.6% patients (n = 82) within three years of following up (Hb1Ac < 0.6%, fasting glucose level < 5.6 mmol/l).

Conclusion: Thus, the procedure sleeve gastrectomy of patients with Type II diabetes mellitus was not only effective in reducing body mass index and correction of metabolic syndrome. First of all, it has been proven to be a satisfactory control of stable glycemic control as well as carbohydrate metabolism in the postoperative period.


SILS (Single Incision Laparoscopic Surgery)

Lakshman Agarwal, Mbbs, MS; Swai Man Singh Medical College, Jaipur, Rajasthan, India

Gall stones (cholelithiasis) are common condition. Advent of ultra sonography has increased its detection in a large way. The exact number of cholecystectomy performed in India is difficult to know as there is no standard national registery for it. We are practising SILS since last 4 years and the number exceed 600.

Langenbuch in 1882 did first open cholecystectomy, Conventional four port laparoscopic cholecystectomy (Philippe Mouret 1987), Single incision laparoscopic cholecystectomy (Navarra 1997) and NOTES (Natural orifice transluminal endoscopic surgery)

Materials and Methods: This study comprises of 600 cases of SILC (87% female and 13% male)

A four fascial incision approach was used with conventional staright and reticulating instrument.

Results: This study comprises of 600 cases of SILC (87% female and 13% male) with AGE ranging from age 9-90 (mean 39.91)

USG Findings in our study were Cholelithiasis with chronic cholecystitis (553 patients), Cholelithiasis with acute cholecystitis (36 patients), Acalculouschlecystitis (7 patients) And Gall bladder polyp (4 patients)

Previous Abdominal Surgery- Lap tubectomy 3%, hysterectomy 2%, L.S.C.S. 3%, Appendicectomy 2%, Exploratory Laparotomy 2%.

Intra-Op Findings were – Adhesion 20%, distended gall bladder 12%, Contracted gall bladder 9%, normal gall bladder 59%

Operative time range from 26.3 to 75 min (mean 46.96 min)

Intra-Op Complications were – bleeding 5%, content leak from gallbladder 9% and spillage of stones in 5% patients

Conversion rate was 3%. Post-Operative Hospital stay was 1.24 + 0.46 days

Post-Operative Complications (wound infections) was 2%

Scar length was 2.07 cm (range 1.6-2.7 cm)

Conclusion: SILC is feasible, safe and reproducible with shorter hospital stay and better cosmesis, but has larger learning curve and longer operative time.

It does not add to cost if conventional instruments are used as we did in our study.


Direct Laparoscopic Transverse Abdominis Plane (TAP) Block: New Approach

Ali Hasan, MD; Saudi German Hospital, UAE

The transverse abdominis plane (TAP) block is a peripheral nerve block designed to anesthetize the nerves supplying the anterior abdominal wall (T6 to L1). It was first described in 2001 by Rafi as a traditional blind landmark technique using the lumbar triangle of Petit. The initial technique described the lumbar triangle of Petit as the landmark used to access the TAP in order to facilitate the deposition of local anaesthetic solution in the neurovascular plane. Other techniques include ultrasound-guided access to the neurovascular plane via the mid-axillary line between the iliac crest and the costal margin, Open transversus abdominis plane block,and a subcostal access termed the ‘oblique subcostal’ access.

Objectives: New technique review aiming to describe the technique of direct laparoscopic technique in transverse abdominal plan blockade for different surgical interventions

Methods: Detailed review of TAP blockad starting from relevant anatomy, brief description of old TAP blockade techniques. Details of Direct Laparoscopic TAP blockade, with description of complications, technical difficulties, results and expectations

Conclusion: Direct laparoscopic transverse abdominal plan blockades is simple procedure, with high quality efficacy, can be used routinely in most of laparoscopic surgery procedures of the abdomen and pelvis

I describe here a new laparoscopic technique for safe, effective transverse abdominis plane (TAP) block which is handable and accessible for all laparoscopic surgeon

This paper shows the feasibility of alternative approach for transverse abdominis plane (TAP) block in laparoscopic cholecystectomy


Our Retraction Methods for Securing the Surgical Field that Facilitates Laparoscopic Pancreaticoduodenectomy

Nagakawa Yuichi, MD, FACS, Yatsuka Sahara, Chie Takishita, Yousuke Hijikata; Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University

Laparoscopic pancreaticoduodenectomy (LPD) comprises various procedures including reconstruction and requires an advanced level of laparoscopic skill. Therefore, techniques to reduce the difficulty of LPD are needed. The visual field for LPD is different from that of open surgery. Even experts of laparoscopic surgery may increase the difficulty if the surgical field is not secured, increase surgical time and blood loss, and cause vascular injury. The establishment of effective retraction methods is important at each site to achieve an effective three-way retraction. Although the SMA first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the IPDA from left side of the SMA. We introduce the proximal dorsal jejunal vein (PDJV) preisolation method which facilitate approaching the SMA from the right side of the SMA under good surgical field. Although the mean operation time from the initial cases to 47 cases was 551.6 (374-646) minutes, operation time from 60 to 85 cases was significantly reduced from the initial cases was significantly decrease Although laparoscopic pancreaticoduodenectomy (LPD) is considered as minimally invasive surgery, an advanced level of laparoscopic skill is still required. LPD comprises various procedures including reconstruction. Recently, laparoscopic pancreaticoduodenectomy (LPD) has been used as a novel minimally invasive surgery. However, advanced laparoscopic skills are required. Therefore, techniques to reduce the difficulty of LPD are needed. The visual field for LPD is different from that of open surgery. Even experts of laparoscopic surgery may increase the difficulty if the surgical field is not secured, increase surgical time and blood loss, and cause vascular injury. The establishment of effective retraction methods is important at each site to achieve an effective three-way retraction. Although the artery-first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the IPDA from left side of the SMA. We introduce the proximal dorsal jejunal vein (PDJV) preisolation method which facilitate approaching the SMA from the right side of the SMA under good surgical field. Although the mean operation time from the initial cases to 47 cases was 551.6 (374-646) minutes, operation time from 61 to 85 cases was significantly reduced from the initial cases was significantly decrease (405.1 min; 370-480) by the above attempt. We introduce our approaches to reduce surgical difficulty of the above attempt. We introduce our approaches to reduce surgical difficulty of LPD.


Gangrenous Cholecystitis: Delays in Surgical Evaluation And Outcomes in the Era of Minimally Invasive Surgery

Rebecca C Gologorsky, MD 1, Justin Tse, MD2, Dylan Wolman, MD2, Aya Kamaya, MD21University of California San Francisco-East Bay, 2Stanford University

Introduction: Gangrenous cholecystitis (GC) is a highly morbid complication of acute cholecystitis (AC). Risk factors for gangrenous progression are poorly described, as are pre-operative clinical features and post-operative outcomes in the era of minimally invasive surgery.

Methods and Procedures: Patients who underwent cholecystectomy for AC from January 2014-May 2018 at a single academic medical center were retrospectively reviewed, with pathologic confirmation of GC vs. uncomplicated acute cholecystitis (UAC) in all included patients.

Pertinent clinical features, demographics, and laboratory values were recorded. Two-tailed t-tests and Fisher’s exact tests were used to determine statistical significance for continuous and categorical variables, respectively.

Results: Among the 101 patients reviewed, 48 (48%) had GC and 53 (52%) had UAC. Patients with GC were older (62 ± 17 vs. 48 ± 18; p = 0.0001) and predominantly male (65% vs 38%; p = 0.005). Delays in diagnosis or treatment were significantly more common among patients with GC (46% vs 17%, p = 0.0025), defined as a failure to recognize or treat acute cholecystitis at initial emergency department or urgent care visit up to 14 days prior to surgical admission (Table 1). Among patients with delayed care, none were surgically evaluated until subsequent admission. Mean time from imaging to surgical consult did not differ between groups (4.3 h vs. 4.6 h, p = 0.9167). Following surgical consultation, there was no difference in mean time to surgery (24.6 h vs. 21.0 h, p = 0.4128). Among patients with GC, 17 (35%) underwent open cholecystectomy, of which 13 (27%) were converted from a laparoscopic approach. Among patients with UAC, only 2 (3.7%; p = 0.0001) underwent open cholecystectomy, both converted from a laparoscopic approach. Postoperatively, 5 (10%) patients with GC were admitted to the ICU versus 1 (2%) UAC patient (p = 0.0994), and total length of hospitalization was greater among GC patients (5.0d vs. 2.7d; p = 0.0022). Complication rates were higher among GC patients (17% vs. 3.8%; p = 0.0441), with greater complication severity, including one death (2%).

Conclusion: GC is a clinically under-recognized surgical urgency. Delays in diagnosis of AC and subsequent surgical consultation contribute to its prevalence. A need for improved diagnostic recognition of AC is necessary to reduce risk of progression to GC, and to rapidly treat GC on presentation.


Epidemiological Profile and Evaluation of Health Care in Patients with Biliary Atresia: A Descriptive Study

Caline S Medeiros, Medical Student1, Eduardo V Holanda, Medical Student1, Rodrigo M Gallindo, MD, phD1, Raquel N Cordeiro, Medical Student1Diego L Lima, MD 21Pernambuco Health College, 2State Servers Hospital

Introduction: Biliary atresia (BA) is a rare pediatric pathology, but it is the main cause of liver transplantation in children when not treated with the Kasai procedure. There is a tendency for the surgical procedure to be delayed throughout Brazil and an investigation of its cause is necessary.

Objective: to determine the epidemiological profile of the patient with BA and to evaluate the health care focused on this diagnosis.

Methods: a descriptive, retrospective, cross-sectional study was performed with the medical records of patients diagnosed with BA and followed between 1996 and 2015.

Results: We analyzed the medical records of 72 patients but only 52 patients had complete records available. Twenty-six patients were included in the study: the mean age at admission was 87,9 days. 24 cases were diagnosed with ultrasonography and 10 needed to repeat the exam for confirmation. The Kasai surgery were performed in 50% of the patients, 38.4% of them in the appropriate time. Of the patients who were operated late, 25% were transplanted and 50% died. In the patients who had the procedure early, only one was transplanted and there were no deaths.

Conclusion: The diagnostic difficulties: failure in suspecting of BA in primary or tertiary care, and the high rate of false-negative results in USG delayed the surgical treatment, contributing to the worst outcome for patients who were operated late.


An Unusual Presentation of Acute Cholecystitis: Gallbladder Volvulus

Elizabeth E Price, DO, Luciano Dimarco, DO; UPMC Pinnacle Community Osteopathic Hospital

Gallbladder volvulus is an uncommon disease caused by torsion of the gallbladder around its mesentery along the axis of the cystic duct and artery, ultimately leading to gallbladder ischemia and obstruction of biliary drainage. The etiology of the condition is unknown; however, hypothesized contributory factors include anatomical abnormalities including a long gallbladder mesentery allowing it to float freely from the liver bed and easily twist upon itself. Volvulus can be seen more commonly in older females and is likely due to loss of visceral fat with aging. This diagnosis was first discovered in 1898 by an American surgeon Wendel, who referred to the condition as “floating gallbladder.” Gallbladder volvulus only accounts for 1 out of 365,000 cases of gallbladder disease. Thus, although rare, laparoscopic cholecystectomies are one of the most common surgical procedures performed in the United States and it is important for surgeons to familiarize themselves with the condition due to its severe complications.

Here, we present a case of a 77-year-old female who presented for right upper quadrant pain, weight loss and nausea associated with eating. CT scan and ultrasound demonstrated a distended hydropic-appearing gallbladder with pericholecystic fluid and wall thickening without evidence of gallstones. Upon laparoscopic inspection, the gallbladder was necrotic, gangrenous and mostly detached from the liver bed as a result of twisting upon its mesenteric stalk. The mesentery was unable to be detorsed because the gallbladder was enlarged and necrotic in appearance with only its neck clearly identifiable. A laparoscopic subtotal reconstituting cholecystectomy was able to be performed without postoperative complication.

In conclusion, gallbladder volvulus is a rare presentation of acute right upper quadrant abdominal pain. The patient’s clinical presentation and imaging can mimic those seen in patients with biliary colic or acute cholecystitis. Pre-operative diagnosis is rare; however, a high suspicion should prompt urgent surgical intervention in order to prevent necrosis and possible perforation. Ideally, the surgeon should attempt to return the gallbladder to its anatomic position. However, due to the severe distension and the necrotic presentation usually seen with this disease, obtaining the critical view of safety can present as an intraoperative challenge. Intraoperative decision making plays a crucial role in this condition in order to proceed with the procedure safely and without increasing morbidity and mortality.


Laparoscopic Management of Gastro Intestinal Stromal Tumours

Ajay H Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS1, Jalbaji P More, MS1, Amol N Wagh, MS, FMAS, FIAGES, FAIS, FICS, FBMS1, Shekhar A Jadhav, MS, FMAS1, Amarjeet E Tandur, MS1, Priyanka Saha, MBBS1, Khushboo Kadakia, MBBS1, Soumya Chatnalkar, MBBS1, Ruchira Bhattacharya, MBBS1Shraddha R Gajbhiye, MBBS, MD Associate Professor 21Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India, 2Govt. Medical College, Nagpur,Maharashtra,India


Background: Gall bladder perforation is a rare clinical entity but life-threatening complication of cholecystitis with or without stones and associated with increased rate of mortality and morbidity due to late presentation and diagnosis.Niemeier classified gallbladder perforation into three types.

Objectives: To discuss the laparoscopic management of gall bladder perforation in emergency patients at tertiary care centre in government setup.

Method: Patients diagnosed as gall bladder perforation type1 &2 were included in the study.

Results: 13 patients (5 males, 8 females) with an average age of 58 ± 2 years had Gall bladder perforation. Patients with Gall bladder perforation type 1, 2 were 4 and 9. All patients were subjected to surgery via laparoscopic approach with conversion to open in 1 case. Gallbladder perforation was located on the fundus in 8 cases and body in 4 cases and 1 at hartman’s pouch. The average duration of stay in patients with laparoscopic surgery was 4 days while it was 8-10 days in case of open surgery. The overall mortality rate was 7.7% (1 cases). Complications included wound infection in 4 cases

Conclusion:The laparoscopic approach can be a safe and feasible method in order to treat both the cause and the complication in this situation. Early diagnosis and appropriate minimally invasive approach are the key to manage this condition.


Trans-nasobiliary Cholangiography Guided Laparoscopic Cholecystectomy After ERCP

Alaa Sewefy, Dr; Minia university

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), up till now, is the most common management of gallstone combined with CBD stones. In difficult LC, intraoperative cholangiography (IOC) is recommended to identify the anatomy of the biliary tree. This study is a randomized clinical trial aimed to evaluate the routine insertion of nasobiliary (NB) catheter during ERCP to be used as a method for IOC during LC in difficult cases.

Methods and procedure: One hundred sixty patients had combined gallstone & CBD stone underwent ERCP followed by LC in the same session. They divided into equal 2 groups: NB group, in which NB catheter was inserted after CBD clearance, Control group in which only CBD clearance was done. In NB group: tans-nasobiliary IOC was done during LC. At the end of the procedure trans-nasobiliay methylene blue test was done to detect any hidden biliary injury.

Result: Eighty seven patients (54.4%) were male and 73 (45.6%) were female. Median age was 56. The average operative time in NB group was 120 min. VS. 129 min. in Control group (P = 0.002). No conversion in NB group (0%) VS. 6 cases (7.5%) in Control group (P = 0.013). One case of biliary leak (1.3%) occurred in NB group, which discovered by intraoperative methylene blue test and was managed conservatively by leaving the MB tube in place till the postoperative trans-NB cholangiography revealed no leak, VS. 2 cases (2.5%) in Control group (P = 0.560), the 2 cases were discovered postoperatively and managed by hepaticojejenostomy. The average postoperative hospital stay was 1 ± 0.2 days in NB group VS. 1.6 ± 3.3 days in Control group (P = 0.1).

Conclusion: Insertion of NB catheter during ERCP is simple and dynamic method for IOC. It decreases the conversion rate. It doesn’t decrease the incidence of BDI but it can diagnose, minimize the severity and treat BDI with shorter operative time

Figure 1 : Endoscopic picture of NB tube
Figure 2Trans- NB IOC with the supposed cystic duct is closed with empty clipper to make sure that it was not the CBD
Figure 3Intraoperative Trans-NB Methylene blue test with postive leak which was not discovered before the test


Over Usage of ERCP Following Negative MRCP in Patients with Suspected Choledocholithiasis

Damian Korsich, Swati Patel, Paula Veldhuis, Sebastian De La Fuente; Florida Hospital Orlando

Introduction: The ideal algorithm for evaluation of the biliary system remains contentious. Historically, patients with suspected choledocholithiasis were subject to intraoperative cholangiograms at the time of cholecystectomy but with the introduction of less invasive, albeit more expensive imaging studies, this approach has changed in recent years. Not uncommonly, patients with suspected choledocholithiasis undergo Magnetic Resonance Cholangiopancreatography (MRCP) to determine the presence of stones in the bile duct system. If choledocholithiasis is indeed found on MRCP, Endoscopic Retrograde Cholangiopancreatography (ERCP) is often recommended to clear the bile duct system preoperatively. In this study, we aim to determine the number of patients with suspected choledocholithiasis that despite a negative MRCP, were still subject to ERCP.

Methods: A retrospective review of medical records and administrative databases was used to include all consecutive patients suspected of gallstones, biliary obstructions and common bile duct filling defects between August 2010 to August 2017. Inclusion criteria included all patients who underwent MRCP for these indications. Subgroup analysis then included those that were subjected to ERCP.

Results: A total of 7,488 patients underwent MRCP for suspected common bile duct stones during the study period. Of these, 5,126 patients were found to have no stones on MRCP. Of the patients that did have stones on MRCP, 806 were also found subsequently to have stones on ERCP. There were 209 patients with stones on MRCP but were found not to have lithiasis on ERCP. Interestingly, a total number of 1178 patients underwent an ERCP despite a MRCP that had shown no evidence of choledocholithiasis.

Conclusion: A significant number of patients with suspected choledocholithiasis undergo MRCP at a single institution, in spite of evidence that shows that simple lab testing can often be sufficient. There are also a substantial number of patients with no radiologic evidence of choledocholithiasis that are subject to unnecessary invasive procedures.


The Outcome of Laparoscopic Cholecystectomy in Situs Inversus Totalis: Technique and Anatomical Variation. Case Report

Omar A Ibrahim, MD, Surgical Resident, Tahir I Yunus, General Surgery and Bariatric Consultant, Ahmed M Mai, MD, Surgical Resident; International Medical Center

Situs inversus totalis (SIT) is an rare medical condition where thoracic and abdominal organs are in the mirror-image reversal of their natural position. Many difficulties faces surgeons to diagnose and manage chronic cholecystitis via laparoscopic cholecystectomy in patient with SIT. This is because the changes in the anatomical positions of organs influences the location of signs and symptoms of the diseased organ in addition to the special demands on the diagnostic and surgical skills of the surgeons. The current case report illustrates one of these cases in term of diagnosis and management.

Case presentation: A 32 years old female came to the clinic with chronic cholecystitis and multiple gallstones, in addition to dextrocardia on chest radiograph. The CT scan demonstrated SIT, cholecystitis and cholelithiasis. Laparoscopic cholecystectomy was conducted using mirror image port placement of conventional laparoscopic cholecystectomy. A right-handed surgeon conducted the operation, with reoriented visual images and the surgical steps were performed in clock wise rotation manner.

Conclusion: Chronic cholecystitis in SIT patient is considered to be a rare condition. Several precautions should be taken for proper diagnosis and adequate laparoscopic cholecystectomy procedures. Mirror image techniques, using right-handed surgeon, reoriented visual images and performing in a clock wise rotation were essential steps for the surgery success.


Single Incision Laparoscopic Cholecystectomy (SILC) for Emergency and Elective Cases: Eight-year Experience in More Than 250 Patients

Fernando Arias, MD, FACS1, Gabriel Herrera, MD1, Camilo Cetares, MD2Manuel Arrieta, MD 31University Hospital Fundación Santa Fe de Bogota - University of the Andes, Bogotá Colombia, 2University Hospital Fundacion Santa Fe de Bogota, 3University of Sabana, Bogota, Colombia

Introduction: Single incision laparoscopic cholecystectomy has gained increasing attention over conventional technique due to the potential benefits such as less postoperative pain, less length of hospital stay and more patient satisfaction regarding post-operative scar and cosmesis. However, it is a technically challenging procedure with an apparent increased risk of bile duct injury.

Methods: We review medical records from July 2008 to December 2016 of patients who underwent single incision laparoscopic cholecystectomy performed by our group. Our team used SILS port, GelPort, Triport and hybrid port (Alexis + glove) to perform the procedure. The following data was collected: patient’s demographics, indications for surgery, single port devised used, operative time, conversions, postoperative complications, length of hospital stay and mortality.

Results: A total of 273 patients underwent SILC from the registry. The median age was 44.2 years with a mean BMI of 24.1. The mean surgical time was 72 min; we exclude 3 patients that additionally underwent to exploration of the common bile duct. There was no mortality in hospital and no cases of 30-day-mortality. One procedure was converted to multi-port and none to open surgery. A total of 7 postoperative minor complications with no bile duct injuries were reported. The mean length of hospital stay was 14.86 h. Finally, there were 133 (48.7%) emergent and 140 (51.3%) elective cases.

Conclusions: SILC is a safe and a feasible alternative to standard laparoscopic cholecystectomy even in emergency cases. Our series show similar outcomes and complication rates compared to cases reported in literature about standard multiport cholecystectomy. Finally, experience of the group is important to obtain appropriate results.


Gallbladder Perforation with Hemoperitoneum Secondary to Ulceration from Densely Packed Gallstones in a Minimally Symptomatic Patient

Elizabeth A Verrico, DO 1, Lindsay Tse, DO2, Justin Sargent, DO1, Fred Wolodiger, MD3, Steven Shikiar, MD11Hackensack Meridian Health Palisades Medical Center, 2Houston Methodist Hospital, 3Englewood Hospital and Medical Center

Acute cholecystitis is one of the most common general surgery pathologies. Perforated cholecystitis is a rare potentially life threatening complication of acute cholecystitis. It is often described as acute perforation with acute peritonitis, subacute perforation with abscess and localized peritonitis, or chronic perforation with cholecystoenteric fistulation. Rare cases of spontaneous perforation have been reported but almost all cases are associated with acute inflammation.

This is a case of a 51 year old female who presented with mild non-radiating right upper quadrant and epigastric abdominal pain without associated nausea, vomiting, or fever. She denied similar symptoms in the past and her past medical history was only significant for hypertension and migraine headaches. She had no prior history of abdominal surgery. Physical exam revealed tenderness in the right upper quadrant without peritoneal signs. Labs were unremarkable except for mild leukocytosis. Ultrasound revealed a gallbladder filled with stones without pericholecystic fluid or gallbladder wall thickening. Due to persistence of symptoms the patient was taken to the operating room for laparoscopic cholecystectomy. Upon entry into the peritoneal cavity, hemoperitoneum was noted, particularly in the right paracolic gutter and perihepatic spaces. Upon further inspection and dissection, a gall bladder ulceration and perforation was noted with bleeding of the ulcerated edges and multiple stones visible. Successful laparoscopic cholecystectomy was performed with evacuation of the hemoperitoneum and collection of loose gallstones. Post-operative course was uneventful. Pathology revealed a 2.3 cm jagged hemorrhagic ulceratation/perforation of the gall bladder with multiple stones causing indentations in the mucosa with moderate acute and chronic cholecystitis.

Perforated cholecystitis is uncommon. Presentation varies and can be indistinguishable from uncomplicated acute cholecystitis or can present with peritonitis, sepsis, and hemodynamic instability. This case demonstrates a very unique presentation of gall bladder perforation. The patient was minimally symptomatic without definite signs or symptoms of acute cholecystitis. There was minimal to no bile leakage from the gall bladder but there was hemoperitoneum and hemorrhage from the ulcerated edges of the perforation. Consideration of perforated cholecystitis is important on the differential diagnosis when treating patients presenting with right upper quadrant abdominal pain. There is relatively high morbidity and mortality from delay in diagnosis and high index of suspicion is required. Treatment varies depending on presentation.


Recurrent Right Upper Quadrant Pain and Complications of Progression

Zachary Walker, Kejal Shah, MD, Michael P Meara, MD, MBA, FACS; The Ohio State University Wexner Medical Center

Background: Complicated Cholelithiasis can result in episodes of cholangitis and Mirizzi syndrome, extrinsic compression of the common hepatic duct by a stone in the cystic duct or gallbladder. Endoscopic retrograde cholangiopancreatography (ERCP) can be used for diagnosis and stent placement to temporarily treat Mirizzi syndrome. Cholecystectomy remains the definitive treatment for Mirizzi syndrome. Chronic inflammation in Mirrizi syndrome can result in fibrosis of surrounding tissues complicating resection and increasing risk of iatrogenic bile duct injury and intraperitoneal bleeding. The subject of this case study presented with extensive fibrosis extending O.R time.

Case Presentation: A 35-year-old Caucasian female presented to the emergency department jaundiced with right upper quadrant pain and emesis for three days. Her vital signs were within normal limits. Her history was significant for the previous diagnosis of cholelithiasis with subsequent common bile duct (CBD) stent placement two years prior. Ultrasound lead to the diagnosis of choledocholithiasis with common bile duct dilation to 11 mm on date of admission. An ERCP was performed on the day of admission with the removal and replacement of the previous stent. ERCP lead to suspicion of Mirizzi syndrome due to apparent hepatic duct filling defect which was confirmed on MRI. Three weeks later a robotic cholecystectomy was performed with an operative time of two hours and fifteen minutes. One week postoperative symptoms resolved with no complications.

Conclusions: Mirizzi syndrome can cause repeated inflammation of the cystic walls and subsequent fibrosis may cause adherence to nearby structures (1,7), which complicated this procedure. Avoiding extensive fibrosis and inflammation with appropriately timed surgery in calculous cholecystitis may decrease complications.

Keywords: Mirizzi Syndrome, Choledocholithiasis, robotic cholecystectomy


Cholelithiasis in Sickle Cell Disease

Prachi Mahajan, MS, FRCS, FMAS, FIAGES; Mahajan ortho and surgical hospital

Vidarbha region of Central India hosts a large population suffering from sickle cell disease (SCD). Patients may be divided into 2 categories depending upon whether they harbour the sickle cell trait ‘ SA’ pattern or ‘ SS’ haemoglobinopathy. 25% of people suffering from either condition have gallstones due to haemolysis owing to polymerization of the HbS within the Red Blood Cells and sequestration of RBC’s in the spleen. This leads to the formation of pigment stones in the gall bladder.

Most of the patients have symptoms such as chronic right upper quadrant with intermittent pain acute exacerbations. Patients may be jaundiced due to the chronic haemolysis and also have bouts of obstructive jaundice from calculi that may intermittently slip into the common bile duct unless treated.

Materials and Methods: 70 patients with cholelithiasis were studied over 5 years. 42 patients had sickle cell trait while 28 had ‘SS’ disease. The age range was between 15-40 years, with a mean age of 24 years. All the patients had symptoms of chronic cholecystitis. Mean bilirubin was 4.8 mg/DL Laparoscopy revealed characteristic features of chronic cholecystitis in all patients. The gall bladders were small, shrunken, thick walled and contained multiple pigmented calculi.

The technical difficulties were as follows:
  1. 1)

    Very small size of gall bladder in all (100%) patients.

  2. 2)

    Chronic adhesions in the Calot’s triangle in 75% of patients.

  3. 3)

    Thickened short contracted cystic duct in 90% of patients.

  4. 4)

    Impacted stones at the neck, causing difficulty in dissection (20%)

  5. 5)

    Intrahepatic gall bladder (25%) Results: Subtotal cholecystectomy had to be performed in 3 cases due to severe adhesions in the Calot’s triangle.


Post operative complications: Sickle cell crisis- acute chest syndrome, joint painsin 3 cases Extended hospital stay of over 5 days in 15 patients due to SCD related complications. Port infection in 4 patients. Mortality in 1 patient due to sickle cell crisis.


1) Laparoscopic cholecystectomy is technically difficult in patients with sickle cell conditions due to chronic inflammatory changes in the area.

2) Meticulous pre and post operative care is mandatory with adequate fluid infusions, good oxygenation, maintenance of OR temperature above 25 degrees Celsius, pre operative folic acid, sodium bicarbonate, hydroxyurea to prevent hypoxaemia, dehydration and hypothermia.


Primary Closure of Common Bile Duct with Biliary Stents

Vladimir Grubnik, MD, Professor 1, Viktor Grubnyk1, Vadim Ilyashenko, PhD1, Alexander Kovalchuk, MD, Professor21Odessa National Medical University, 2Ternopil State Medical University

Introduction: Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis is a popular option in many surgical institutes. Decompression of biliary system via T-tube post supra-duodenal choledochotomy has been the traditional surgical practice. Primary closure of common bile duct (CBD) has been shown to reduce hospital stay but bears a risk of bile leak. We conducted a prospective randomized trial to compare complications and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy.

Methods and Procedures: The study involves 65 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either antegrade biliary stent or T-tube insertion. A 7 French biliary stent (9–10 cm long) have been placed in 33 patients (group I), T-tube insertion has been used for 32 patients (group II). The length of hospital stay and complications were recorded. All transcystic explorations were excluded.

Results: There were no signi?cant differences between groups with respect to age, sex, comorbidities, number and size of CBD stones. Postoperative complications have been observed in 4 patients (12.5%) in the T-tube group (two patients needed reoperation: 1 patient for dislocation of T-tube, another one for biliary peritonitis due to extraction of T-tube 6 weeks after operation). And 1 patient (3.0%) in the biliary stent group (p < 0.05). The mean postoperative hospital stay was 3.4 ± 1.3 days for group I, and 6.5 ± 1.6 days for group II (p < 0.05).

Conclusions: Our results showed a reduction of length of hospital stay and morbidity following stent insertion compared to T-tube drainage. Also, the use of biliary stent after LCBDE can reduce costs and increase patient satisfaction.


Results in the Endoscopic Management of Giant Common Bile Duct Stones: Stent and Pneumatic Dilatation

Carlos Leal, MD, General Surgery, Gastroenterology1Andres Mendoza, MD, General Surgery 1, Luis Cabrera, MD, General Surgery1, Mauricio Pedraza1, Sebastian Sanchez1, Jean Pulido1, Daniel Gomez, MD, FACS21Bosque University, 2CPO

Background: The endoscopic management of choledocholithiasis remains a challenge for the general surgeon due to the complications that can arise from it. Traditional management has been surgical, but in recent years endoscopic management has had great relevance due to the high rate of effectiveness and for demonstrating lower morbidity and mortality rates.

Materials and Methods: We describe our experience at a third level surgical center of patients taken to Endoscopic Retrograde Cholangiopancreatography (ERCP), endoscopic balloon dilation and placement of biliary prosthesis (stent), during January 2016 to July 2017, for the management of giant common bile duct stones.

Results: A total of 11 cases completed the inclusion criteria. Eight (72.7%) patients corresponded to the female gender. Patient age averaged 62.3 years. A resolution frequency of giant common bile duct stones was found with this endoscopic procedure in 90%, without any reported complications. A decrease in the size of the stones, with a range of 2-3 procedures per patient.

Conclusion: The endoscopic procedure with ERCP dilatations of the bile duct and stent placement proves to be effective in the management of giant common bile duct stones with low complication rates.

Key Words: Common bile duct stones, stent, pneumatic dilatation


Endoscopic Management of the Difficult Hepatic Biliary Duct Stone with Digital Direct Cholangiography

Renzo Pinto, Efrain J Isaacs, Laura Quintero, Luis F Cabrera, General Surgeon, Daniel Gomez, MD, FACS, Mauricio Pedraza, Jean Pulido; Bosque University

Introduction:Digital direct cholangiography or Spyglass (Boston Scientific Corp., Natick, MA, USA) is a modern and simplified technique, which allows a single endoscopist a better visualization of the biliary tract and equipment maneuverability. Using this unique technique, it is possible to fragment and extract bile stones using a mechanical lithotripter or a pulsed dye laser, with a successful rate greater than 90%

Objective: To describe the utility of the direct cholangioscopy and laser lithotripsy in the management of the difficult common bile duct stones, in two patients with biliary stenosis

Materials and Methods: 2 patients were treated in the Bogota, Colombia, between the years of 2015 and 2018 in a fourth level hospital, who presented with distal biliary stenosis and choledocolitiasis. This patients also had difficult bile duct stones criteria, which is the reason why direct cholangioscopy and laser lithotripsy was indicated, with 100% success and no complications.

Results: The 2 cases had complete resolution of hepatolithiasis, being able to overcome the distal stenosis and preventing new episodes of cholangitis.

Conclusions: Digital direct cholangiography or Spyglass, is an endoscopic technique which allows direct vision of the biliary tract and the bile ducts. Using this technique, it is possible to fragmentate all the bile stones and overcome bile duct stenosis, prevent cholangitis and spare the patient of a possible hepatectomy


Technique of Critical View of Safety for Acute Cholecystitis Cases During Laparoscopic Cholecystectomy

Ali Uzunkoy; Harran University School of Medicine

Introduction: The technique critical view of safety is important to prevent biliary injury during laparoscopic cholecystectomy (LC). Bile duct injuries can be observed more frequently in acute cholecystitis. In this study, it was aimed to investigate whether a critical view of safety could be formed in cases with acute cholecystitis during LC.

Material and Procedures: LC was applied to forty-two patients who applied for acute cholecystitis. Patients who applied for acute cholecystitis were divided into two groups: those who were operated in the first 72 h (first group) and those who were operated after 6 weeks (second group). Fifteen cases were operated within the first 72 h. Twenty-seven cases were operated 6 weeks after medical treatment. The applicability of the critical view safety technique during the LC, hospitalization times, the rate of complications, and the rate of conversion to open technique was compared between the groups.

Results: There was no statistical difference between the groups in terms of demographic data (p > 0.05). The operating times were slightly longer in patients who underwent surgery in the first 72 h. The mean operating times respectively were 62 and 54 min (p < 0.05). In two cases (13.3%) in the first group could not be established critical vision safety. In one of these patients the first fundus technique was applied for LC. The other patient underwent laparoscopic partial cholecystectomy. In the first group, the structures within the hepatocystic triangles could not be revealed in one patient (6.6%) and the open procedure was converted. LC was performed without any problems in 2 cases(13.3%) of gallbladder empyema in the first group. There was no statistical difference between the groups in terms of postoperative complications except wound infection(p > 0.05). Wound infection was more observed in the first group. In the first group, in 4 cases (26.6%) of superficial wound infections were observed at the incision site where the gallbladder was removed. All patients recovered without any need for additional intervention (p < 0.05). Total hospital stay was significantly longer in the second group because of medical treatment. The mean of totally hospital stays in the groups were 3.6 and 8.1 day (p < 0.05). There was no mortality in the groups.

Conclusion: In acute cholecystitis cases, critical view of safety technique during LC can be performed safely in the first 72 h. However, wound infection rates are increasing in these cases. Delayed LC is safer, but the total length of hospital stay is longer.


Intraoperative Fluoroscopic-guided Balloon Choledocholithotomy and Laparoscopic Cholecystectomy : A New Technique for the Treatment of Choledocholithiasis

Yasunobu Kobayashi, MD 1, Hironori Ohdaira, MDPhD1, Mutsumi Kaji, MD1, Norihiko Suzuki, MD1, Satoshi Narihiro, MD1, Taigo Hata, MD1, Soujun Hoshimoto, MDPhD1, Masashi Yoshida, MDPhD1, Jun Horiguchi, MDPhD1, Eigoro Yamanouchi, MDPhD2, Masaki Kitajima, MDPhD1, Yutaka Suzuki, MDPhD11Dept of Surgery, International University of Health and Welfare, 2Dept of Radiology, International University of Health and Welfare

Background: Patients with choledocholithiasis often are undergone preoperative endoscopic retrograde cholangiography (ERCP) following laparoscopic cholecystectomy (LC). However, ERCP has risks of acute pancreatitis, bleeding, and perforation. Consequently, there might be unexpected interval between ERCP and LC.

Objective: We report on a single-stage operation (LC + fluoroscopic-guided balloon choledocholithotomy) as a new technique of treatment for choledocholithiasis.

Patients: From April 2015 to August 2018, 15 patients with choledocholithiasis (male: female = 6 : 9, median 75 (range, 62 - 91) years old)) were enrolled.

Methods: Calot’s triangle were dissected and exposed with the same procedure as conventional LC. Cystic duct was incised, the sheath of angiography catheter percutaneously was placed through right upper quadrant, and cannulated to cystic duct. Guide wire was inserted with fluoroscopy, and cannulated the duodenum beyond the Vater papilla. Existence of choledocholithiasis was confirmed, Vater papilla was dilated with balloon. Subsequently, the balloon was expanded upstream of the choledocholithiasis and stones ware removed by the extrusion method. Common bile duct was imaged again to confirm that there was no remaining stone. Finally temporally plastic stent was placed.

Results: Operation was completed in all 15 patients, and in all cases stones could be removed. Median operative time was 139 min (range, 87-341 min) and median fluoroscopic time of stone removal was 45 min (range, 7-120 min). Median postoperative hospital stay was 3 days (range, 2-11 days). No complications related to surgery were observed in all cases, and it was confirmed that there was no residual stone in the biliary tract by MRCP one month after the operation.

Conclusion: LC + fluoroscopic stone removal technique is safe and reliable and can be one of new treatments for choledocholithiasis.


Clinical Differences of Young Population Underwent Laparoscopic Cholecystectomy

Yoo Shin Choi, Suk Won Suh, MD, Seung Eun Lee; Chung-Ang University

Introduction: Laparoscopic cholecystectomy (LC) in young population is relatively uncommon, despite being one of the most common surgical procedures in adults. Although clinical characteristic of adult patients with gallbladder (GB) disease is well established, scanty information have been for youth. In the present study, we aimed to comprehensively review the young population underwent LC compared to older population.

Methods: A total 2,115 patients who received LC for GB stones were retrospectively analyzed. The patients were categorized into two clinical groups according to the age of patients: (young (< 24) group and the elder group). We compared two groups according to its clinical characteristics.

Results: In univariate analysis, significant factors between two groups were found in the concomitant of choledocholithiasis and American Society of Anesthesiologists score I/II. By multivariate analysis, the concomitant of choledocholithiasis (OR 1.152, 95% CI, 0.663 – 2.001, p < 0.001) were independent factors between young group and the elder group.

Conclusions: In our study, young population with gallstone disease had more prevalence of choledocholithiasis. Therefore, young patients with gallstone disease require special attention for choledocholithiasis.


Hyperkinetic Gallbladder: An Indication for Cholecystectomy?

Baongoc Nasri, MD, PhD 1, Brian Gilchrist, MD2, Timothy Glass, MD1, Jonathan Saxe, MD11St. Vincent Hospital, 2New York University Winthrop Hospital

Background: The main indications for laparoscopic cholecystectomy are stone related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder ejection fraction (GBEF < 35%) is a recognized indication for cholecystectomy in children. However, not only do patients have low ejection fractions, but a significant number have hyperactive ejection fractions with GBEF > 80%. There are multiple articles showing long term resolution of symptoms in children with hyperkinetic ejection fractions on HIDA scan. The purpose of this study is to evaluate whether hyperkinetic gallbladder (GBEF > 80%) could be an indication for cholecystectomy in adult population.

Methods: Data were consecutively collected from all patient underwent laparoscopic cholecystectomies between June 2012 and June 2017 at a single institution. Patients less than 18 year of age or missing data were excluded. Patients with a negative US (no stone, no sludge, no gallbladder wall thickening) and GBEF greater than 80% were included in this study.

Results: Over a five-year period from June 2012 until June 2017, 36 patients were identified to fit the inclusion criteria for this study. There were 33 women and 3 men with a mean age of 52 ± 13.87 years, all had an GBEF greater than 80% with a mean of 89 ± 4.45%. Mean BMI was 30 kg/m2 (range, 14- 48.8) 3 patients (8.3%) had daily bouts of nausea or emesis. All patients had biliary colicky pain for more than one month. Patients had undergone several additional studies: endoscopy (23), colonoscopy (6), gastric emptying study (6), CT scan (9). Pathology reports were reviewed: only 3 (8.3%) patients had a normal gallbladder, 27 (75%) had chronic cholecystitis, and 6 (16.7%) had chronic cholecystitis with cholesterolosis. All patients were seen in follow up 4 to 6 weeks postoperatively. 33 had complete resolution of symptoms, two had partial resolution and one had no change. There was a complete resolution rate of 91.7% and an improvement rate of 97.2%.

Conclusions: Long term resolution of symptoms in children with hyperkinetic ejection fractions on HIDA scan have been documented. In this series of adult patients who presented with biliary symptoms, negative ultrasound and elevated GBEF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to significant rate of symptomatic relief. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.


Laparoscopic Cholecystectomy: A Review of Operative Timing and Complications

Chetna Bakshi, MD, Gainosuke Sugiyama, MD, FACS, Charles Choy, MD, FACS, Gene Coppa, MD, FACS, Antonio Alfonso, MD, FACS, Paul Chung, MD; Zucker School of Medicine at Hofstra/Northwell

Background: Laparoscopic cholecystectomy is one of the most common operations performed in general surgery in the United States. It has been suggested that increased operative time (OT) is correlated with increased risk of complications in laparoscopic surgeries across various surgical fields1,2,3.

Objective: To determine if increased operative time is associated with increased risk of complications in laparoscopic cholecystectomy.

Methods: Using ACS NSQIP from 2006-2015, we identified all adult (≥ 18 years) patients that underwent an emergent laparoscopic cholecystectomy with a postoperative diagnosis of cholecystitis performed within 3 days of admission, by a general surgeon with a wound classification of clean/contaminated or contaminated. We excluded cases with preoperative SIRS/sepsis, ASA class IV or V, and cases that had additional procedures listed. We also limited our analysis to cases with OT ≥ 15 min and ≤ 360 min. Risk variables included age, sex, race, morbid obesity (BMI ≥ 40 kg/m2), functional status, ASA class, and operative time. Outcome variables included postoperative superficial surgical site infection (SSI), deep SSI, organ-space SSI, dehiscence, pneumonia, reintubation, failure to wean from ventilator, pulmonary embolism, renal failure, urinary tract infection, cardiac arrest, myocardial infarct, bleeding, deep vein thrombosis, sepsis, septic shock, return to the operating room, and death. Multivariable logistic regression was performed adjusting for all risk variables. Postoperative length of stay (LOS) was analyzed using negative binomial regression adjusting for all risk variables.

Results: A total of 7,031 cases met inclusion criteria, of which the majority were women (71.5%), Caucasian (80.0%), with a mean age of 46.1 years. Median OT was 63 min, first quartile was 46 min and third quartile was 87 min. Logistic regression analysis showed that increased OT (third vs first quartile) was an independent risk factor for superficial SSI (OR 1.75, 95% CI 1.36-2.25, p < 0.0001), organ-space SSI (OR 1.77, 95% CI 1.33-2.35, p < 0.0001), dehiscence (OR 2.03, 95% CI 1.01-4.07, p = 0.0470), septic shock (OR 1.81, 95% CI 1.06-3.09, p = 0.0286). Increased OT was independently associated with increased LOS (fourth vs 1st quartile: IRR 1.53, p < 0.0001; third vs 1st quartile: IRR 1.29, p < 0.0001; 2nd vs 1st quartile: IRR 1.16, p < 0.0001).

Conclusion: In this large observational study we found that increased OT is independently associated with morbidity and increased postoperative LOS following laparoscopic cholecystectomy for cholecystitis. Prospective studies are warranted to determine whether increased OT from resident training is a contributing factor.


Laparoscopic Completion Cholecystectomy for Left out Gall Bladder Remnant and Stump: Technique and Results of a Series of 52 Cases

Subhash Khanna, PROF; Swagat Super Speciality Surgical Institute

Background: Laparoscopic cholecystectomy is presently the standard of care for most cases of calculus cholecystitis. Although it is practiced and being routinely done in both acute and chronically inflammed gall bladders, but many a times a surgeon knowingly or inadvertently ends up leaving a large stump of gall bladder and cystic duct that may harbor a calculus.

Such large stump may be the cause of persistent pain and may necessitate removal of the stump or may at times be a formal completion cholecystectomy.

In a span of nearly 20 years we encountered 52 such cases of left out stump and post partial cholecystectomy gall bladder remnant.

We are presenting the technique and our results of laparoscopic excision in these cases.

The Technique: Of the 52 cases, 35 were post conventional cholecystectomy having a scar (sub costal in all 34 except one right paramedian) and rest 17 were after laparoscopic cholecystectomy.

A modified open technique was used to create pneumoperitoneum. In most of the post open cholecystectomy cases gross omental adhesions were seen to the scar and the falciform ligament.

The second port was made in the left midclavicular line to the left of umbilicus. The first step was to remove adherent falciform and omental adhesions from the previous laparotomy scar, followed by separating the hepatic adhesions from diaphragm. At this stage the third and mid clavicular port was made followed by right anterior axillary port. Finally with gentle blunt dissection the omental adhesions were lysed from the gall bladder fossa and the stump exposed.

The stump varied in size from 1 cm to 5 cm and many a times clips were seen on the wall of the left out gall bladder. Complete removal of gall bladder was successful in 51 out of 52 cases with no major morbidity.

Discussion: Although a simple technique Laparoscopic cholecystectomy at times ends up with unwanted complications. One of the rare causes of post laparoscopic cholecystectomy pain is the left out stone in the cystic duct remnant or the gall bladder remnant. We present our series of 52 cases of excision of left out gall bladder and stump in a span of last 20 years. All such cases can be done laparoscopically. Usually the cystic duct and artery can be dissected in most of these cases. Laparoscopy should be the standard technique for all such cases of incomplete removal of gall bladder.


Determinant of Quality of Life After Laparoscopic Cholecystectomy

Heba A Elghalban, MD 1, Nagwa Nashat, MD1, Rami R Mustafa, MD2, Hatem Soltan, MD3, Hala Shaheen, MD1, Taghreed Farahat, MD11Family Medicine Department, Faculty of Medicine, Menoufia University, 2Department of surgery, Cleveland Medical Center, University Hosptals, 3Department of surgery, Faculty of medicne, Menoufia University

Introduction: cholecystitis is a striking public health issue with high socioeconomic impact. About 10%- 15% of the general population have gallstone, with a high risk for morbidity or even mortality. Risk factor for cholecystitis include increasing age, female sex, certain ethnic groups, obesity or rapid weight loss, certain diet, drugs and pregnancy. Gallstone disease is the second most costly digestive disease and the single most common indication for abdominal surgery; as more than 75%of patients who suffer from cholelithiasis combined with chronic cholecystitis undergo laparoscopic cholecystectomy (LC) surgery. The measurement of quality of life (QOL) issues make it possible to obtain standardized information about a patient perception of the specific disease and its impact on his or her life. Quality of life (QOL) is a critical consideration when evaluating treatment options for cholelithiasis. Therefore, understanding the postoperative physical, psychological, and social outcomes associated with cholecystectomy is essential. few studies have assessed the role of socioeconomic characteristics on outcomes after a cholecystectomy.

Methods: a cohort study that was conducted through an entire year (December 2016-december 2017); in Menoufia University hospital as all patient prepared for laparoscopic cholecystectomy was offered to join the study, with exclusion of those who refuse to participate, having malignancy, patient with sever organic or psychiatric illness and contraindication for anesthesia. Preoperatively patients were interviewed and promoted to complete a pre-designed questionnaire that include full patient history (age, sex, history of present illness with its onset, duration and any associated gastroenterological symptoms. Past medical history of presence of comorbid conditions, previous operations and hospitalization. Patients also subjected to detailed general and local physical examination. Revision patient’s investigation include U/S and some lab correlation when needed. Complete operative details collected. postoperatively all patients were interviewed for gastrointestinal quality-of-life index (GIQLI) after a month of the operation day; as part of the follow up process for the patients.

Results: among 200 patients enrolled in the study, (76% were females), mean age (43 ± 2.65), with prevalence of (64%) of low socioeconomic level. Although more female patients were enrolled in the study; male patients had lower score of (GQOLI). Compared to younger groups, patients older than 65 years old were the lowest in the (GQOLI) scores.

Conclusion: age and sex could be used as a predictor of quality of life after laparoscopic cholecystectomy.

Keywords: cholecystitis, gallstone, quality of life .


Incidence of Concomitant Vascular Injuries in Post-cholecystectomy Benign Biliary Strictures and Impact on Long-term Outcomes

Saurabh Galodha, MSMCh 1, Rajan Saxena, MS2, Rajneesh K Singh, MSMCh2, Ashok K Gupta, MCh2, Anu Behari, MS2, Vinay K Kapoor, MS21Indira Gandhi Medical College, Shimla, 2SGPGIMS, Lucknow

Objective: The impact of concomitant vascular injury on the long-term outcome of post- cholecystectomy benign biliary stricture (BBS) repair is controversial. In this study we tried to find out the incidence of a concomitant vascular biliary injury (CVBI) and their impact on the long-term outcomes.

Methods: All consecutive patients with BBS from December 2010 to May 2012 were included. Magnetic resonance angiography (MRA) with MRCP was done prior to repair. Long-term outcomes were analysed on basis of McDonald grading.

Results: 36 patients of BBS were included. Median age was 36 (15-70) years and 28 (78%) were females. 10 patients (28%) had prior failed repair. CVBI was present in 22 (61%) and all had right hepatic artery (RHA) injury. Laparoscopic cholecystectomy was primary surgery in 18 patients with VBI (82%) and in 5 patients without CVBI (p = 0.016). Right portal vein injury was present in one patient. CVBI was noted in 9 patients with prior failed repair (p = 0.027). 23 (64%)patients had high strictures (Bismuth Type ≥ 3); 19 had CVBI (p < 0.001). 34 patients underwent Roux en Y hepaticojejunostomy (RYHJ). Mean operative time was 3.2 ± 1.1 h and mean blood loss was 300 ± 150 ml. Post-operative complications were present in 13 (36%) patients but there was no perioperative mortality. At median follow up of 42 months (24 – 60), there were 8 failures in CVBI group (Success = 64%). Of these, 1 patient underwent right hepatectomy, 3 had percutaneous dilatation and 4 underwent revision RYHJ. In patients without CVBI only 1 patient had failure (p = 0.07).

Conclusion: Concomitant vascular injuries have considerable impact on long-term outcomes of post-cholecystectomy BBS repair and are significantly associated with failed repairs. MR angiography is a good adjunct in the diagnostic armamentarium of BBS and can help in appropriate management of these patients.


Endoscopic Transpapillary Stenting for the Management of Acute Cholecystitis

Danielle Hayes, MD, Gary Lucas, MD, Bryce French, MD, Andrew Discolo, MD, Rajnish Mishra, MD, Sean Wells, MD; Swedish Medical Center - First Hill

Introduction: Cholecystectomy is the gold standard treatment of acute cholecystitis. Patients with multiple comorbidities who are considered high-risk surgical candidates are commonly recommended to undergo percutaneous cholecystostomy tube placement; however, long-term external drainage is undesirable for many patients. Endoscopic transpapillary stent placement (ETSP) has been described as an alternative method for decompression of the gallbladder. The purpose of our study is to assess which patients would benefit from this treatment compared to traditional treatments of cholecystitis.

Methods: We performed a retrospective chart review of patients with cholecystitis who underwent ETSP at our institution between January 2015 and July 2018. This study was performed to identify indication, comorbidities, length of stay, labs, outcomes, additional procedures, and whether cholecystectomy was eventually performed.

Results: During the study period, 12 patients underwent ETSP. The mean age was 68.2 years (± SD 12.4) with an average ASA class of 3.2. The Charlson Comorbidity Index was greater than seven in 75% of patients, indicating a zero percent 10-year survival. The NSQUIP surgical risk calculator estimated an average mortality risk for laparoscopic cholecystectomy of 4.8% (± 3.3, 95% CI) in our study population; the estimated risk in the general population is 0.1%. Resolution of symptoms with endoscopic drainage was achieved in 11 of 12 patients (91.7%); one patient experienced no symptom resolution with endoscopic drainage nor subsequent percutaneous cholecystostomy tube placement. Six of 12 patients underwent interval cholecystectomy.

Adverse events occurred in four cases which consisted solely of post-ERCP stent migration or occlusion. Estimated time to stent occlusion or migration ranged from 20-400 days. Two patients died in the time of the study, one from sepsis in the setting of metastatic pancreatic cancer and the second from biliary sepsis after stent migration.

Conclusion: Endoscopic transpapillary stent placement is an effective and safe method for the temporary management of acute cholecystitis in high risk surgical patients. We recommend attempting ETSP as a temporizing measure for acute cholecystitis in high risk surgical patients who are undergoing ERCP for other diagnostic or therapeutic purposes and patients with anatomy that would make percutaneous cholecystostomy tube placement challenging. Randomized studies would be helpful to further investigate the utility and safety of ETSP in the management of acute cholecystitis.

Keywords: Endoscopic Transpapillary Stenting; Cholecystitis; Gallbladder Drainage; Percutaneous Cholecystostomy Tube; Cholecystectomy


Sinistroposition of the Gallbladder

David L Rhoiney, DO, Raymond Laird, DO; Beaumont Health-Trenton

Introduction: Sinistroposition of the gallbladder is a rare anomaly and has been reported to occur in approximately 0.3% of patients surgically treated for their gallbladder disease. Knowledge of this variation is paramount as the presentation of sinistroposition is not unlike traditional right-sided gallbladders and is often identified at the time of the operation.

Case Presentation: A 43-year-old woman with a history of gallstones and symptoms suspicious for acute cholecystitis was taken to the operating room for a laparoscopic cholecystectomy. Upon entrance into the abdomen and inspection of the liver, the gallbladder was observed to be present to the left of the falciform ligament and likely arising from segment III of the liver. An uneventful laparoscopic cholecystectomy was completed with some modification of technique and the patient did very well postoperatively.

Sinistroposition of the gallbladder is a rare anatomic variation, which is typically diagnosed upon intraoperative inspection of the liver bed during laparoscopic cholecystectomy. There are two anatomical variations of the presentation and the surgeon must be familiar with both in order to perform a laparoscopic cholecystectomy in a safe-manner.

Conclusion: Laparoscopic cholecystectomy can be performed safely without modification of technique provided the surgeon is aware of the anatomical variations which commonly occur with sinistroposition of the gallbladder.


Efficacy of Pancreatic Enzyme Replacement Therapy in the Treatment of Pancreatic Exocrine Insufficiency Following Pancreatic Surgery, A Systematic Review

Alysha R Keehn, MD, MSc, candidate 1, Stephen N Quigley, MD, FRCSC2, Elijah Dixon, MD, MSc, FRCSC11University of Calgary, Department of Surgery, 2Memorial University, Department of Surgery

Background: Mortality from pancreatic surgery has decreased over the years, however morbidity remains high. 45% of patients demonstrate pancreatic exocrine insufficiency prior to surgery with post-operative incidences ranging form 56-98%. This contributes to poor quality of life, readmission to hospital and reduced survival.

Objectives: Few studies have reported on the efficacy of pancreatic enzyme replacement therapy following pancreatic surgery. The aim of this review is to systematically summarize the evidence to guide and inform practice.

Methods: A systematic review was conducted using Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL & Google Scholar. Bibliographies of all included publications were cross-referenced. PRISMA guidelines were used to structure the review and evidence was appraised using the GRADE system.

Results: Eleven studies were included (4 prospective observational and 7 RCTs). Pancreatic enzyme replacement therapy was found to significantly reduce fecal fat excretion (p < 0.001) in 3 RCTs and significantly reduce stool frequency (p < 0.001) in 1 RCT. It was found to significantly improve both the coefficient of fat absorption and of nitrogen absorption (p < 0.001, 0.05 respectively) in 2 RCT’s. There is mixed evidence for whether PERT improves mean body weight and BMI. 3 RCT’s showed an improvement in clinical symptomatology with PERT while 1 found no difference.

Conclusion: There is grade A evidence to support that PERT reduces fecal fat excretion and improves stool frequency, and fat/nitrogen absorption. There is mixed evidence (Grade C) that it has an effect on mean body weight and BMI. There is Grade A evidence to support a reduction in clinical symptoms. The data from this systematic review will be used in a subsequent meta-analysis.

Key Words: Pancreatic exocrine insufficiency, pancreatic enzyme replacement therapy, pancrealipase, CREON®, pancreatic surgery, pancreaticoduodenectomy


Feasibility of Two-port Laparoscopic Cholecystectomycompared to Standard Four-port Laparoscopic Cholecystectomy: Randomized Control Study

Ibrahim A Salama, MDPhD; Department of Surgery,National Liver Institutee, Menoufia University

Introduction: Two-port laparoscopic Cholecystectomy (LC) has been proposed as a safe and feasible technique. However, there are limited Studies to evaluate the effectiveness of the procedure. This is a prospective randomized control study to Compare the standard four-port LC with two-port L.C.

Materials and Methods: A total of 316 Consecutive patients undergoing LC were randomized to four-port (Group A)/two-port mini LC (Group B) from January 2013 to January 2018 In two-port LC, a 10-mm umbilical and a 5-mm left hypochondruim port were used with polyprolene thread was used for lateral -cephalic retraction of the fundus and another thread used for traction of the Hartman pouch if needed. Outcomes measured were duration and difficulty of Operation, post-operative pain, analgesia requirements, Post-operative stay, complications and cosmetic score at 30 days.

Results: Out of 316 patients, the ratio of M: F was 1:4, with mean age 40.79 ± 12.6 years.. The mean Operative time were similar (P = 0.727). Addition 3rd port was used in seven cases. Post-operative pain was significantly low in the two-port group at up to 24 h (P = 0.023). The overall analgesia requirements (P = 0.003) and return to daily activity (P = 0.00) were Significantly lower in two-port group. The cosmesis score of the two-port group was better than four-port group (P = 0.00). However, the length of hospital stay (P = 0.760) and complications (P = 0.247) were similar between the two groups.

Conclusion: Two –port LC result in reduced pain, need for analgesia, and improved cosmesis without increasing the operative time and complication rates compared to that in four-port LC. Thus, it can be recommended in selected patients


Endoscopic Biliary Intervention Following Orthotopic Liver Transplantation

Krishnaraj Mahendraraj, MD, Guillermo Medrano Del Rosal, MD, Michelle Kruse, BS; Lincoln Medical Center

Introduction: Biliary tract complications that require endoscopic decompression represent a greater challenge after liver transplantation than in non transplanted patients. Immunosuppressive therapy predisposes patients to a greater risk of infections and poor healing process. This comparative study analyzes risk factors and outcomes in liver transplant patients with biliary pathology that requires endoscopic intervention.

Methods: Information obtained from National Inpatient Sample database over a 15-year period (2001-2011). This included a total 10,252 patients who underwent liver transplantation, 581(6%) if these patients experienced biliary system complications. Univariate and multivariate was obtained via Statistical Package for the Social Sciences (SPSS). Statistical significance was accepted for p-value < 0.05.

Results: A total of 581 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) after hepatic transplantation, 80% of them had sphincterotomy and stent placement. These were mostly seen in men (64.5%), caucasians (69.8%) with a mean age of 52 years, however these results were similar to the no intervention group. These patients were diabetic with chronic complications (4.9% vs 2.9%) and had congestive heart failure (3.8% vs 2.4%). Choledochoenterostomy was a protective factor for having biliary pathology requiring endoscopic intervention. Biliary complications that required intervention were; choledocholithiasis (18.8% vs 9.5%), cholangitis (36.7% vs 7.5%), biliary stricture (36.7% vs 3.8%), biliary leak (0.7% vs 0.1%). Length of stay > 1 week was greater in the biliary intervention group (98.3% vs 77.6%). Significant complications seen in patients requiring intervention were; sepsis (23.2% vs 11.8%), urinary tract infections (12.6% vs 8.5%), acute renal failure (39.9% vs 31.1%), peritonitis or intra abdominal abscess (11.4% vs 6.0%), wound infection (11.7% vs 6.0%) and acute rejection (46.1% vs 18.4%). In-hospital mortality was significantly higher for patients with biliary pathology requiring endoscopic intervention (7.2% vs 5.3%).

Conclusion: Biliary system pathologies requiring endoscopic intervention had life threatening complications and thus mortality rate on the same admission. Interestingly, choledochoenterostomy decreased the risk of biliary tract pathology that required instrumentation.


Less Invasive Single Port Laparoscopic Cholecystectomy with 2 Fine Needle Forceps

Junko Takita, MD, Norihiro Haga, MD, Norihiro Masuda, MD, Yuta Shibasaki, MD; NHO Utsunomiya National Hospital

Introduction: Single port surgery (SPS) has been reported to reduce the abdominal wall damages. To reduce the length of umbilical scar and to keep the triangulation, we use 2 additional fine needle forceps for laparoscopic cholecystectomy (LC).

Patients and Methods: From 2007 to May 2018, 597 consecutive LC patients were retrospectively investigated. There were 345 male and 252 female. Severe cholecystitis was observed in 30% of the cases. We use two 5 mm ports (1 for the scope and 1 for the operator’s right hand forceps) through an umbilical multi-channel port and 2 additional 2.4 mm fine needle instruments are pierced. One of the forceps is placed on the right side of the lower end of sternum and the other is on the right side of abdomen. A 5 mm flexible scope allowed us to keep the triangular formation easily. We performed cholecystectomy by this plus two punctures SPS (PTP-SPS) for 464 patients. The rest of patients were operated by one 11 mm port, one 5 mm port and two fine needle forceps as conventional reduced port surgery (RP). We employed the RP method until 2011, however from 2012 to now, we perform cholecystectomy by PTP-SPS. We studied the safety and usefulness of PTP-SPS from the viewpoints of operation time and the complications.

Results: Median operation time of PTP-SPS (464 cases) was 83 (28-227) minutes, while RP (133 cases) was 84 (26-191) minutes. In PTP-SPS, 66 cases (14.2%) needed 1 or 2 additional 5 mm ports and 7 (1.5%) were converted to open surgery. Postoperative complications were conservatively treated 2 bile leakage (0.4%) and 3 incisional hernia (0.6%). There was no severe wound infection in our series. In RP, 2 cases were converted to open surgery (1.5%). Severe postoperative complication was 1 incisional hernia (0.75%) that needed surgical repair. Umbilical scars and the pierced needle instrument scars became gradually invisible within 1 or 2 months. There was no learning curve with operators changing over from RP to PTP-SPS method.

Conclusions: There were no differences between PTP-SPS and RP in operation time and complications. Operative scar of PTP-SPS is smaller than RP because of using the fine needle forceps instead of 5 mm port. Therefore, the patients appreciate PTP-SPS by better cosmesis than the conventional LC or RP. PTP-SPS may become the standard approach as less invasive laparoscopic cholecystectomy.


Surgical Response in Patients with Normokinetic Biliary Colic

Robert C Wright, MD, FACS, Rachel Robles, Haley Peffer, Nina Thach, Robert J Wright; Meridian Surgery Center

Background: Clinical response of patients with symptomatic biliary colic but with atypical findings of gallbladder polyps, hyper-dynamic gallbladder and otherwise negative biliary work up are underrepresented in the literature.

Methods: A clinical outcome study with a retrospective design compared the pre-operative pain to the post-operative pain reported by patients with pre-operatively diagnosed biliary dyskinesia to all other patients with biliary colic and atypical pre-operative diagnoses. A visual analog scale was used. All patients underwent surgery at Meridian Surgery Center from the years 2010 to 2017. 600 patients were reviewed for biliary dyskinesia, gallbladder polyps, hyper-dynamic gallbladder and negative work up. Patients with cholelithiasis or sludge were excluded from the study. Post-operative pathology reports were reviewed.

Results: Responses were received from 17 biliary dyskinesia patients, 10 hyper-dynamic patients, 10 polyps patients, 3 adenomyosis patients and 9 negative work up patients. Based on a 10 point pain scale, we found a mean drop in pain scale among biliary dyskinesia patients (-5.6) and among all other atypical findings (-5.7), with -6.1 for hyper-dynamic patients, -5.7 for adenomyosis patients, -6.0 for polyps patients and -5.0 for negative work up patients. There is no significant difference between pain recovery of patients with biliary dyskinesia and those with another atypical diagnosis. From the surgical pathology reports, all 17 of the of the biliary dyskinesia patients had chronic cholecystitis. Similarly, 9 hyper-dynamic patients, 10 polyps patients, 9 negative work up patients and 3 adenomyosis patients had chronic cholecystitis. Only 2 of the polyp patients’ pathology reports showed polyps. Gallstones were reported in 2 biliary dyskinesia patients, 1 hyper-dynamic patient and 2 of the 3 adenomyosis patients. One patient had a completely normal report was in the hyper-dynamic group. Our poor response rates were disappointing.

Conclusion: These results allow us to conclude that there is a comparable surgical pain relief between biliary colic patients with gallbladder polyps, hyper-dynamic gallbladder, negative work up and those with conventional biliary dyskinesia.


Comparison of Long-term Outcomes Between Laparoscopic and Open Liver Resection in Combined Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma

So Hyun Kang, Woohyung Lee, Youngrok Choi, Ho-Seong Han, Yoo-Seok Yoon, Jai Young Cho, Kilhwan Kim, In-Gun Hyun, Sunjong Han; Seoul National University Bundang Hospital

Introduction: Combined hepatocellular carcinoma and cholagiocarcinoma (HCC-CCC) is a rare primary hepatic neoplasm with incidence reporting up to 3.5%. Liver resection is still the preferred method for curative treatment. With the advancement of minimally invasive techniques, laparoscopic liver resection (LLR) is now a possible option for patients with resectable HCC-CCC, yet there are no published studies that analyze the feasibility of LLR in HCC-CCC alone. This study aims to compare the long-term survival and postoperative complications of LLR with open liver resection (OLR) in HCC-CCC.

Methods: Patients who underwent liver resection for HCC-CCC from August 2004 to June 2015 were enrolled. Those who received palliative surgery, and those who underwent open conversion after laparoscopic surgery were excluded. Medical records of these patients were retrospectively reviewed. Primary endpoint was 3-year disease-free survival (DFS) and 3-year overall survival (OS), and secondary enpoints were 3-year disease-specific survival, 1-year OS, 1-year DFS, operative outcome, and postoperative complications. Kaplan–Meier survival analysis was performed to compare survival.

Results: After exclusion, 13 patients were enrolled in the OLR group and 13 patients in the LLR group. There was no difference in age, gender, type of liver surgery (major or minor hepatectomy), tumor location (favorable or unfavorable), liver function, size of largest tumor, and pathologic stanging. Mean operation time for OLR was 314.2 ± 135.1 min and for LLR it was 337.3 ± 155.9 min with no statistical significance (p = 0.690). There was also no statistical difference in estimated blood loss (1173.1 ± 1459.7 vs 453.8 ± 271.9, p = 0.105). The 3-year disease free survival for the OLR group was 38.5% while the LLR group was slightly higher with 53.8%, but there was no statistical difference (p = 0.828). The 3-year overall survival was the same in both groups (69.2%). The 3-year disease-specific survival was also analyzed, and the OLR group was higher with 76.9% to 73.1% for the LLR group, but there was also no statistical significance (p = 0.591).

Conclusion: Laparoscopic liver resection for HCC-CCC is technically feasible showing similar long-term outcome with open liver resection. However, a large scale cohort study is still needed to provide better evidence, and until then, careful patient selection must be taken place.


Laparoscopic Management of Type II (Rare Type) Choledochal Cyst

Sumita A Jain, Senior Professor; SMS Hospital and Medical College

Choledochal cysts (CCs) are rare medical conditions with an incidence in the western population of 1 in 100 000–150 000 live births.

50%–80% are type I, 2% type II, 1.4%–4.5% type III, 15%–35% type IV 20% type V.

The etiology of CCs is still unclear. Babbitt’s theory of cysts caused by an abnormal pancreaticobiliary duct junction (APBDJ) such that the pancreatic duct and the common bile duct meet outside the ampulla of Vater, thus forming a long common channel, has gained much popularity.

CC is a premalignant state. The overall risk of cancer has been reported to be 10%–15%, and increases with age.

MRCP is currently the most accurate preoperative imaging study to assess cyst anatomy and classify the disease according to standard Todani classification

The treatment of choice for choledochal cysts is complete excision with construction of a biliary-enteric anastomosis to restore continuity with the gastrointestinal tract.

Type I: is complete excision of the involved portion of the extrahepatic bile duct; & Roux-en-Y hepaticojejunostomy

Type II: Complete excision of the dilated diverticulum comprising a type II choledochal cyst; the resultant defect in the common bile duct is closed over a T-tube

Type III (choledochocele): 3 cm or less can be treated with endoscopic sphincterotomy, > 3 cm are excised surgically via a transduodenal approach.

Type IV: Complete excision of dilated duct followed by a Roux-en-Y hepaticojejunostomy.

Type V (Caroli disease): One lobe-Hepatic Lobectomy, Bilobar-Liver transplantation.

We present a 17 year old girl who had type 2 (saccular) choledochal cyst which is very rare and that’s why Very few cases of laparoscopic management of type 2 choledochal cyst has been reported in the literature. We managed this case by laparoscopic excision of choledchal cyst in its entirety and closure of defect.


The Impact of Clostridium Difficile Infection on Treatment Outcomes Among Patients with Acute Pancreatitis: A Nationwide Analysis

Heather Peluso, DO 1, Wesley B Jones, MD1, Marwan S Abougergi, MD21Greenville Health System, 2Catalyst Medical Consulting, LLC

Introduction: Antibiotics are frequently used to treat acute pancreatitis before the presence of infected necrosis is established, which predisposes patients to Clostridium Difficile Infection (CDI). We sought to determine the impact of CDI on mortality, 30-day readmission, morbidity and resource utilization among patients with acute pancreatitis in the United States.

Methods: Retrospective cohort study using the 2014 National Readmission Database, the largest publicly available national readmission database. Patients were included if they had a principal diagnosis of acute pancreatitis. Exclusion criteria were age < 18 years and December admission. Readmission was defined as the first admission to any hospital for any non-trauma diagnosis within 30 days of the index admission. The primary outcome was in-hospital mortality rate. Secondary outcomes were 30-day readmission, morbidity (intensive care unit (ICU) admission, systemic inflammatory response syndrome with organ failure (SIRS/OF), total parenteral nutrition (TPN), shock) and resource utilization (length of stay (LOS), total hospitalization costs and charges). The following confounders were accounted for using multivariate regression analysis: age, sex, median income in patient’s zipcode, Charlson comorbidity score, hospital urban location, bedsize, teaching status.

Results: 236,066 patients were included, 2,362 of whom developed CDI. The mean age was 52.3 years and 47% were female. After adjusting for confounders, CDI was associated with > 2-fold increase in mortality (adjusted odds ratio (aOR: 2.64 (1.70-4.12),p < 0.01). In addition, patients with CDI were twice as likely to be readmitted within 30 days (aOR: 1.97 (1.68-2.30),p < 0.01). CDI was associated with a substantial increase in morbidity: ICU admission (aOR: 9.07 (6.88-11.96), p < 0.01), SIRS/OF (aOR: 3.26 (1.72-6.17),p < 0.01), TPN (aOR: 5.68 (4.55-7.08),p < 0.01), and shock (aOR: 6.50 (4.51-9.36),p < 0.01). Finally, CDI was associated with significantly higher resource utilization: LOS (adjusted mean difference (aMD): 7.07 (6.33-7.81) days,p < 0.01), total hospitalization costs (aMD: $16,278 ($13,820-$18,736),p < 0.01) and charges (aMD: $60,758 ($49,896-$71,620),p < 0.01).

Discussion: The development of CDI among patients with acute pancreatitis has a detrimental effect on treatment outcomes. It is associated with substantially higher mortality, 30-day readmission, morbidity and resource utilization. Therefore, judicious antibiotics use in this setting is of crucial importance and should be advocated for at the national level.


Laparoscopy Versus Transmural Endoscopic Drainage of a Pancreatic Pseudocyst

Ionut Bogdan I Diaconescu, MD, PhD, Matei Razvan Bratu, Madalina Ilie, Gabriel Constantinescu, Mircea Beuran; Carol Davila University of Medicine and Pharmacy

Introduction: Laparoscopic cystogastrostomy is an suitable procedure for the drainage of pancreatic pseudocysts if the cysts is present in the lesser sac (retro-gastric).

Methods: We present a series of 7 consecutive cases. First option was endoscopic transmural drainage like an ideal procedure. It was tried, but for two cases it failed, because the cyst wall was thick and the cyst had completely compressed the stomach, making endoscopic manipulation difficult inside the stomach.

Results: For 5 cases Endoscopic drainage was the only procedures. Laparoscopic drainage was a simple solutions to the problems in managing a huge pancreatic pseudocyst of 17 cm × 18 cm in a 57 years old male with a history of acute pancreatitis. Ultrasound and computed tomography revealed showed a walled off cystic collection that pushed the stomach superiorly. The cyst was exposed by dissecting the lesser omentum and found to have no adhesion to the surrounding tissues. Anastomosis was performed using an endoscopic linear stapler via small cystotomy and gastrotomy openings on the lesser curvature, which were then sutured laparoscopically. The postoperative course was uneventful.

Conclusion: Laparoscopic surgery is recommended as a safe, reliable, and minimally invasive treatment for managing pancreatic pseudocyst. Both techniques are suitable but with different indications that should be adapted to the case.


The Endoscopic Correction of Anastomotic Strictures After Liver Transplantation

Bolatbek Baimakhanov, Prof, PhD, MD, Yerlan Abdirashev, MD, Maksat Doskhanov, MD, Nurken Abdiyev, MD; JSC “National Scientific center of surgery named after A.N. Syzganov’s”

Background/Aims: The purpose is a retrospective analysis of endoscopic treatment (ET) of anastomotic strictures (AS) after LDLT and DDLT.

Methods: In the period from December 2015 to August 2018, we analyzed 107 patients after LT. LDLT was performed in 89 (83.1%) patients and DDLT in 18 (16.9%) patients. The whole liver in 18 (16.9%) patients, the right lobe in 81 (75.7%) patients, the left lobe in 7 (6.5%) patients, right posterior section in 1 (0.9%) patient. In 107 (100%) cases after LT in 25 (23.3%) patients BC of bile ducts were occurred. The early strictures (< 90 days) of duct to duct anastomosis developed in 11 (44%) patients and 15 (54%) recipients developed late strictures (> 720 days). The ET was performed to 20 (80%) patients. Other BC of 5 (20%) patients was solved by PTBD and open surgery.

Results: The retrograde ET was successful in 14 (70%) patients. In 11 (55%) cases we deployed plastic stent. To 3 (15%) patients only balloon dilation of AS was done. The 6 (30%) cases of ET were not effective. The main reasons were late diagnostic and treatment, severe stenosis of AS and unsufficient certain necessary equipments (guidewire, stents etc.). Also it was due to a small experience in this pathology. However, by growing of experience, the amount of successful ET increased.

Conclusions: Thus, ET on time is good solution to solve BC after LT. These category patients require careful and timely diagnosis of early BC (MRCP etc.), using single-use and sufficient quantity accessories, advanced experience of ERCP.


Adenomyomatous Hyperplasia of Distal Common Bile Duct: A Case Report and Review of the Literature

Paul S Chandler, MD, Jonathan Harris, Danny Sherwinter, MD; Maimonides Medical Center

Adenomyomatous hyperplasia (AH) is commonly found in the gallbladder and is considered a tumor-like inflammatory lesion arising from Rokitansky-Aschoff sinus. It is extremely rare in the extrahepatic bile duct and only 15 cases have been reported to date. We describe a 63-year-old male patient who presented with cholangitis, underwent an extensive diagnostic workup, and ultimately had a Whipple procedure. Final pathology showed a 2.0 × 1.5 × 0.5 cm3 granular lesion in the distal common bile duct. There was prominent biliary epithelial proliferation with tubular–papillary architecture and minimal nuclear atypia in association with chronic inflammation, stroma reaction and smooth muscle proliferation. AH of the extrahepatic bile duct is a benign process but often requires a major operation to definitively diagnose.


Total Laparoscopic Cholecystectomy in Moderate to Severe Acute Cholecystitis: Still a Safe Procedure

Juan D Hernandez, MD, FACS1, Gabriela L Larios, MD, FACS2, Diana C Quintero2, Gabriel Herrera, MD, FACS1, Roosevelt Fajardo, MD, FACS1, Felipe Perdomo, MD3, Francisco J Diaz, MD1, Ricardo M Nassar, MD31Hospital Universitario Fundacion Santa Fe de Bogota, Universidad de los Andes School of Medicine, 2Universidad de los Andes School of Medicine, 3Hospital Universitario Fundacion Santa Fe de Bogota

Introduction: Cholecystectomy is one of the most common procedures in general surgery and was responsible for the dissemination of laparoscopy among surgeons from the late 1980’s. Due to the catastrophic implications of bile duct injury, major efforts such as SAGES safe cholecystectomy program have been put forth to reduce this risk in laparoscopic cholecystectomy (LC), especially in severe cases. Also, bleeding and infection are major concerns. However, it is feared that an excess of precaution may lead to unnecessary conversions or partial cholecystectomies, procedures that can carry their own complications. A case series of LCs in complex cholecystitis and the incidence of intraoperative and postoperative complications is presented.

Methods: A prospectively maintained database was queried for patients who underwent LC at a tertiary care university hospital between January 2017 and June 2018, all conducted by surgeons with laparoscopic expertise. Inclusion criteria were patients with moderate or severe cholecystitis according to Tokyo guidelines 2018 (TG18). Exclusion criteria are age under 17 years, cholecystectomy as a secondary procedure, open cholecystectomy, mild cholecystitis according to TG18, pregnancy and incomplete records. The primary outcomes were three main complications: bile duct injury, hemorrhage or bleeding and infection. The secondary outcomes were conversion and mortality.

Results: Of 764 consecutive patients, 149 were identified as having moderate cholecystitis (19.5%), and 5 as severe cholecystitis (0.65%), and comprised the study group. The frequency of main complications reported in our study was 1 infection and 1 major bleeding (1.29% total); there were no bile duct injuries. There were two conversions, one due to technical difficulties and associated medical conditions of the patient. The other one was due to difficult bleeding control, also requiring subtotal cholecystectomy. There was only one other subtotal cholecystectomy, performed because Calot triangle was unidentifiable. It was completed laparoscopically. Only one mortality was found and it was not associated with the procedure (leukemia).

Discussion: This series of patients with moderate to severe cholecystitis who underwent total LC shows good outcomes with low incidence of complications and no bile duct injuries. This incidence was not superior to that in international literature. Conversion to open or subtotal was decided only in truly severe disease or when the anatomy was impossible to discern. TG18 frequently did not correlate to severity or difficulty. A consensus on the indications or findings to decide conversion or subtotal cholecystectomy should be achieved to prevent overuse and the complications associated to them.


Laparoscopic Bile Duct Injury.Effect of Surgical Repair

Shahidur Rahman, Professor; Bangobandhu Sheikh Mujib Medical University

Introduction: The aim of this study was to analyze the surgical treatment results of major bile duct injuries.

A single institution prospective analysis of 30 patients with bile duct injuries, underwent surgical repair.

Methods: From January 2004 to september 2018, a prospective records of all patients with a BDI following LC was The bile duct injuries were classified using the Stewart–Way classifion. Class II injuries consisted of lateral damage to the hepatic duct with a resultant stenosis and/or fistula. Class III injuries, the most common involved transection and excision of a variable length of the duct, which always included the cystic duct–common duct junction. The surgeon transected the common duct (deliberately, thinking it was the cystic duct) early in the dissection and transected the common hepatic duct. Class III injuries were subdivided based on the proximal extent of the injury as follows: in class IIIa injuries, a remnant of the common bile duct or common hepatic duct remained; in class IIIb injuries, the proximal transaction was at the bifurcation of the common hepatic duct; in class IIIc injuries, the bifurcation of the common hepatic duct had been excised, and in class IIId injuries, the proximal line of resection was above the first bifurcation of the lobar ducts (into segmental ducts).

Results: Over 14 years, 30 patients were treated for a major BDI following LC. Patient demographics were notable for women with a mean age of 45.5 years (median 44 years). All patients sustained their BDI at outside hospital. The mean interval from the time of BDI to referral was 22 weeks (median 3 weeks). Thirty patients underwent definitive biliary reconstruction hepaticojejunostomY. Five patients sustained at least 1 postoperative complication. The most common complications were wound infection, cholangitis, and intraabdominal abscess/biloma The mean postoperative length of stay was 9.5 days (median 9 days). Later repairs might have been more successful than earlier ones. Multivariate analysis, however, showed that the timing of the repair was unimportant. Instead, success correlated with: eradication of intra-abdominal infection; complete preoperative cholangiography; use of correct surgical technique, and repair by a biliary surgeon.

Conclusions: In conclusion, this study demonstrates that the most important factors associated with the success of biliary reconstruction include the complete eradication of intra-abdominal infection (drainage of all bile and fluid collections), complete characterization of the injury with cholangiography, use of the correct surgical technique, and repair performed by an experienced biliary surgeon.


The Application of Laparoscopy in Staged and Redo Surgery in Children with Choledochal Cysts

Mei Diao, Professor, Long Li, Professor; Department of Pediatric Surgery, Capital Institute of Pediatrics

Purpose: Conventionally, staged and redo surgeries are thought to be contra-indications for laparoscopy in children with choledochal cysts (CDC) because of adhesions, deranged anatomy, and demanding techniques. The current study is to assess the efficacy of laparoscopic staged and redo surgeries in CDC children.

Methods: Between January 2006 and September 2018, 178 patients were referred to our hospital for the second stage or redo surgeries. Of them, 163 patients successfully underwent laparoscopic definitive surgeries, including 1) staged surgery (n = 79), i.e. external biliary drainages before cyst excision and RYHJ for i) CDC perforation with general peritonitis (n = 60), and ii) severe inflammation or neonates with huge CDCs (n = 19); 2) redo surgeries (n = 84): i) revision of choledocho- or cholecysto-jejunostomies (n = 4), ii) postoperative bile leak repairs (n = 16, 3 of them caused by aberrant hepatic ducts which located in middle portion of cystic duct), iii) postoperative biliary obstructions (n = 64). A series of transabdominal retraction sutures were placed through 1) serosa of gallbladder fundus or gallbladder fossa in staged and redo surgeries respectively, 2) proximal common hepatic duct to facilitate dissection and anastomosis, 3) proximal → distal → posterior wall of CDC in staged surgery, 4) hepatic lobe to facilitate anastomosis of aberrant hepatic duct to jejunum.

Results: Conversion rate was 8.4% (15 out of 178 patients), including 1) unclear anatomical structure caused by dense adhesions (n = 5), 2) uncontrolled oozing (n = 4), 3) stenotic segments extended to the intrahepatic bile ducts, which required extensive dissections (n = 4), 4) anastomosis of aberrant hepatic duct to jejunum in early practice (n = 2). Of remaining 163 patients, mean age at surgery was 3.5 years. Average operative time was 4.5 h. Mean postoperative hospital stay, resumption of full diet, and duration of drainage were 6.5 days, 3.1 days, and 4.2 days respectively. Median follow-up period was 45 months. None of patients had biliary re-obstruction, intrahepatic stone formation, cholangitis, pancreatic fluid leak, pancreatitis, wound infection/dehiscence, or accidental injury of viscera which were directly adherent to the abdominal scar of primary surgery. Two (1.2%) patients with perforated CDCs who underwent staged surgeries developed bile leaks. The bile leaks were caused by unrecognized aberrant hepatic ducts and repaired laparoscopically. Liver function tests were normalized within 1 year.

Conclusions: In experienced hands, laparoscopic staged and redo surgeries is safe and effective in selected CDC children.


Clinical, Radiological and Pathological Presentation of Intramural Intraductal Papillary Mucinous Neoplasm of the Gallbladder

Indraneil Mukherjee, Aleksandr Demin, DO, Ian Provancha, Jocelyn Villanueva, Anupma Agarwal; Staten Island

Introduction: The clinicopathologic characteristics of epithelial neoplasms of the gallbladder is limited, due to its rarity and because of the variability in terminology. The World Health Organization classification of 2010 added Mucinous cystic neoplasms as a separate entity. The Category of lntracystic papillary neoplasm was created to encompass a vast spectrum of lesions, ranging from innocuous cyst lined by benign epithelium without atypia to extensive invasive carcinomas of mucinous type. We present a case of an incidentally found Intra mural Intraductal Papillary Mucinous Neoplasm of the Gallbladder.

Clinical Details: A 67-year-old lady with a BMI of 27 presented with postprandial Right Upper Quadrant Pain. Past Medical History of H.Pylori Gastritis which had been eradicated and 3.3 cm stable Liver Hemangioma. She also had a remote 20 Packyears of smoking.

Imaging: Sonogram for suspected Gallstones, did not show any gallstones. MRI showed a focal form of adenomyomatosis of the gallbladder fundus and small hemangioma and cysts. Hepatobiliary Scintigraphy with HIDA (99mTc-hepatic iminodiacetic acid) and CCK (cholecystokinin)-stimulated cholescintigraphy demonstrated a gallbladder ejection fraction of 8%.

Management: She underwent an uneventful Laparoscopic Cholecystectomy for Biliary Dyskinesia.

Pathology: Grossly gallbladder measured 9 x 3 x 2 cm, with smooth and glistening serosa. The gallbladder contained thin green bile with no stones. The wall measuring 0.1 cm in thickness and the mucosa was unremarkable. A thin-walled cyst measuring 2.3x1.8x1.2 cm was seen at the fundus. On cut sections, the cyst contained clear fluid and had a firm, white, 0.1 cm thick wall. It was deemed to be adenomyoma with low grade mucinous dysplastic process or “mural IPMN” pattern is at the fundus of the gallbladder away from the uninvolved cystic duct margin. It was deemed safe to assume that this was clinically inconsequential and the patient was not offered any further invasive treatment other than follow up.

Conclusion: Adenomyomatous (AM) is seen in < 7% of cholecystectomies. It does not have the association of being neoplastic itself, but rather appears to be a developmental/malformative process, possibly a version of a duplication/diverticulum. Thus, adenomyomatous nodule may be a more accurate name. Mucinous change with papillary units (“mural IPMN” pattern) occurs in 7%. High-grade dysplasia is seen in 3% and invasive carcinoma, often small, arises in 2%. Overall prognosis is good, but depends on degree of dysplasia or invasion.


Muscle Splitting Cholecystectomy: A Prospective Study

Ashish Prasad Rajbhandari, MS, Surgery; Nepal Medical College Teaching Hospital

Laparoscopic cholecystectomy is now regarded as the gold standard treatment for symptomatic cholelithiasis. Muscle splitting mini cholecystectomy is a good alternate option for those who are not fit for the laparoscopic procedure and in those institutes where the laparoscopic facilities are not available. It is the muscle division which is supposed to be responsible for postoperative pain and the resultant local and systemic effects.

All cases of symptomatic cholelithiasis were advised laparoscopic cholecystectomy and only those cases which opted for open cholecystectomy or were not fit for the laparoscopic procedure were included in the study.16 cases of consecutive open cholecystectomies underwent muscle splitting procedure from June 2016 to May 2018 at Stupa community hospital. 13 were female and age ranged from19 – 82 years. I case was of morbid obesity with a weight of 99.6 kg and BMI of 44. 2 cases were of preoperative diagnosis of empyema gallbladder and 1 case was of perforated gall bladder. The subcutaneous fat thickness ranged from 1.5 to 4 inches. All cases had a transverse incision in the RUQ around the tip of the 9th coastal cartilage; the length was usually around 5 cm (mini cholecystectomy)except for the complicated cases which extended to 7 cm. Drain was kept in the 3 complicated cases. The duration of surgery varied from 35- 85 min.

Post operative pain scale was taken in all cases, on 1st post operative day pain scale ranged from 4-6 and on 2nd post operative day 2-5. 13 cases (except the complicated cases) were discharged on the 2nd post operative day. All cases with drain had an uneventful period with no leakage of bile and were removed on the 3rd post operative day and discharged on the 5th post operative day after completion of a course of antibiotics.

Muscle splitting cholecystectomy is a good alternative to traditional rectus muscle dividing open cholecystectomy and maybe comparable to laparoscopic cholecystectomy as it offers less post operative hospital stay, post operative pain and discomfort with no increased incidence of intra or post operative complications and can be safe and effectively performed where and when needed.


Single-Incision Laparoscopic Cholecystectomy in Patients with Previous Upper Abdominal Surgery

Junpei Suzuki, Nobumi Tagaya, Horoshi Kusaba, Yuichi Obana, Yuhei Nakano, Masako Mizoguchi, Yukino Yoshimura, Takashi Arai, Yako Hasegawa, Junichi Suzuki, Tomoki Kido, Koji Matsushita, Nobuhisa Teranishi, Toshifumi Arai, Tetsuya Kurosaki, Masayuki Hatanaka; Itabashi Chuo General Hospital

Introduction: Single-incision laparoscopic cholecystectomy (SILC) has become a treatment of choice for symptom gallbladder diseases. However, its indication is still limited to uncomplicated cases. We investigated the feasibility and safety of SILC for the patients with previous upper abdominal surgery.

Patients and Methods: Recent five years we performed SILC in 307 patients with various gallbladder diseases. The patients were classified into 2 groups: Group1, patients with a prior history of upper abdominal surgery (n = 14); Group 2, patients without any risk factors including acute cholecystitis or morbid obesity (n = 247). The data were analyzed in age, conversion rate, operation time, blood loss, postoperative complication, and postoperative hospital stay.

Results: There were no significant differences between PUAS and UC in gender (M:F) (10 : 4 and 116 : 131, p = 0.075), BMI (kg/m2) (24.4 : 23.9, p = 0.717), blood loss (ml) (8.1 : 7.7, p = 0.954) and postoperative hospital stay (day) (3.5 : 3.2, p = 0.282). Mean age (years) (66.0 and 56.5: p = 0.004) and operation time (min) of PUAS and UC (115.0 and 84.8; p = 0.003) were significant factors. There was no conversion to open laparotomy in both groups. Additional ports were inserted one case (7.1%) in PUAS and 11 cases (4.5%) in UC (p = 0.642). Postoperative bile leakage was seen one case in UC, and it showed spontaneous remission.

Conclusion: Previous upper abdominal surgery is not a contraindication to perform a safe SILC, however, previous upper abdominal surgery is associated with a prolonged operation time.


Possible Variables to Develop a Scoring System to Predict Preoperative Diagnosis of Acute Cholecystitis

Theophilus Pham, MBA 1, Daron Jacob, BS1, Chanaka Kahathuduwa, PhD2, Adel Alhaj Saleh, MD, MRCS1, Amir H Aryaie, MD, FACS11Texas Tech University Health Sciences Center, 2Texas Tech University

Introduction: Cholecystitis and symptomatic cholelithiasis are two diseases that can present with very similar general symptoms making it difficult to distinguish between them based solely on clinical findings. Abdominal ultrasounds (US), and hepatobiliary iminodiacetic acid (HIDA) scans, are used to confirm diagnosis.

Objective: to determine predictive factors that can help the clinician more precisely diagnose acute cholecystitis for patients who were diagnosed with symptomatic cholelithiasis based on ultrasound.

Method: A retrospective review of all patients diagnoses with symptomatic cholelithiasis for last five years based on US. Data collection included demographics, admission, presence of nausea, presence of pain, presence of postprandial pain, positive Murphy’s sign, serum alkaline phosphatase (ALP), serum bilirubin, total White blood cell count, and the presence of a left shift in neutrophils.

Results: 287 patients with preoperative diagnosis of symptomatic cholelithiasis were included in the study, 226 (78.7%) of them had intra-operative findings of either acute or chronic cholecystitis. Pathology confirmed inflammation of the gall bladder in 282 (98.3%) of the patients. Presence of macroscopic features of cholecystitis during surgery was best predicted by the combination of sex, bilirubin level and the presence of left shift of neutrophils. The odds of a male patient having macroscopic features of cholecystitis was 1.12 times greater than the odds of a female patient having features of cholecystitis during surgery (p = 0.03). Similarly, the odds of a surgeon encountering features of acute or chronic cholecystitis was 1.17 time higher for patients with left shifted neutrophils (p = 0.003). Each 1 mg increase in serum bilirubin decreased the odds of having macroscopic features of cholecystitis by approximately 4% (OR = 0.96, p = 0.037). (Table #1)

Conclusion: Our data showed that only male sex, the presence of left-shifted neutrophils, and bilirubin were statistically significant to predict the intraoperative finding of cholecystitis. Additional studies could be used to expand the data pool in order to create a comprehensive preoperative scoring system to further differentiate between symptomatic cholelithasis and acute cholecystitis.


Impact of On-Table ERCP in the Acute Setting on Length of Stay at a Tertiary Care Center

Samantha R Witte, MD, Katelin Mirkin, MD, Jerome Lyn-Sue, MD; Penn State Health

Introduction: The management of acute complicated cholecystitis with choledocholithiasis diagnosed either during the initial workup or in the operating room by cholangiogram can be a complex and challenging problem to manage. We compared outcomes between patients who underwent preoperative ERCP followed by delayed cholecystectomy during the same hospital admission with patients who underwent a combined procedure with intraoperative ERCP. We hypothesize that on-table ERCP will decrease length of stay and associated hospital cost, without increasing the rate of procedural complication.

Methods and Procedures: We retrospectively reviewed the 2017-2018 database of an academic hospital for patients with acute complicated cholecystitis or choledocholithiasis who underwent laparoscopic cholecystectomy and ERCP. The study population was then divided into two cohorts: those who underwent preoperative ERCP followed by laparoscopic cholecystectomy, and those who underwent combined interventions. Primary outcomes evaluated were hospital length of stay, discharge destination, and days remaining in hospital after operation.

Results: A total of 29 patients were included in this study. One patient was excluded for oncologic pathology, and one patient was excluded for pregnancy. 16 underwent preoperative ERCP and 11 underwent combined interventions. There was no difference in patient age between the two groups (p-value 0.77). All patients presented with a diagnosis of acute cholecystitis with or without pancreatitis. Patients who were confirmed or suspected to have choledocholithiasis underwent ERCP either pre-operatively or as a combined procedure. The average length of stay was compared between the two groups. Patients who underwent two separate procedures had an average length of stay of 6 days while patients who underwent a combined procedure with a single anesthetic exposure had an average length of stay of 3.45 days, which was a statistically significant difference with a p-value of 0.05.

Conclusions: This data suggests that there is a benefit both for patient outcomes as well as from the standpoint of cost to performing combined procedures when feasible, even in an urgent setting.


Acute Intestinal Obstruction Due to Gallstone Ileus: Case Report

Gessica P Vasconcelos, MD1Diego L Lima, MD 2, Raquel N Cordeiro, Medical Student3, Italo C Moreira, MD1, Adalberto G Araujo, MD11Getulio Vargas Hospital, 2State Servers Hospital, 3Pernambuco Health College

Introduction: Gallstone ileus (GI) have an incidence of 0.3% to 0.5% of the patients with cholelithiasis. It is the cause of intestinal obstruction in 1 to 4% of the cases. Typically, GI starts with chronic cholelithiasis, which evolves with the formation of a cholecystoduodenal fistula, with the passing of a large calculus to the gastrointestinal tract, resulting in obstruction. Approximately 50% of patients with the disease have a history of gallstones, but only 0.3 to 1.5% of patients with gallstones present GI.

Case Report: A 64 years-old male, with history of no bowel movements, nausea, vomits and abdominal pain for 3 days. A nasogastric tube presented fecal fluid in high quantity (500 ml in 12 h). CT scan of the abdomen showed an image that suggested a gallstone ileus. Patient was submitted to an emergency surgical procedure with the following findings: distension of jejunal loops in its proximal third by a stone of 4.0 x 3.0 cm, stuck 160 cm of the ileocecal valve. Besides, an intense blockage involving duodenum, epiploon and gallbladder was noted (a cholecystoduodenal fistula). The surgical team opted to perform an enterolithotomy. The surgical team opted to not approach the blockage area which could cause an iatrogenic lesion of the biliary tract. Patient had no further complications, with good oral diet and he was discharged 6 days after the surgery.


Live QA, Live Image Sharing and Grading to Evaluate the CVS in Cholecystitis

Kathryn S Sobba, MD, Adolfo Fernandez, MD, Stephen Mcnatt, MD, Myron Powell, MD, Andrew Nunn, MD, Amy Hildreth, MD, Clancy Clark, MD, Barbara Yoza, PhD, Lauren Mccormack, MD, Amit Saha, PhD, Jessica Gross, MD, Preston Miller, MD, Carl Westcott, MD, Matthew Tufts, MD; Wake Forest Baptist Medical Center

Objective: The Critical View of safety is a technique widely believed to decrease the risk of bile duct injury. The general quality of CVS in cholecystectomy has been studied and those evaluations generally questioned the consistency and accuracy of the CVS in practice. The aim of this study is to use an already established SMS image sharing and grading system to evaluate if and how cholecystitis changes surgeons ability to attain a CVS.

Methods and Procedures: Live QA is an image sharing and grading system where a standard doublet CVS image set can be sent by sms picture/text via hand held smart phones to a group of experts. No PHI is put at risk. A grade for the two images is immediately provided and returned to the operating team. 38 urgent laparoscopic cholecystectomies done for cholecystitis and 117 done for gallstones by sixteen surgeons between 8/2017 and 9/2018 were included. CVS doublets were attained prior to clipping and sent out to the group. The images were graded remotely and returned. The ability to attain good grades and the consistency of scores amongst the graders were compared between the two groups.

Results: There were no bile duct injuries or leaks. There was 1 post operative hematoma in the inflamed group that required operative evacuation. The average time to first response was less than 2 min and the average number of responses was 3.6. Average CVS scores were lower for cholecystitis patients (anterior average 5.41 vs 5.45 in cholecystitis (p value 0.836), posterior average 5.16 vs 4.95 in cholecystitis (p value 0.375)), however a sufficient CVS grade (5 or better in at least one view) was attained in 36 of 38. The consistency of CVS scores for cholecystitis patients was 91% for anterior images and 86% for posterior images (p value 0.69).

Conclusions: Adequate CVS is almost always attainable in cholecystitis, however pericystic inflammation decreases CVS quality and grading agreement. The posterior view suffers and varies the most. Larger sample sizes would be needed to study the CVS and the effect of this image grading system on adverse events associated with cholecystectomy.


Safety and Feasibility of Day Care Laparoscopic Cholecystectomy in a Tertiary Care University Hospital – A Randomized Controlled Study

Anubhav Vindal, MS, DNB, MRCSEd, FRCSGlas, FACS, FAIS, Saurav Kumar, MBBS, Pawanindra Lal, MS, DNB, FRCSEd, FRCSGlas, FACS, FAIS; Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College, New Delhi, India

Background: Day care laparoscopic cholecystectomy (DCLC) is increasingly replacing inpatient cholecystectomy in the developed nations. Early mobilization and return to normal activities has many positive implications for the patient, the hospital, and society. However, the safety and efficacy of DCLC is yet to be tested in developing nations especially in centres without dedicated units and well-established protocols for day care surgery.

We present the results of our prospective randomized double blind study to evaluate feasibility and safety of DCLC in unselected patients in a tertiary care university hospital of a developing country without a separate facility for day care surgery.

Methods and Procedures: Hundred patients of symptomatic gall stone disease planned for elective LC were included in the study. The only selection criteria that were used to screen the patients were residence within 1 h of travel time to the hospital, ability to comprehend written, verbal and telephonic instructions and a responsible adult company at home.

The patients were randomized at the conclusion of the surgery into two groups of 50 patients each (DCLC and in-patient LC). The surgeon and the observer were blinded to the groups of the patients.

Post-operative pain (at 6, 12, 24 h and 1 week) (using VAS), time of return to activities and patient satisfaction (using Capuzzo score) were recorded and compared between the two groups. Discharge and readmission rates were also recorded in the DCLC group.

Results: The mean VAS at 6, 12, 24 h and 1 week was more or less similar in the two groups (p = 0.637, 0.612, 0.582 and 0.536 respectively). However the mean time to return to activities was significantly lower (p < 0.0001) and mean Capuzzo score (patient satisfaction) higher (p < 0.05) in DCLC group compared to in-patient LC group. The discharge rate for the DCLC group was 98% (49/50 patients discharged as planned). There were no readmissions in this group (0%).

Conclusions: DCLC is safe and feasible in unselected patients even in centres without dedicated day care units. Proper patient counselling and adherence to standard discharge protocols may help in reducing readmission rates and increasing patient satisfaction and acceptability of this pathway. Developing countries have a lot to gain from day care approach, in the form of decreased health care costs, higher turnover of hospital beds, and decreased loss of work days.


Outsized Approaches in the Diagnosis of Biliary Pancreatitis

I. Fedoriv, MD, V. Myesoyedova, MD; Dpt. of Surgery. Ivano-Frankivsk national medical university. Ukraine

The purpose of the study was to determine the differences in the dynamics of glycemia in the first few minutes after glucose loading, because in that time the diagnostically valuable indicators that would show a statistically proven correlation with the severity of pancreatitis were supposed to be detected.

The main criteria for the selection of patients for examination were: the presence of gallstone disease, an attack of cholecystitis during the hospitalization or in the recent medical history and the presence of the pancreatic lesion syndromes.

Methods of the Research: general-clinical to clarify the diagnosis and monitor the dynamics of the disease; biochemical - determination of the level of cholecystokinin, alpha-amylase and gamma-glutamyl transpeptidase of serum; instrumental methods, such as ultrasound examination of the liver bile ducts and pancreas were used.

Results of the research and their discussion. 120 patients were examined, which were divided into 4 groups.

The results of examinations of 30 volunteers without pathology of biliary tract and pancreas were used as a control.

The age of the patients ranged from 20 to 80 years. The average age of patients with gallstone disease, complicated by acute pancreatitis was 49,6 years. Among them, females were predominant - 94 (78,3%). The largest number of patients was in the age group of 40-49 and 50-59 years old (20,8% and 18,3% respectively). There were 26 men (21,7%), the highest number of men (8 men) was in the age group of 50-59, which was 6,7%.


1. An exacerbation of biliary pancreatitis in gallstone disease does not lead to complete insular insufficiency. β-cells respond adequately to the amount of glucose in the blood.

2. In acute biliary pancreatitis the violation of the dynamics of the insulin response to intravenous glucose stimulation has been confirmed. There was a certain delay in the reaction of islet cells, which was from 1 to 10 min.

3. The insulin response over 3 min shows an incretory pancreatic insufficiency in the early stages of pancreatitis.

4. Based on the findings of the study, we have proposed the use of an intravenous glucose tolerance test in the diagnosis of acute biliary pancreatitis, since its advantage is the ability to avoid the effect of the rate of absorption of glucose in the digestive tract on the result of investigation. Thus, this test reflects the adequacy of the reaction of the insulin apparatus of the pancreas to the administration of glucose.


Usefulness of the Laparoscopic Approach for Liver Resection of Multi-site Lesions

Masayasu Aikawa, Kenichiro Takase, Yukihiro Watanabe, Katsuya Okada, Kojun Okamoto, Shinichi Sakuramoto, Shigeki Yamaguchi, Isamu Koyama; Saitama medical university, international medical center

Introduction: The laparoscopic liver resection (LLR) has become widespread because it is less invasive. However, the evidence of its less invasiveness has not been reported in multiple resections for hepatomas. We investigated the less invasiveness and safety of LLR in multiple resections in comparison with those of the laparoscopic and open approaches.

Methods: Between 2008 and 2018, of 340 patients who underwent LLR for whole hepatoma in our facility, 36 underwent LLR for dual-site hepatoma. Before definitive induction of the LLR, 30 patients underwent open liver resection (OLR) for dual-site hepatoma. The patients’ background, characteristics, and perioperative outcomes were compared between LLR and OLR for dual-site hepatoma.

Results: No significant differences in the patients’ background were found between the two groups except for the type of hepatoma. The operative durations were prolonged in the LLR group as compared with those in the OLR group. The blood loss volumes, pain score, and hospital stay in the LLR group were lower than those in the OLR group. A postoperative complication higher than grade III according to the Clavien-Dindo classification did not occur in any of the patients in the LLR group but occurred in 3 patients in the OLR group.

Conclusion: OLR requires an extended wound for resection of multi-site lesions in hepatoma. In contrast, LLR makes it possible to resect multi-site lesions by the addition of a few laparoscopic ports. LLR may be useful, particularly for resection of multi-site lesions.


Biliary Hyperkinesa: Is It a True Indication for Cholecystectomy?

Ratnakishore Pallapothu, MD, FACS, FASMBS 1, Matthew Protas, MSIII2, Todd Prier, MD, FACS3, Jerome Brustein, MD3, Nirupama Anne, MD, FACS11Our Lady of Lourdes Memorial Hospital, Binghamton, NY. SUNY Upstate Medical University, Binghamton Clinical Campus, Clinical Assistant Professor of Surgery., 2SUNY Upstate Medical University Syracuse NY, 3Our Lady of Lourdes Memorial Hospital, Binghamton, NY

Background: Biliary hyperkinesia is poorly understood and the diagnosis is questioned. The literature regarding surgical intervention for biliary hyperkinesia is limited. We present a case series of 41 patients who underwent laparoscopic cholecystectomy for biliary hyperkinesia and had symptomatic relief.

Methods: Patients presenting with symptoms of biliary colic, with a negative ultrasound for gallstones, underwent HIDA scan with CCK. Patients with ejection fraction (EF) greater than 80% were considered to have biliary hyperkinesia based on radiology literature. An IRB approval was obtained for a prospective study for the team comprising of surgeons and a radiologist. The study time was between March 2011- May 2018. 41 patients with ongoing refractory symptoms consistent with biliary colic, affecting quality of life, with negative upper GI work up (endoscopy), were considered for laparoscopic cholecystectomy. All the 41 patients were followed subsequently with postoperative follow up visits.

Results: 41 patients underwent laparoscopic cholecystectomy. 33 patients were women and 8 patients were men. 14 patients had EF between 80-90% and 27 patients had EF between 90-100%. The chief complaint in all these patients was abdominal pain in epigastrium or right upper quadrant. The mean duration of symptoms is at least 6 months. The final histopathology showed cholecystitis in 32 patients; chronic cholecystitis (n = 31) and one patient had acute cholecystitis (n = 1). Cholesterolosis in 11 patients and 8 patients had no pathologic findings. 40 patients had symptomatic relief and improved quality of life after surgical intervention. One patient had no change in her symptomatology. None of these patients had any postoperative complications.

Conclusion: There is enough evidence regarding the surgical intervention for symptomatic biliary hypo/dyskinesia (EF < 35%). The literature regarding the diagnosis of biliary hyperkinesia which is defined as EF > 80% is limited and most commonly misinterpreted as normal gall bladder function. Hence the diagnosis is missed and patients continue to have ongoing symptoms typical for biliary colic affecting the quality of life with multiple office and emergency room visits. Even though our number is limited, as demonstrated in our case series the entity of biliary hyperkinesia is true, as cholecystitis is noted in most pathology specimens (approximately 80%) and symptomatic response was noted in 98% of the patients with no postoperative complications. Hence cholecystectomy should be considered as an option for symptomatic patients with EF > 80% when conservative measures such as life style and diet changes have failed and the symptoms become refractory.


The Use of Indocyanine Green (ICG) for Image-Guided Laparoscopic Cholecystectomy. Comparison of Two Methods of ICG Administration

Nikolaos Antoniou, Orestis Ioannidis, Ioannis Mantzoros, Stathis Kotidis, Loukiani Kitsikosta, Dimitris Konstantaras, Konstantinos Tsalis; Aristotle University

Laparoscopic cholecystectomy is one of the most commonly performed operations worldwide. Bile duct injury (BDI) is a rare but very serious complication of of the procedure, with a significant impact on quality of life and overall survival. The high frequency of BDI with laparoscopic cholecystectomy was first considered to be a consequence of the initial learning curve of the surgeon, but it later became clear that the primary cause of BDI is misinterpretation of biliary anatomy. Intraoperative cholangiography (IOC) has been advised by many authors as the technique reduces the risk of BDI. However, the procedure has inherent limitations and is therefore reserved for select cases.Fluorescent cholangiography using indocyanine green(ICG) is a novel approach, which offers real-time intraoperative imaging of the biliary anatomy. A comparative study was contacted by administering ICG intravenously or intrabiliary during the operation.

Forty patients scheduled to undergo an elective lap. cholecystectomy were randomly divided in two groups:
  • In Group A ICG was administered in a dose 2.5 mg in 2 mL solution intravenously 1 h before surgery.

  • In Group B ICG was injected intrabiliary in a 0.025 mg/mL solution mixed with the patient’s bile.

  • Group A. Intravenous ICG was administered in 20 patients. There was no any reaction and the extrahepatic biliary anatomy was identified well. There was no BDI or any complication related to the procedure.

  • Group B. ICG was injected intrabiliary in 20 patients during the laparoscopic procedure. In all but one patient the extrahepatic biliary tree was delineated very well. In one patient part of ICG solution was injected into the gallbladder wall and this resulted in a partially confusing image. There was no BDI and no postoperative complication

Conclusions: Fluorescence cholangiography can be used during laparoscopic cholecystectomy to obtain fluorescence images of the bile ducts following intrabiliary injection during the operation or intravenous injection 1 h before the procedure. The later technique is more easy to perform and does not require catheterization of the biliary tree.


Simplified Laparoscopic Bile Duct Reconstruction Using a Double-Omega: An 18 Patient Case Series Introducing a Novel Surgical Approach

Daniel Gomez, MD, FACS1, Luis F Cabrera, MD2, Ricardo Villarreal2, Andres Urrutia3, Eric Vinck2Mauricio Pedraza 2, Sebastian Sanchez2, Jean Pulido21Military University, 2Bosque University, 3Universidad Pedagógica y Tecnológica de Tunja

Introduction: The management of Laparoscopic from the benign bile duct pathologies has become a mainstay approach because of the advantages offered to patients. Even though patients recover from the use of laparoscopic approach swiftness, bile duct trauma secondary to laparoscopic manipulation still remains a significant complication with an incidence of 0.6% in laparoscopic gallbladder surgeries.

Methods: We describe a case series use of 18 patients taken to a novel modified and simplified laparoscopic technique for a hepatic duct jejunostomy with a Roux in Y reconstruction reducing the surgical complexity and the duration of surgery of bile duct reconstruction secondary to benign bile duct pathologies.

Results: The surgery was allocated an average of 139 min, an average of 15 cc for intraoperative bleeding, no re-intervention was required, there were no mortalities, and the average period of hospitalization was 5 days. No patients required ICU admission, no patients had postoperative bile leaks, none were converted to open surgery and all patients had oral feeding and adequate tolerance at POP 2. Long-term term follow-up showed no bile stenosis at 12 months following surgery.

Conclusion: This simplified laparoscopic approach to bile duct reconstruction long with Roux in Y anastomosis seems to be an effective, seemingly safe alternative to bile duct surgery offering patients a quicker surgery time with fewer complications.

Key words: Laparoscopic; approach; bile duct; reconstruction; duct surgery.


A Case Report of Double Gallbladder and Choledochal Cyst in a Single Patient

Abdulaziz A Arishi, MD, Amin M Ahmad, MD, Wesley C Judy, David Heidt, MD; University of Toledo Medical Center

Introduction: Double gallbladder is an uncommon condition. The incidence of Double gallbladder alone is about 1 in 3000-4000 cases where the incidence of choledochal cyst is ranging from 1 in 13 000 persons to 1 in 200 000 persons. There is no known reported case of both anomalies in a single patient.

Presentation of case: This is a 26-year-old male who presents with intermittent right upper quadrant abdominal pain for one month associated with nausea and no vomiting. Ultrasound of abdomen revealed duplications of gallbladder. MRCP shows duplication of gallbladder, and Type I choledochal cyst. No family history of cancer. He underwent an exploratory laparotomy, cholecystectomy, common bile duct resection, and hepaticojejunostomy.

Discussion: Double gallbladder and choledochal cyst are well described rare clinical entities. Classification system of abnormal anatomic variation of gallbladder was developed by Harlaftis and Boyden. Proposed theories of embryologic development suggest that it develops either as a bifurcation of the cystic primordia or duplication of it. Gallbladder duplication can be classified as a type-I anomaly a split primordial gallbladder, where gallbladder can be partially, incomplete or completely split. Type-II anomaly, which is the most common, where two separate gallbladders, each with their own cystic duct, or a rare type-III anomaly, where triple gallbladders draining by 1–3 separate cystic ducts. In other hand choledochal cyst was classified by Todani into five types based on location and the degree of biliary tract dilation. Choledochal cyst are associated with high risk of cholangitis, pancreatitis, and cancer development. Surgery is indicated to prevent those complications.

Conclusion: The important point of this case is the unusual presentation of two relatively rare congenital conditions. A literature search showed an absence of similar cases ever being reported. Knowledge of anatomy and high level of alertness for congenital abnormalities is key for safe surgical operation. Failure to recognize those anomalies are associated with increased operative difficulty and complications.


Laparoscopic Common Bile Duct Decompression with Primary Closure for CBD stones following failed ERCP: A Case Series

Daniel Gomez, MD, FACS1, Luis F Cabrera, General Surgeon2Andres Mendoza 2, Ricardo Villarreal2, Mauricio Pedraza2, Jean Pulido2, Eric Vinck2, Sebastian Sanchez21CPO, 2Bosque University

Background: Despite studies showing the effectiveness of common bile duct surgery (CBD) using laparoscopy in the international literature, In Colombia there are no series detailing the benefits and advantages of this approach as an alternative to open surgery in CBD stone obstruction. Here we present a case series on our experience with this technique on complex common bile duct stone obstruction using decompressive laparoscopy following failed ERCP.

Methods: During a time frame of 4 years from June 2014 to April 2018, 182 patients were taken to laparoscopic CBD decompression surgery due to complex stone obstruction. Records were reviewed and analyzed for demographic data, mean operative time, blood loss, intra or postoperative complications and hospital stay.

Results: All procedures were carried out successfully with no conversions registered, 100% of these procedures were CBD explorations with choledocotomy and primary duct closure, and in those patients with gallbladders, cholecystectomy was also performed (78%); all procedures using a laparoscopic approach. Surgery duration averaged 85 min, intraoperative bleeding averaged 15 cc, no patients required additional surgery, there were no mortalities, none required ICU admission and average hospital stay was 5 days.

Conclusions: A laparoscopic approach to complex CBD stone obstruction with primary closure after failed ERCP is safe and effective, and in experienced hands offers advantages over open surgery and endoscopic techniques.

Key words: Laparoscopic; approach; bile duct; reconstruction; duct surgery


Minilaparoscopic Cholecystectomy: The Lessons Learned After 18 Years of Experience and More Than 2,530 Cases

Diego L Lima 1, Raquel N Cordeiro2, Gustavo Henrique B De Goes3, Gustavo L Carvalho, MD, phD31State Servers Hospital, 2Faculdade Pernambucana de Saude, 3University of Pernambuco

Objective: To show the results after 18 years of experience of a single surgical team in the Brazil performing minilaparoscopic cholecystectomy by clipless technique.

Method: A total of 2,536 consecutive patients who underwent MLC were analyzed, from January 2000 to January 2018. Of total, 1973 (77,8%) were women whose age ranged from 6 to 99 years old. Surgical technique: after performing the pneumoperitoneum at the umbilical site, four trocars were inserted; three of 3.5 mm, and one of 11 mm in diameter, through which a laparoscope was inserted. Neither the 3-mm laparoscope, nor clips, nor manufactured endobags were used. The cystic artery was safely sealed by electrocautery near the gallbladder neck, and the cystic duct was sealed with surgical knots. Removal of the gallbladder was carried out, in an adapted bag, through the 11-mm umbilical site.

Results: The operation video mean time was 24 min. There was conversion to LC in 32 cases, which represents 1.261% of total. There was no conversion to open surgery, no bleeding, no bile ducts injury, no bowel lesion, no reoperation or mortality, no important complications in intra and postoperative time. There were just 11 cases (0.433%) of umbilical hernia, which occurred in the first 1,000 surgeries, and 23 cases (0.906%) of minor umbilical infection that was treated with antibiotics. There was great satisfaction of patients regarding postoperative pain and reduced hospital stay.

Conclusion: The clipless MLC shows to be a safe and effective technique, with a lower learning curve when compared to other techniques.


Rare Case of Extra-hepatic Biliary Duplication

Nima Fatehi, Praneetha Narahari, MD, Sean Tower, MD; Saint Agnes Medical Center

Introduction: Aberrant right hepatic duct entering cystic duct is fairly common (18%). Main hepatic duct flowing into cystic duct is extremely rare. We report an exceptionally rare case of duplicated right hepatic duct, arising from anterior segments 5 and 8 and draining into the cystic duct.

Case Summary: A 66-year-old male with diabetes, hypertension and CAD, presented with acute cholecystitis. He was obese with RUQ tenderness. LFT’s were normal, with WBC of 12 k hyperglycemia of 330, lactic acid of 2.5. US and CT were suggestive of cholelithiasis, CBD of 7 mm, normal pancreas. Proceeded with Lap Chole/IOC. Dissection initiated at thegallbladder/cystic duct junction. The cystic duct appeared thick and could not be dissected easily. Hence the infundibulum was dissected exposing the base of the gallbladder (cholecysto hepatic plate) and cystic duct partially transected close to the gallbladder and cholangiogram obtained. Abnormal anatomy detected, with duplicated right biliary system. The cystic duct was very short proximal to the insertion of the dilated, anomalous right hepatic duct. There was no filling defect, with good flow into duodenum. No arterial anomaly noted. MRCP was performed post lap chole to delineate the segmental anatomy and to identify reason for anomalous ductal dilatation. MRCP did not show any filling defects, and confirmed the presence of 2 right hepatic ducts. The anterior segments 5 and 8 joined to form the anomalous right hepatic and drained into the cystic duct. The segment 8 duct was dilated, possibly from the spiraling cystic duct, with inadequate emptying. The right hepatic from the posterior segments reached the confluence in a normal fashion and continued to the common hepatic duct.

Conclusion: The anomalous right biliary duct duplication, with the anterior right hepatic duct draining to cystic duct is extremely rare, and underscores the importance of identifying the biliary anatomy to prevent a bile duct injury. Bile duct injury imposes severe consequences to the patient, the surgeon, is burdensome to the medical system, and leads to loss of productivity to the society. Although the incidence of congenital anomalies is low, it is prudent to define the anatomy and prevent complications. We propose routine use of cholangiogram and substantiate the benefits of such a practice, in not only identifying anomalies, and detecting CBD stones, but also limiting the extent of ductal injury by early recognition.


Pancreatic Necrosectomy: Predicting the Morbidity and Mortality of Pancreatic Debridment

Noah J Swann, MD, Nobel Letendre, BS, Brian Cox, MD, James Recabaren, MD, FACS; Huntington Hospital

Introduction: Debridement of pancreatic necrosis is traditionally considered a morbid procedure. Previous multi-center studies using 2007 data have demonstrated 6.8% 30-day mortality for pancreatic necrosectomy; Laparoscopic and percutaneous management of pancreatic and peri-pancreatic necrosis have become increasingly prevalent, but haven’t fully supplanted the traditional open pancreatic Necrosectomy.

Objective: To evaluate the outcomes of pancreatic necrosectomy. Patient demographics, Ranson criteria, patient morbidity and mortality (both observed and expected) were analyzed. A multivariate stepwise regression was performed to analyze the clinical and laboratory parameters predictive of mortality. Patient demographics and comorbidities were analyzed. Post-operative complications were also evaluated.

Participants: The NSQIP national database was searched for all patients who had pancreatic or peri-pancreatic debridement using the Current Procedural Technology (CPT) code 48015 from January 1st, 2007 to December 31st 2015. After exclusion,1590 patients were identified during a 9 year interval.

Results: The patient population was predominantly male (71.2%) and Caucasian (69.8%). The mean age was 53.2 years; mean BMI was 29.7. Smokers comprised 24.1% of the cohort, with 33.9% of the cohort manifesting diabetes. The in hospital mortality (30 day) was 6.8%. Patient BMI (OR 1.02-1.07), Age (1.01-1.03), BUN (1.02–1.03), INR (1.48–4.46), albumin (0.36–0.54) and total bilirubin (1.16-1.31) were independent predictors of mortality. All of these factors reached statistical significance with p-values < 0.05 and significant odds ratios.

Conclusions: Our data demonstrates that pancreatic and peri-pancreatic debridement continues to be a morbid procedure, with 30 day in-hospital mortality (6.8%) and overall morbidity similar to previous multi-center studies. We reaffirmed that BUN and Age were independent risk factors for mortality. BMI, INR, total bilirubin and albumin have also been demonstrated to be independent markers for mortality.


Comparison Between Transpapillary Vs. Transduodenal Biliary Decompression for Biliary Obstruction: A meta-analysis

Aaron Pinnola, DO, Yuan Du, Paula Veldhuis, Sebastian De La Fuente; Institute for Surgical Advancement, Florida Hospital Orlando

Introduction: The effectiveness of transpapillary endoscopic retrograde cholangiopancreatography (ERCP) with stenting for palliative relief of biliary obstruction is well established. Recently, technical advances have led to the development of transduodenal endoscopic ultrasound guided biliary drainage (EUS-BD) for use in cases where the native papilla cannot be accessed. Traditionally, this technique has been mainly restricted to settings of a previously failed ERCP, but primary EUS-BD has now garnered interest to avoid ERCP procedure-related complications. In this study, we performed a meta-analysis comparing efficacy and complications of both approaches.

Methods: Articles written in English were searched in Pubmed. Studies with less than 10 patients, studies with no complications reported, when no comparison between techniques was done or studies with pediatric patients were excluded. Primary outcomes were defined as technical success and procedural complications. Secondary outcomes were clinical success and subsequent stent malfunction. Patient demographics and etiology of obstruction were collected. The pooled proportions were computed using either fixed-effects or random-effects models depending on homogeneity or heterogeneity. The Cochran Q test and I2 were used to evaluate for heterogeneity. The 95% CIs were calculated for all points estimates. P-value < 0.05 was considered as statistically significant. Statistical analysis was performed using the R software. For binary outcome data, the relative risks (RR) were estimated.

Results: Initial database search yielded 245 studies from which 50 were selected for review, and 7 were chosen based on inclusion criteria for final analysis. There was no statistically different technical success rate found when comparing primary EUS-BD to ERCP RR: 1.04 (95% CI (0.96-1.13)), p = 0.33. Likewise, primary EUS-BD compared to ERCP had no statistically different procedural complication rate 1.39 (95% CI (0.47-4.06)), p = 0.55. Based on the Egger regression test and symmetric distribution, there was no obvious publication bias detected.

Conclusions: Primary EUS-BD for biliary obstruction was not associated with either an increased risk of procedural complications or technical success. This technique, however should be limited to palliative procedures to avoid biliary leakage and dissemination of malignant cells in patients with resectable disease. Further studies will be needed to assess the procedure’s effect on long term patient outcomes and strict indications for use over primary ERCP.


Scoring System for Preoperative Diagnosis of Gangrenous Cholecystitis

Rebecca C Gologorsky, MD 1, Justin R Tse, MD2, Aya Kamaya, MD21University of California San Francisco-East Bay, 2Stanford University

Gangrenous cholecystitis is a severe complication of acute cholecystitis and is associated with high morbidity and mortality. There are few characteristic clinical indicators of gangrenous cholecystitis, making preoperative diagnosis difficult. Previously published algorithms involve extensive mathematics and therefore have limited application. We identify sonographic and clinical features of gangrenous cholecystitis and propose a scoring system to facilitate preoperative diagnosis.

We retrospectively reviewed all adult patients from 1/2014-5/2018 who underwent abdominal ultrasound within 48 of cholecystectomy for acute cholecystitis. A diagnosis of gangrenous cholecystitis (GC) versus uncomplicated acute cholecystitis (UAC) was confirmed by review of pathology reports. Pertinent clinical features, demographics, and laboratory values were recorded. Ultrasonographic imaging features were reviewed by a blinded abdominal radiologist. Two-tailed t-tests and Fisher’s exact tests were used to determine statistical significance for continuous and categorical variables, respectively. A multivariate analysis was performed using all statistically variables to create a model to predict a diagnosis of gangrenous cholecystitis.

One-hundred one patients met inclusion criteria. Forty-eight (48%) had GC and 53 (52%) had UAC. Points were assigned to each associated clinical or ultrasonographic feature as detailed in table 1. A total score of 0-2 points correlated with low probability (< 25%), 3-4 points with intermediate probability (25-75%), and 5 or more points high probability (> 75%) of GC. Of our patient cohort 45% (45/101) fell into the low probability, 29% (29/101) fell into the intermediate probability, and 27% (27/101) fell into the high probability category. There were no UAC patients who were categorized as high risk.

We propose a simple scoring system based on clinical and imaging features to facilitate preoperative diagnosis of GC. Prompt identification of GC may improve treatment planning and clinical outcomes. Evaluation of the impact of diagnosis timing versus surgical intervention and outcomes should be studied, as well as clinical factors that lead to late-stage diagnosis of cholecystitis.


NSQIP Database Analysis does not Support Preoperative Antibiotic use for Outpatient Laparoscopic Cholecystectomy

Sora Ely, MD 1, Rebecca C Gologorsky, MD1, Michelle R Huyser, MD1, Genna Beattie, MD1, C K Chang, MD21UCSF East Bay Surgery, 2Kaiser Permanente Oakland Medical Center

Introduction: Debate continues regarding utility and safety of routine antibiotic prophylaxis for elective laparoscopic cholecystectomy. Several small, randomized controlled trials have failed to demonstrate benefit, while a handful of larger meta-analyses have reported statistically significant reductions in surgical site infections. However, most of these studies come from clinical settings outside the United States. We used a national database to examine factors associated with postoperative infection in outpatient laparoscopic cholecystectomy.

Methods: We retrospectively reviewed outpatient laparoscopic cholecystectomy cases from the 2015-2016 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Chi square test and ANOVA were used to identify pre- and intra-operative NSQIP variables associated with postoperative surgical infection, defined as any surgical site, deep wound, or organ space infection.

Results: Postoperative surgical infection occurred in 347 of 41,665 cases (0.8%). Notably, incidence of Clostridium difficile infection in this population was also low (0.2%), but not insignificant by comparison. Furthermore, the majority (91.9%) of C.difficile infections occurred in the absence of a surgical infection.

Factors associated with higher infection rates included: age > 89 years, hypertension, congestive heart failure, acute renal failure, dialysis, and chronic steroid use (p < 0.05). Strongest predictors of postoperative infection included higher wound classification (p < 0.001) and longer operative time (> 80 min, p < 0.001). Infection rates were low in wound classes 1-3, with a marked increase only in class 4 (0.7%, 0.7%, 1.2%, 3.2% respectively).

Using these two clinical variables, we developed a simple scoring system to predict infection risk. Figure 1 shows postoperative infection rates stratified by this score: operating room minutes ≤ 80 (0) or > 80 (1) plus wound class 1-3 (0) or 4 (1).

Conclusions: Risk of postoperative surgical infection after outpatient laparoscopic cholecystectomy is low, and the incidence of C. difficile infection is non-trivial. Although antibiotics may be associated with lower rates of postoperative infection, their marginal clinical benefit in the setting of low absolute risk is tempered by the risk of C. difficile infection, antibiotic resistance, and other adverse effects of antibiotic use.

We recommend against routine antibiotic prophylaxis in low-risk patients undergoing elective, outpatient laparoscopic cholecystectomy. Antibiotics should be considered in cases for which the wound class is 4 and/or the operative time exceeds 80 min. Surgeons may wish to utilize this scoring system intra-operatively to inform their decision to administer antibiotics during the case once operative time can be reasonably estimated. A randomized controlled trial is needed to validate this recommendation.


The Benefits of Our Glove Method for Single Port Laparoscopic Cholecystectomy

Noriaki Kameyama, MD, PhD, Yuki Mae, MD, Masashi Yahagi, MD, Kenta Inomata, MD, Tomoko Takesue, MD, Yoshinobu Akiyama, MD, PhD; KKR Tachikawa Hospital

Background: We introduced single port laparoscopic surgery at our hospitals in May 2009 and our experiences of single port laparoscopic surgery now number more than 1000 as of March 2018. Single port laparoscopic surgery has been gaining attention because of its effectiveness in reducing postoperative wound pain and superior cosmetic results with minimal scarring. In our hospitals, 80% of single port laparoscopic surgery cases were benign diseases such as cholecystectomy, appendectomy, and inguinal hernioplasty (TAPP and TEP). The most common procedure was cholecystectomy (43%).

We performed single port laparoscopic cholecystectomy via an 1.0 cm transumbilical incision (the minimum size for inserting the wound retractor) with the glove method. We examined the cost benefits of this method compared to other platforms for single port laparoscopic surgery and conventional laparoscopic cholecystectomy.

Methods: An 1.0 cm incision was made at the bottom of the umbilicus. After small laparotomy, the Alexis wound retractor (size XXS) was inserted. After inserting the wound retractor, the surgical glove is attached and two low-profile laparoscopic 5 mm ports are inserted through the holes of the surgical glove with cut fingertips. The original pre-bending forceps inserted directly through the hole of the cut fingertip. We usually use 5 mm flexible laparoscopes by Olympus. The data from 484 cases of cholecystectomy performed by this technique were analyzed.

Results: A supplemental miniport or 5 mm port including conversion to conventional laparoscopic cholecystectomy, was required for 6.4%, and the conversion to open surgery in only two cases (0.4%). The rate of complications is only 2.9% with only one case of incisional hernia. Our follow-up outcome is continued until one year after surgery.

Average hospital stay was 3.5 days, and operation time was 70 min overall. (63 min for expert surgeon) The average BMI in our patients was 24.6 kg/m2.

The cost of our glove method was $140.40 compared to $224.50 for “EZ-access”, the most popular platform for single port laparoscopic cholecystectomy in Japan and $163.60 for conventional laparoscopic cholecystectomy.

Conclusions: Single port laparoscopic cholecystectomy can be successfully performed via a minimal 1.0 cm transumbilical incision with our glove method. Our method for single port cholecystectomy is not only minimally invasive but also relatively safe and has cost benefits.


Outcome of Laparoscopic Common Bile Duct Exploration After Failed Ercp. A Comparative Study

Davide Di Mauro 1, Edoardo Ricciardi1, Leandro Siragusa2, Antonio Manzelli11Royal Devon and Exeter NHS Foundation Trust, Exeter, UK, 2Tor Vergata University Hospital, Rome, Italy

Introduction: Common bile duct stones (CBDS) are treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) or with the single-stage laparoscopic common bile duct exploration (LCBDE) and LC. Multiple ERCP attempts and failure increase the risk of post-procedural complications. In such circumstances surgery is advocated.

The aim of the study is to compare the outcome of LCBDE and LC in patients who had never had an ERCP, to that of patients who underwent previously failed ERCP.

Methods and Procedures: A retrospective analysis of 54 patients undergoing LCBDE and LC between 2010 and 2017, was performed. Patients were divided in 2 groups: primary surgery (group 1), surgery after failed ERCP (group 2). Demographics and preoperative investigations results were collected. Comparative outcomes were CBD clearance rate, operative time, conversion to open rate, postoperative morbidity, mortality, hospital stay. Student’s t-test was used for non-parametric data; two-tailed Chi square or Fisher’s tests were used to compare differences in frequencies. Results were considered as statistically significant when p < 0.05.

Results: Results are shown in table 1 below:

No postoperative mortality was recorded.

Conclusions: LCBDE and LC is safe and effective in patients who had previous failed ERCP. If ERCP failure is anticipated and/or the risk of post-ERCP complications is high, surgery should be considered as the first line treatment of CBDS. Longer intraoperative time and hospital stay are expected.


Intracorporeal Versus Extracorporeal Anastomosis in Minimally Invasive Right Hemicolectomy: A Single Institution Case Series Comparison

Peyman Lavi, MD, Vikram Attaluri, MD, Elisabeth C Mclemore, MD; Los Angeles Medical Center, Southern California Permanente Medical Group

Intracorporieal Anastomosis (ICA) vs. Extracorporeal Anastomosis (ECA)




Number of Patients



Number of Laparoscopic Cases

(# Robotic Cases)

17 (3)

20 (1)

Median Age (Range)

65 Years old (38-87)

73 years old (54-87)

Female Sex

10 Female

10 Female

Median BMI (Range)

26 (19-43)

24 (18-36)

Colon Cancer Diagnosis



Median OR Time in Minutes (Range)

168 min (83-227)

130 Minutes (76-320)

Median Length of Stay in Days (Range)

2 days (1-17)

3 days (1-14)



Wound: Surgical Site Infection



Wound: Seroma



Thromboembolic Event

1 Mesenteric Vein Thrombosis

1 Pulmonary Embolism

Urinary Tract Infection (UTI)









Anastomotic Bleeding



Background: Minimally invasive right hemicolectomy with intra-corporeal anastomosis (ICA) has been associated with reduced ileus and shorter length of stay when compared to extra-corporeal anastomosis (ECA). The ICA technique was adopted by colorectal surgery in June of 2015. The short-term outcomes before and after ICA adoption are reviewed.

Methods: An IRB approved retrospective case series review was performed. All laparoscopic and robotic right hemicolectomy cases performed by colorectal surgery at a single teaching institution before and after adoption of ICA into clinical practice were included.

Results: 41 patients underwent right hemicolectomy for colon cancer in the majority of patients from 10/2014 – 6/2018. ECA was performed in 21 cases. The median operative time was longer in the ICA group (168 vs. 130 min). The median length of stay (LOS) was shorter in the ICA group (2 days vs. 3 days). The complication rate was similar with the exception of anastomotic bleeding requiring blood transfusion in the ECA group only.

Conclusions: Right hemicolectomy with ICA has similar outcomes compared to ECA. ICA is associated with a shorter LOS and lower anastomotic bleeding related complications when compared to ECA in the early adoptive phase.


Is Laparoscopic Colectomy Suitable for Right Colon Cancer More Than 6 Centimeter? A Case-Matched Study with Short-Term and Long-Term Outcomes

Weisheng Chen, Jiang Wei, Kai Li, Jun Yan, Xiaoyu Dong, Aorong Ouyang, Dexin Chen, Shaopeng Zhou, Huixin Xu, Pu Luo; Department of General Surgery, Nanfang Hospital, Southern Medical University

Background: In China, the indication of laparoscopic right colectomy is tumor less than 6 cm. The purpose of this study is to investigate whether laparoscopic right colectomy is suitable for right colon cancer more than 6 cm.

Methods: A case-matched study was conducted to compare short-term and long-term outcomes between laparoscopic right colectomy and open right colectomy using propensity scores from patients with right colon cancer more than 6 cm between January 2006 and December 2015.

Results: In our institution, 224 eligible patients with right colon cancer more than 6 cm underwent laparoscopic or open right colectomy by same surgical team. 150 patients were selected by 1:1 propensity score matching, with 75 patients in the laparoscopic group and 75 in the open group. Mean operating time, hospital costs, postoperative complication rate were similar between two groups. Length of incision, estimated blood loss, time to first flatus, time to first liquid intake, hospital stay of laparoscopic group were significantly shorter than those of open group. Harvest lymph node of laparoscopic group was significantly more than that of open group. Conversion was performed in 6.67% (5 out of 75) cases. The significant differences of overall survival and disease-free survival between two groups were not observed (p = 0.843 & p = 0.765, respectively).

Conclusions: Laparoscopic right colectomy is suitable for patients with right colon cancer more than 6 cm in centers with expertise in minimally invasive surgery.


Comparison of Preoperative Versus Postoperative Transversus Abdominis Plane Block in Patients Undergoing Robotic-Assisted Colorectal Surgery

Julia Xia, BA1, Terrah J Paul Olson, MD1, Yuan Liu, SPH1, Shawn Tritt, MD2Seth A Rosen, MD 11Emory University School of Medicine, 2Emory Johns Creek Hospital

Introduction: Using transversus abdominis plane block (TAP) decreases pain scores and narcotic use post-operatively after colorectal surgery (CRS). It is unclear if TAP effectiveness varies if performed before versus after surgery.

Methods: All eligible patients undergoing CRS are offered TAP. In 2017, we transitioned from pre-operative to post-operative TAP to improve efficiency. Using a prospectively maintained database of robotic-assisted surgery, we compared 115 patients who underwent pre-operative TAP with 53 patients who underwent post-operative TAP. Primary endpoints were pain scores and morphine equivalent (ME) use post-operatively. Secondary endpoints included perioperative factors contributing to pain scores and post-operative ME use. Summary statistics and univariate analysis by non-parametric tests were utilized.

Results: From April 2015 through May 2018, 168 patients received TAP before or after CRS. The cohort included 79 (47.0%) women, average age 59.11 (± 12.32) years, and mean body mass index (BMI) 28.32 (± 5.82) kg/m2. Surgery indication was cancer in 66 (39.3%), polyp in 43 (25.6%), and diverticulitis in 43 (25.6%) patients. Right colectomy was performed in 61 (36.3%), low anterior resection (LAR) in 46 (27.4%) and sigmoid colectomy in 40 (23.8%) patients. Demographics of the two groups were equivalent. Comparison of post-operative pain scores and ME use revealed no significant differences (See Table and Graph). Average pain scores and ME use were lower in patients who were older, underwent right colectomy, or had intracorporeal anastomosis.

Conclusions: In our cohort, no differences were seen in pain scores or ME use for patients receiving TAP pre-operatively versus post-operatively.


A North American Single-Blinded Pilot Randomized Controlled Trial for Outpatient Non-antibiotic Management of Acute Uncomplicated Diverticulitis (Mud Trial): Feasibility and Lessons Learned

Safiya Al-Mansouri, MD, MSc 1, Ebram Salama, MD1, Sebastien Lachance, MD, FRCSC1, Sarah Faris-Sabboobeh, MSc2, Julie Savard, RN2, Nancy Morin, MD, FRCSC2, Carol-Ann Vasilevsky, MD, FRCSC2, Gabriela Ghitulescu, MD, FRCSC2, Julio Faria, MD, FRCSC2, Marylise Boutros, MD, FRCSC2; 1McGill University, 2Jewish General hospital

Introduction: Antibiotics remain the mainstay of treatment of uncomplicated diverticulitis in North America despite recent European literature challenging their utility. This pilot study assesses the feasibility of the first North American randomized controlled trial for outpatient non-antibiotic management of uncomplicated diverticulitis ( identifier-NCT03146091).

Methods and Procedures: After institutional review board approval, adults presenting to the Emergency Department from April to September 2018 with CT-proven acute uncomplicated left-sided diverticulitis were screened for eligibility, and those meeting inclusion/exclusion criteria offered enrollment (Figure-1). Participants were randomized to receive either oral antibiotics or analgesia alone. Follow-up included daily phone calls for 7 days by a blinded nurse and clinic visits at 14-, 30-, and 60-days. Our primary endpoint was recruitment rate. Secondary outcomes included median visual analogue pain scores at 7 days and treatment failures (defined as persistent diverticulitis at 60-days, progression to complicated diverticulitis, hospital admission, and mortality). We determined a sample size of 40 patients would allow for an estimation of the recruitment rate to within a 14% margin of error with 95% confidence. Reporting of the pilot complied with the 2010-CONSORT extension for Pilot/Feasibility Trials.

Results: Of the 37 patients screened, 24 met inclusion/exclusion criteria and 12 consented to participation. This represented a recruitment rate of 32%. Patients refusing participation (n = 12) cited inability to attend clinic follow-ups, preconceived expectations of receiving antibiotics, and belief that antibiotics would expedite recovery. Seven patients were randomized to the antibiotic arm and 5 to the non-antibiotic arm. Median age of participants was 54 (30-70) years with an even gender distribution. Eleven patients (92%) completed the 7-day phone follow-up and expressed that they were satisfied and reassured by the phone calls. Ninety percent completed at least 30 days of follow-up, but only 44% adhered to all scheduled visits. Median follow-up was 45 days. One patient (8%) was lost to follow-up. There were no treatment failures in either group. Median pain scores at 7 days were 0 for both arms (0–2 for controls, 0–4 for experimental).

Conclusions: A large-scale RCT is feasible assuming a 32% recruitment rate and 92% retention rate. Recruitment and retention rates are likely to improve with (1) a more rigorous electronic platform to facilitate screening and appropriate implementation of inclusion/exclusion criteria, and (2) less stringent follow-up (i.e. a single visit at 30-days and phone follow-ups over the study year). Further investigation into non-antibiotic management of acute uncomplicated diverticulitis is warranted.


All That is Right Lower Quadrant Pain is Not Appendicitis

Rebekah S Wood, BS 1, Michael D Sarap, MD, FACS21Wright State Boonshoft School of Medicine, 2South Eastern Ohio Regional Medical Center

Introduction: Three rare surgical cases in a rural setting over the course of three weeks of right lower quadrant abdominal pain. Resulting diagnoses of infarcted cecal diverticulum, cecal perforation due to actinomycosis infection, and low grade appendiceal mucinous neoplasm

Case Presentation, Management, and Outcome: 55-year-old male presented to emergency department with sudden onset right lower quadrant abdominal pain and nausea without fever or vomiting. CT scan with contrast showed no intestinal obstruction or inflammation, normal appendix, no abnormal fluid or gas collection, present diverticulosis without associated inflammation, and no kidney stones. He was admitted and given pain medicine and IV hydration without any improvement of symptoms. Decision was made to take patient to the operating room due to concerns for an ongoing acute process from no improvement of symptoms, peritoneal signs on exam, and white count of 16,000. Patient underwent laparoscopy and was found to have an infarcted cecal diverticulum. Pathology reported transmural necrosis and acute suppurative inflammation of cecal diverticulum. On post operative day 1 he was eating, walking and feeling well.

14-year-old male presented for intermittent right lower quadrant abdominal pain for 5 months after a negative appendicitis workup. Upon presentation, CT and ultrasound showed large phlegmon in right lower quadrant. Patient was taken to surgery for laparoscopy, conversion to laparotomy with ileocecectomy and primary small bowel-colon anastomosis. Pathology returned as perforation at base of cecum as primary event leading to abscess formation with possible cause being an Actinomycoses infection due to presence of sulfur granules. Pathology specimen sent to Children’s infectious disease also indicated Actinomycoses as cause of perforation.

59-year-old male with mild right lower quadrant pain was referred after colonoscopy showed inverted large appendix and benign biopsies of the base of the appendix. Patient underwent outpatient laparoscopic appendectomy with removal of cuff of cecum due to concern for malignant etiology. Pathologic diagnosis of low-grade appendiceal mucinous neoplasm. Patient followed-up in office with complete resolution of symptoms.

Discussion: Appendicitis is a common etiology of right lower quadrant pain. However, there are many causes of right lower quadrant pain that mimic appendicitis. These other causes may differ from an appendicitis presentation in only one aspect. Full appendicitis workup if possible or exploratory laparoscopy with surgical abdomen while keeping in mind other etiologies of right lower quadrant pain, allowed for tremendous improvement post operatively for all three cases.


Laparoscopic Versus Open Emergent Sigmoid Resection for Perforated Diverticulitis

Yongjin F Lee, MD, June Hsu, MD, Michael Battaglia, MS, Robert K Cleary, MD; St. Joseph Mercy Ann Arbor

Introduction: The role of the laparoscopic approach to emergent resection for diverticulitis is unclear. Previous studies have demonstrated its safety and feasibility. There is a need for a large risk-adjusted database analysis of emergent operations for Hinchey III or IV diverticulitis that focuses on the role for minimally invasive options. The objective of this study is to compare outcomes between the laparoscopic and open approach to emergent sigmoidectomy for perforated diverticulitis.

Methods and Procedures: The national American College of Surgeons-National Surgical Quality Program (ACS-NSQIP) database was queried for cases of laparoscopic and open emergent sigmoid resection for perforated diverticulitis from January 1, 2012 through December 31, 2016. Propensity scores were converted to weights and weighted generalized linear models created. 30-day outcomes were compared between emergent laparoscopic and open sigmoidectomy. Two subgroup analyses were performed comparing 1) laparoscopic to open Hartmann’s procedure, and 2) laparoscopic to open sigmoidectomy with primary anastomosis and diverting stoma.

Results: 2,845 patients were included in the study - 2,581 open, and 264 laparoscopic sigmoidectomy. Compared to the laparoscopic approach, open sigmoidectomy had a higher rate of complications overall (p < 0.001), and a longer hospital length of stay (p < 0.001). Specifically, the open approach had higher rates of ileus (p = 0.003), acute renal failure (p < 0.001), unplanned intubation (p < 0.001), superficial SSI (p < 0.001)), re-operation within 30 days (p = 0.04), and discharge destination other than home (p < 0.001). Mortality rate favored the laparoscopic to open approach (2.99% vs. 6.97%, respectively), although this difference was not statistically significant (p = 0.089). Subgroup analyses showed similar findings. 2,007 patients underwent open and 152 patients underwent laparoscopic Hartmann’s procedure. Compared to laparoscopic, open Hartmann’s had an overall higher rate of complications (p < 0.001), including a higher rate of acute renal failure (p < 0.001), pneumonia (p = 0.02), unplanned intubation (p < 0.001) and superficial SSI (p < 0.001). Mortality was higher but not statistically significant following open compared to laparoscopic Hartmann’s (7.35% vs. 2.09%, p = 0.07). Subgroup analysis comparing laparoscopic and open sigmoidectomy with primary anastomosis and diverting stoma favored the laparoscopic approach, although it was limited by sample size (n = 10 and 85, respectively).

Conclusion: The laparoscopic approach has better outcomes than the traditional open approach in emergent sigmoid resection for perforated diverticulitis. Additional studies are needed to confirm this finding in a randomized controlled setting.


Open Colectomies Associated with Increased Retrieval of Twelve or More Lymph Nodes Compared to Laparoscopic Colectomies in Colon Cancer Surgery

Yana Puckett, MD, MPH, MBA, MSc, Diana Mitchell, MBA, RN, Theophilus Pham, MBA, Amir Aryaie, MD; Texas Tech University Health Sciences Center

Background: Studies have suggested that excising 12 or more lymph nodes during colectomy in patients with colon cancer is associated with improved survival. To date, no study has investigated whether minimally invasive surgery affects ability to retrieve 12 + lymph nodes in elective colon cancer surgery. We elected to determine whether a difference exits on ability to retrieve 12 + nodes in elective colon cancer colectomies performed open vs. laparoscopic.

Methods: The National Surgical Quality Improvement Program (NSQIP) database was analyzed for the year 2014, 2015. Inclusion criteria was Colon Cancer (ICD-9 Code 153.9), age greater than 18. Exclusion criteria was missing data. Data abstracted included number of lymph nodes retrieved and type of operation performed. Data was compared between patients that underwent laparoscopic colectomy compared to open colectomy. Binary logistic regression was used to identify confounding variables in retrieval of 12 + lymph nodes.

Results: After accounting for missing cases, a total of 18,792 patients with a diagnosis of colon cancer were analyzed. Greater than 12 lymph nodes were retrieved in 88% (16,538) of patients. Overall mean lymph nodes retrieved were the same between two groups 20 (SD 11) (p = 0.43). However, open operative approach compared to laparoscopic was associated with 15% greater odds of retrieval of 12 + lymph nodes (OR 1.148; 95%CI (1.035-1.272); P = 0.009).

Conclusion: Majority of colectomies, whether done open or laparoscopically, retrieve 12 or more lymph nodes. However, there may be increased odds of retrieving more than 12 lymph nodes with open approach compared to laparoscopic.


The Relaparoscopy Threshold in Colorectal Surgery

Mariana Matzner Perfumo, MD, José Piatti, MD, Mariano Laporte, MD, Maximiliano Bun, MD, Nicolás Rotholtz, MD; Hospital Aleman

Introduction: In the last few years there was an increased use of laparoscopic approach for colorectal surgery as well as the use of this approach to treat postoperative complications (re laparoscopy). Like in other procedures, re-laparoscopy in colorectal surgery requires a learning curve. The aim of this study was to identify variables that determines the acquisition of the learning curve.

Methods and Procedures: A consecutive cohort of patients who underwent re-laparoscopy after colorectal surgery was analyzed from a prospectively collected database during the period 2002-2017. Patients were divided into two groups according to surgeon´s experience: G1: less than five years of attending; G2: more than five years of attending. Demographics data, intraoperative complications, and postoperative outcomes were analyzed.

Results: From a total of 1580 patients who underwent laparoscopic colorectal resection, 146 (9, 3%) required a re-operation. One hundred of them underwent a re-laparoscopy. The median age was 60.5 (27-92) years. There were no differences in demographic data and conversion rate between the groups. In G2 CT scan was used as diagnostic tool before re-laparoscopy with lower frequency {G1: 37(74%) vs. G2 26 (52%); p < 0.05)}. There was a trend towards shorter time to decide the re-laparoscopy as well as shorter operative time in G2 (p < 0,08). There were no differences in length of hospital stay, post-operative morbidity and mortality rate.

Conclusion: Experienced colorectal surgeons showed earlier time to decide the re-laparosopy and shorter surgical time as compare to their younger counterparts. Time to re-laparoscopy and use of imaging studies to diagnose postoperative complications might be good indicators of reaching the learning curve in colorectal surgery.


Does Enhanced Recovery After Surgery Affect Time to Delivery of Adjuvant Systemic Therapy in Patients with Stage III Colon Cancer?

Tiffany Paradis, Maude Trepanier, Pepa Kaneva, A. Sender Liberman, Patrick Charlebois, Barry L Stein, Liane S Feldman, Lawrence Lee; McGill University Health Center

Introduction: Timely delivery of adjuvant systemic therapy is important for oncologic outcomes in stage III colon adenocarcinoma. However, many patients do not receive or have delays in adjuvant treatment secondary to poor recovery or postoperative complications. Enhanced recovery pathways(ERP) decrease complications and improve recovery, but their effect on delivery of adjuvant treatment is unknown. Therefore, the objective of this study is to determine the effect of ERPs on the time to delivery of adjuvant systemic therapy and overall survival(OS) in patients with resected stage III adenocarcinoma.

Methods: All patients with stage III adenocarcinoma undergoing elective surgery at a single colorectal referral centre from 01/2005-12/2013 were reviewed. Patients were divided into two groups: ERP and conventional care(CC). The ERP was implemented fully in 2010. The main outcome measured was time to initiation of adjuvant systemic therapy (none, ≤ 8 weeks, and > 8 weeks) and 5-year overall survival(OS). 30-day postoperative complications were grouped using the Clavien-Dindo classification into none, mild (Clavien-Dindo 1-2) and severe (Clavien-Dindo ≥ 3). Kaplan–Meier method was used to estimate OS. Multinominal logistic regression was performed to identify predictors of time to initiation of adjuvant chemotherapy (reference group: ≤ 8 weeks). A Cox proportional hazard model was used to determine predictors of 5-year OS.

Results: A total of 209 patients were included(112 ERP, 97 CC). Patients were well balanced between groups. ERP was associated with shorter hospitalization (4 days[IQR3-7] vs. CC 6 days[IQR 5-10], p < 0.001) and fewer complications (39.1% vs. 57.6%, p = 0.028). Median time to initiation of adjuvant therapy (ERAS 67 days[IQR57-80] vs. CC 65 days[IQR56-80], p = 0.415) and delays in initiation (63.1% vs. 63.5%, p = 0.288) were similar (Figure 1A). Five-year OS was also similar between the two groups (ERAS 56.6% vs. CC 45.0%, logrank p = 0.319). The multinomial model for time to initiation of adjuvant treatment reported that only older age (OR1.05 per year, 95%CI1.01-1.11) and severe complications (OR9.92, 95%CI1.02-30.04) independently predicted no receipt. Only male gender (OR2.38, 95%CI1.01-5.56) predicted delay > 8 weeks. In the adjusted survival analysis, no adjuvant treatment (HR2.56, 95%CI1.17-5.60), stage IIIC (HR3.36, 95%CI1.40-8.05), and severe complications (HR2.78, 95%CI1.06-7.35) were associated with poorer 5-year OS. Perioperative care was not independently associated with delivery of adjuvant treatment or 5-year OS.

Conclusion: Perioperative management did not affect delivery of adjuvant systemic therapy or long-term survival for stage III colon cancer. The occurrence of severe complications appears to have the greatest effect on both adjuvant treatment and overall survival.


A Unique Case of Metastatic Cervix Squamous Cell Carcinoma Presenting as a Large Bowel Obstruction

Andrew Lelchuk, DO1, Nicholas Morin, DO2, Vadim Meytes, DO3, Michael Nicoara, DO2Kevin Bain, DO 21Nova Southeastern University College of Osteopathic Medicine, 2NYU Langone Hospital - Brooklyn, 3Vassar Brothers Medical Center

Introduction: Cervical cancer is the third most common cancer in women. Histologically, squamous cell carcinoma (SCC) accounts for approximately 70% of all cervical cancers. Disease progression through metastasis or recurrence usually occurs within the first two years of treatment. Metastasis to the gastrointestinal tract is extremely uncommon.

Case report: A 47 year-old female presented to the ED with abdominal pain and bloody stool for two days. Past history was significant for hysterectomy for uterine leiomyomas. Pathology revealed high grade dysplasia with squamous cell carcinoma in situ, and negative margins.

In the ED a CT scan was obtained which demonstrated dilated loops of bowel, with a transition point at the rectosigmoid junction secondary to a soft tissue density.

The patient was taken to the operating theatre for non resolving high grade colonic obstruction. A densely adherent mass was discovered in the pelvis. En bloc resection was performed of the rectosigmoid colon, bilateral ovaries, and portion of the bladder wall. Surgical pathology demonstrated poorly differentiated squamous cell carcinoma of cervical origin.

Discussion: Squamous cell carcinoma (SCC) of the colon is a rare entity. As a primary tumor its pathogenesis is unclear, and as a secondary tumor it arises through metastasis. It is important to differentiate between the two, as metastatic SCC to the colon carries a significantly worse prognosis. In either case, early detection and prompt intervention improve overall survival and disease free survival rates.

Colonic metastasis is often reported from primary sites such as the breast, kidney, ovary, and melanomas. It is rare that metastatic disease to the colon arises from the cervix. In advanced SCC of the cervix, distant metastasis occurs in 9-27% of patients. The most common sites include lung and para-aortic lymph nodes.

In general, sigmoid colon metastasis carries a poor prognosis due to its late presentation. The treatment for colonic metastatic tumor arising from cervical SCC remains controversial, as not enough cases have been reported to compare treatment outcomes. Surgery and debulking are the primary treatment modalities, while the role for radiotherapy and chemotherapy remain somewhat ambiguous.

Conclusion: In this report, we describe the case of colonic metastasis presenting as a large bowel obstruction. Surgery is the primary mode of therapy. Radiotherapy is indicated for unresectable masses, while the role of chemotherapy remains controversial. Ultimately, resection of metastatic lesions may help in palliative measures, and prevent recurrent obstructions.


Transanal Minimally Invasive Surgery for the Treatment of T1/T2 Rectal Cancer in Elderly Patients

Yu Sato, MD, PhD, Takashi Oshiro, MD, PhD, Tomoaki Kitahara, MD, Yutaka Yoshida, MD, Tasuku Urita, MD, Ryuichi Takagi, MD, Kentaro Kawamitsu, MD, Kengo Kadoya, MD, Taiki Nabekura, MD, Shin-Ichi Okazumi, MD, PhD; Department of Surgery, Toho University Sakura Medical Center

Introduction: In elderly patients with cancer, radical surgery is sometimes not selected because of their vulnerabilities. For cases of rectal cancer, total mesorectal excision has been regarded as a standard therapy. However, it can cause some lethal complications and impair the quality of life. Local excision (LE) for low to mid rectal cancer in elderly patients with T1/T2 lesions is an attractive therapeutic method. This study revealed the outcomes of our conventional transanal LE and evaluated the benefit of transanal minimally invasive surgery (TAMIS) for the treatment of T1/T2 rectal cancer in elderly patients.

Methods and Procedures: Fifteen patients with low rectal tumors underwent conventional non-endoscopic transanal LE at our institution between January 2012 and December 2016. After this period, TAMIS was applied to the LE in elderly patients with T1/T2 rectal cancer, and chemoradiation (45 Gy plus 1650 mg/m2 of capecitabine per day) was administered to those who were pathologically diagnosed as possessing high-risk factors for lymph node metastasis. We presented 3 cases of this treatment.

Results: In the cohort of conventional transanal LE, the range of tumor location was 1 to 5 cm from the anal verge. Piecemeal resection of the tumor was performed in 2 patients. Postoperative bleeding occurred in 1 patient. Six patients (40%) had positive or unevaluable margins, and 3 patients (20%) had recurrences. Among the TAMIS group, en bloc full-thickness resection with clear margins was possible in all patients. No intraoperative or postoperative complications occurred, and anal function after treatment was retained as that before surgery. One patient had a pT2 tumor with lymphatic invasion and received adjuvant radiotherapy, but he developed distant recurrences 3 months after surgery. On the other hand, 2 patients had pT1 cancer and were followed-up observationally without any additional treatment. Both patients did not show evidence of recurrence.

Conclusions: TAMIS followed by chemoradiotherapy was demonstrated to be safe for elderly patients with T1/T2 rectal cancer. While long-term oncological outcomes are limited, this treatment might be less invasive for vulnerable patients.


The Feasibility and Application Value of D3 Lymph Node Dissection around the Superior Mesenteric Artery with Preservation of Autonomic Nerves for the Treatment of Right Hemi-colon Cancer

Xiaojiang Yi, Dechang Diao; Department of Gastrointestinal (Tumor) Surgery, Guangdong Province Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine

Objective: To explore the feasibility and application value of the preservation of plant nerve function in the radical resection for right hemicolon cancer.

Methods: Clinical data of 55 cases of right hemicolon cancer undergoing laparoscopic D3 + CME radical resection, including 29 cases of partial resection of superior mesenteric plexus (nerve partial resection group, NPRG) and 26 cases of completely preserved of mesenteric plexus (nerve preserved group, NPG), from January 2017 to July 2018 in the department of Gastrointestinal Surgery of Guangdong Province Hospital of Traditional Chinese Medicine were retrospectively analyzed. Intra-operative and postoperative complications were compared between the two groups.

Results: The baseline information was not significantly different between the two groups (all P > 0.05). The operation time in the NPG and the NPRG group was (164.0 + 19.8) and (176.0 + 19.7) min respectively, which has a significant difference (P < 0.05). The number of harvested lymph nodes in the two groups were 28.5 + 7.8 and 27.6 + 6.47 respectively (P > 0.05), which was not significantly different. One case (3.8%) of Chylous leakage in the NPG group, which was significantly lower than that of the NPRG group (11 cases, 37.9%) (P < 0.05), meanwhile, the postoperative abdominal pain occurred in 4 cases (15.4%) and 12 cases (41.4%) in the two groups, which was significantly different (P < 0.05). Compared with the NPRG group, there was no significant difference in the operative blood loss, postoperative time to flatus and postoperative hospitalization time in the NPG group (P > 0.05). All patients were followed up for more than 6 months, and the rates of 30-day re-hospitalization and mortality were 0.

Conclusion: It is safe and feasible to preserve the plant nerve in the operation of right hemicolon cancer and prevents the postoperative gastrointestinal dysfunction caused by nerve injury.


Recent Advances and Comparison of Different Fistula-in-ano Classifications: Has the Problem Been Solved?

Pankaj Garg, Dr1, Sachi Singhal, MBBS2Sachin B Jamma, MBBS, MS 3, Suresh Vasistha, MBBS, MS41Garg Fistula Research Institute, 2Dayanand Medical College, Ludhiana, Punjab, India, 3Ashwini Rural Medical College, Kumbhari, Solapur, Maharashtra, India, 4Mangalam Hospital, Gurgaon, India

Objective: Classification is done to grade the disease according to severity and guide regarding its management. There are four classifications published for fistula-in-ano- Parks1(1976), St James university hospital(SJUH)2(2000) and Standard Practice Task Force (SPTF)3(2005) classification and a recent Garg4(2017) classification. Considering there is lot of confusion regarding management of fistula-in-ano, the objective of the study was to ascertain as which classification is most relevant and useful to the operating surgeon.

Method: The basis, methodology, utility(correlation with disease severity and guidance regarding disease management) and strong points of each classification were analyzed.

Results: All the classifications are compared in Figure-1.

Parks and SPTF were based on clinical experience, SJUH was MRI based and Garg was based on both clinical experience and MRI. Parks and SJUH did not correlate with disease severity whereas Garg and SPTF correlated well with disease severity. Whereas Parks, SJUH and SPTF were not validated by patient data, Garg classification was validated by patient data (440 patients). Whereas Parks, SJUH and SPTF had no role in the disease management, Garg classification guided the operating surgeon regarding the treatment of all types of anal fistulas. Garg grade I-II are simple fistulas and can be safely managed by fistulotomy without any risk to continence whereas Garg grade III-V are complex fistulas and fistulotomy should not be even attempted in these fistulas. The latter may be dealt with sphincter saving procedures like advancement flap, Anal Fistula Plug, LIFT or VAAFT. Thus this classification guides a general surgeon regarding the fistulas (grade I-II) which can be easily managed and the fistulas (grade III-V) that need to be referred to an expert(Figure-2).

Conclusion: Garg classification is a significant advancement over existing classification (Parks, SJUH & SPTF) with regard to accuracy and utility to the operating surgeon. It classifies the fistulas accurately as per disease severity as well as guides the operating surgeon regarding the disease management. Therefore, Garg classification should be used by radiologists and the surgeons.


(1) Parks A. al.(1976) A classification of fistula-in-ano. Br J Surg 63:1-12

(2) Morris al.(2000) MR imaging classification of perianal fistulas. Radiographics 20:623-635

(3) Whiteford M. al.(2005) Practice parameters for treatment of fistula-in-ano (revised). Dis Colon Rectum 48:1337-1342

(4) Garg P(2017) Comparing existing classifications of fistula-in-ano in 440 operated patients: Is it time for a new classification? Int J Surg 42:34-40


Malignant Mixed Mullerian Tumor (MMMT) Presents as a Retro-rectal Mass: A Case Report

Anthony Dakwar, MD, Melissa S Zoumberos, MD, Alexandria Glenn, MD, Sowsan Rasheid, MD; University of South Florida, Tampa General Hospital

Malignant Mixed Mullerian Tumors (MMMT) are a rare and aggressively malignant cancer of the female genital tract, usually arising from the uterus, cervix, and ovaries. MMMT are considered a carcinosarcoma, due their histological characteristics of both epithelial cells as well as connective tissues. Prognosis is mainly poor, even after appropriate surgery and adjuvant therapy treatments. We report a case of a MMMT having an unusual presentation as a retro-rectal tumor.

MMMT are mostly consistent with a history of vague abdominal pain and associated vaginal bleeding. These tumors can grow to a substantial size and encompass the entirety of the abdominal compartment, as an intra-peritoneal mass. The patient we are presenting complained of vague perineal pain along with a radiculopathy to her right leg. Physical exam revealed an enlarged right buttock, with mass effect along with erythema and skin-dimpling (Figure 1). The abdominal and pelvic exams were normal. Vaginal ultrasound and computed tomography (CT) did not illustrate the origin of this tumor, only confirming it location in the pre-sacral space tracking into the her pelvic organs. Magnetic resonance imaging (MRI) was obtained to further characterize the mass. It showed a 16x11x12 cm heterogenous mass with cystic components, hyper-intense on T2 weighted image (Figure 2). Tumor markers and other lab work were unremarkable.

The patient underwent a retro-rectal tumor excision via Kraske approach. The tumor appeared to be involving the uterus and base of the cervix at the time of surgery, requiring a trans-abdominal approach to adequately remove it and all its components. Patient recovered well and discharged home. Pathology revealed that the tumor was indeed a MMMT, arising from polypoid endometriosis.

In conclusion, we report a case of a Malignant Mixed Mullerian Tumor that presented in the pre-sacral space. Tumors of gynecological origin are known to occur in the retro-rectal space, however such a rare pathology as MMMT usually is limited to the peritoneal cavity. A high index of suspicion must be maintained during the evaluation of giant retro-rectal tumors that are found to be heterogenous with multiple cystic components on pre-operative imaging. The extent of disease in this case and its unusual location is indicative of the potential for aggressive endometrial transformation and migration.

Figure 1. Physical exam findings of right buttock.

Figure 2.

Magnetic Resonance Image (MRI) of retro-rectal tumor.


Combined Laparoscopic Right Hemicolectomy and Sigmoid Colectomy for Simultaneous Cecal and Sigmoid Volvulus

Hugo Bonatti, Kiran Khosha; Meritus Health, Hagerstown MD

Introduction: Cecal (CV) and sigmoid volvulus (SV) are acute surgical disorders frequently requiring emergent surgery. Colonoscopic decompression may temporize the condition; however; CV and SV may recur requiring colectomy. Only few cases of combined CV and SV have been reported and open surgery has remained the more common approach.

Case Report: A 40-year-old African-American female with cerebral palsy came to the ER with acute abdominal distention and pain. CT-scan revealed acute CV. Multiple episodes of SV had been treated nonoperatively in the past. The proximal bowel was decompressed through her PEG tube and the large bowel by colonoscopy. Laparoscopic (partial) colectomy with ostomy was planned. The patient was placed supine, trocars were placed in the left upper (U) and left lower quadrant (LQ) and into an old upper midline incision from a fundoplication. Transverse colon adhesions at the PEG tube site were lysed, the right (R) colon was completely mobilized together with 25 cm terminal ileum involved in the torque; an extra corporeal ileotransverse anastomosis was created using a 4 cm periumbilical incision, which was closed. Trocars were switched to the RU and RLQ. The elongated, twisted sigmoid colon was mobilized out of the pelvis, the mesentery was divided and the rectum was stapled. The specimen was removed through the colostomy site in the LLQ. The postoperative course was uneventful.

Conclusion: We report the first laparoscopic right hemicolectomy plus sigmoid colectomy preserving the transverse/descending colon for combined CV and SV. Colonoscopic decompression temporized the disorder allowing for subsequent minimally invasive surgery.


Outcomes Following Colorectal Surgery: A Comparative Study of CR –POSSUM and ACS – NSQIP Risk Calculator

Nitin Vashistha, MS, FACS 1, Arati Verma, MBBS, DHHM, PGDMLS2, Dinesh Singhl, MS, FACS, DNB, Surgical, Gastroenterology11Department of Surgical Gastroenterology, Max Super Speciality Hospital, Delhi, India, 2Department of Medical Quality, Max Super Speciality Hospital, Delhi, India

Background: Several studies have reported outcomes of colorectal surgery (CRS) based either on CR – POSSUM or ACS - NSQIP risk calculator. To the best of our knowledge, no study to date has evaluated/compared outcomes of the two risk calculators on same patient cohort .

We report outcomes of elective and emergency CRS by CR – POSSUM and ACS – NSQIP risk calculator.

Patients and Methods: This is a single center observational study of 86 consecutive adult (≥ 18 years) patients who underwent elective or emergency, resective &/or reconstructive CRS from March 2013 to March 2018. Procedures such as appendicectomy, diverting colostomy, laparoscopic rectopexy were excluded from analysis.

Data was accessed from institutional electronic health record system. The CR – POSSUM and ACS – NSQIP scores for each patient was calculated. Actual outcomes were then compared with those predicted by risk calculators.

Results: Of the 86 patients (60 Indians and 26 International) there were 56 males and 30 females with a mean age of 57 (range 18-93) years. Of these 59 (68.6%) underwent elective whereas 27(31.4%) had emergency CRS. Sixty two (72%) and 24 (38%) patients underwent open and minimally invasive procedures (laparoscopic -21 and robotic -3) respectively. The median length of stay was 08 (range 02-40) days. The mortality following elective and emergency operations was 1/59 (1.6%) and 8/27(29.6%) respectively.

By CR- POSSUM, ratio of observed to expected mortality was 1.29 with no significant difference between the two values.

Objective comparison between overall actual outcomes and those predicted by ACS – NSQIP risk calculator revealed no significant difference in any of the parameters studied (Figure 1).

A comparison of actual and predicted ACS – NSQIP outcomes in elective and emergency CRS is provided in Table 1. The score significantly underestimated SSI and over predicted the length of stay following emergency CRS.

Conclusions: Both CR – POSSUM and ACS – NSQIP risk calculator accurately predicted mortality in our cohort of CRS patients. CR – POSSUM provides information on single domain of mortality only and requires operative findings to calculate the score and is therefore more useful for surgical audits. In comparison ACS – NSQIP risk calculator provides comprehensive information prior to surgical intervention that may be useful for both individual prognostication as well as surgical audits.

Figure 1: Actual versus predicted outcomes by ACS-NSQIP risk calculator
Table 1: Outcomes of Emergency and Elective CRS by ACS-NSQIP risk calculator


Initial Experience Using Transanal Approach to Low Rectal cancer

Adrian Maghiar, George Dejeu, Octavian Maghiar; Spital Pelican Oradea

In our institution we have a vast experience with rectal cancer patients, with a number of over 50 cases per year that get resection with anastomosis. In the recent years we have started studying and attending courses to using TA-TME. We have a 8 years experience of using transanal devices for both benign and malignant disease, but we only started doing TA-TME in our Clinic this year.

We present our experience after 5 cases of low rectal cancer patients using the transanal approach for the rectal dissection, using the conventional laparoscopic approach for the vascular dissection and the left colon mobilisation (we always mobilise the splenic flexure).

We operated on 4 men and 1 female. All patient were between the ages of 60 and 75, with no major comorbidities (3 male and 1 female with hypertension and 2 male with diabetes). The mean operating time was 230 min, with the first case lasting 320 min and last one 195 min (skin to skin). All cases were R0 resection, with an average lymph node harvest of 16 nodes (13 to 25), and an average height of the anastomosis of 3 cm (1,5 to 4 cm). The average length of stay was 7 days (5 to 14). All patients had a ileostomy done prior to neoadjuvant therapy. 2 patients needed readmission before 30 days after surgery (one for constipation and dehydration, and one for vomiting). None patients presented with fistula, and all patients had their ileostomy reversed after 6 weeks with normal bowel function at 3 and 6 months (3 cases have more than 6 months, one has less than 3 months after surgery). We conclude that TA-TME is feasible in a center with a reasonably high volume of rectal cancer patients and a big experience with advanced oncologic laparoscopic surgery. The duration of surgery goes down with experience, but the visualisation during dissection is much superior than that of the normal laparoscopic approach. Needs further study to see the benefits compared to the robotic approach (we have no experience with the robot).


Trends and Clinical Outcomes in Young Patients with Colorectal Cancer: A Comparative Review of Emergency vs Elective Surgical Cases

Edith Loo, Ms 1, Serene Goh, Dr2, Daniel Lee, Dr21Lee Kong Chian School of Medicine, 2Khoo Teck Puat Hospital

Introduction: This study strives to determine trends and clinical outcomes for patients diagnosed with CRC under age 50. This study also aims to evaluate differences in outcome between elective and emergency young CRC cases, as it is stipulated that younger patients who present in acute settings and undergo emergency surgery may have a poorer prognosis. To date, the role of young age of CRC diagnosis as an adverse prognostic factor remains controversial.

Methods: A retrospective study was conducted on 99 patients under 50 years of age presenting to Khoo Teck Puat Hospital (KTPH) with primary CRC from 2010-2017. Patients were stratified into elective or emergency surgery subgroups. Chi square test was used for comparison of the two subgroups, Cox’s proportional hazard regression was used to multivariately assess predictors of outcome and survival analysis was undertaken using Kaplan–Meier survival curves.

Results: In our cohort, 54.5% presented with Stage 3 CRC and above. 68.4% underwent elective surgery, while 31.6% underwent emergency surgery, of which 66.6% presented with obstruction and 33.3% with perforation. 62.1% underwent open surgery, while 37.9% underwent laparoscopic surgery. On univariate analysis, factors demonstrating a significant association with poor prognosis were high CEA levels, advanced overall stage, T stage, presence of signet ring histology, vascular invasion, presence of metastasis and emergency surgery. On multivariate analysis, only advanced stage (stage III and IV) and presence of signet ring histology were independent predictors of poor outcome. Survival outcome was significantly poorer for patients who underwent emergency surgery compared to elective surgery.

Conclusion: Young CRC does not have a poorer prognosis. Advanced stage and signet ring cell histology are both indicators of poor outcome. Emergency presentation exhibits poorer survival, where patients present at later stages with higher rates of metastasis. This raises concerns regarding public knowledge of red-flag symptoms and awareness among clinicians during evaluation of younger patients, to avoid severe ramifications of delayed diagnosis.


A New Minimally Invasive Sphincter-saving Procedure to Treat Highly Complex Anal Fistulas : Transanal Opening of Intersphincteric Space (TROPIS) Procedure in 238 High Complex Anal Fistulas

Pankaj Garg, MBBS, MS, FASCRS1, Sachi Singhal, MBBS2Sachin B Jamma, MS 31Garg Fistula Research Institute, Panchkula, Haryana, India, 2Dayanand Medical College and Hospital, Ludhiana, Punjab, India, 3Ashwini Rural Medical College, Kumbhari, Solapur, Maharashtra, India

Aims: In complex fistulas with significant intersphincteric component(high transsphincteric, horseshoe and supralevator fistulas), the intersphincteric component acts like an abscess. Simply draining the intersphincteric sepsis once as is done in LIFT procedure would lead to recurrence in many cases (up to 50%). In such fistulas, laying open the intersphincteric part of the fistula through the transanal route(deroofing the abscess) ensures healing in most cases. This is the basis of TROPIS(transanal laying open of intersphincteric space) procedure. TROPIS was done and evaluated in high complex fistulas.

Methods: All consecutive operated patients of complex high fistula-in-ano included. All fistula were high (involving more than one-thirds of sphincter complex). Simple fistula in which fistulotomy was possible were excluded. Preoperative MRI scan was done in all the patients. The main outcome measures were healing rate, hospital stay, objective incontinence scores

Operative Procedure: A curved artery forceps was inserted through the internal(primary) opening into the intersphincteric part of the fistula tract. The mucosa and the internal sphincter over the artery forceps were laid open inside the rectum with electrocautery. The incision, starting from the internal opening, was usually curvilinear but could also be oblique, depending upon the direction of the intersphincteric tract. In case of horseshoe fistula, the incision extended on both sides of the midline posterior internal opening. In case of supralevator extension/tract, the incision was extended from the midline posterior internal opening up to the supralevator rectal opening(Figure-1).

Results/Outcome: 238 patients with high complex fistula-in-ano were operated over 4 years with a follow-up of 4-45 months (median-15 months). 29 patients were excluded due to short follow-up. Male/Female: 189/20, age-39.06 ± 9.3 years. 78% (163/209) were recurrent, 89% (186) had multiple tracts, 36.4% (76) had horseshoe tract, 27.8%(58) had supralevator extension and 37.3% (78) had associated abscess. Fistula healed completely in 83.3%(174/209) and didn’t heal in 16.7% (35/209). 27/35 of these were reoperated with the same procedure and fistula healed in 21 patients. Thus overall healing rate was 93.3% (195/209). There was no significant change in incontinence scores.

Conclusions: The success rate of TROPIS(> 93%) in high complex fistula(all were high and majority were recurrent fistula with multiple tracts, horseshoe tracts and supralevator extension) is quite impressive. The external sphincter is not cut or damaged due to which the risk to continence is minimized. The technique is simple, minimally invasive, easy to reproduce, associated with little pain and early resumption of normal activities.


Colorectal Cancer in Patients Under Age 50: Trends in Staging and Mortality

Jaclyn Malat, DO 1, Sarah Martin, BS1, Adrian Ong, MD2, Michael Brown, MD, MBA, FACS21Philadelphia College of Osteopathic Medicine, 2Reading Hospital, Tower Health

Objective: The aim of this study is to compare stage and mortality in colorectal cancer (CRC) patients above and below age 50. We hypothesize that the stage at diagnosis and mortality will both be higher in patients under age 50. Recent national reports show an increase in CRC diagnoses in younger patients. This correlates with the recent change by the American Cancer Society to beging screening colonoscopies at age 45, instead of age 50. Data on this younger patient population, including stage of diagnosis and mortality however, are limited and require further investigation.

Methods: A 20-year retrospective review of electronic medical records was completed at the McGlinn Cancer Institute from 1997 to 2017 of all patients diagnosed with CRC. This data was then aggregated by age, gender, tumor location, stage and mortality over the past 20 years. Univariate analysis of variables was performed where appropriate. Statistical significance was indicated by a p value of 0.05.

Results: Of 3041 patients diagnosed with CRC over the last 20 years, 231 (7.6%) patients were below age 50. These younger patients were diagnosed at higher stages compared to patients age 50 and above; 71.4% (165/231) of younger patients compared to 56.5% (1589/2810) of those above age 50 were diagnosed at stage 2 or higher (p < 0.0001). Despite this, the mortality rate over 20 years in younger patients was lower compared to those above age 50 (35.5% vs 59.3%, p = 0.0001). There was no statistically significant difference in gender or location of tumor between these two age groups.

Conclusion: Although patients under age 50 were more likely to be diagnosed at higher stages of CRC, they demonstrated a lower mortality rate when compared to patients above age 50. Based on our data, initiating screening colonoscopies at age 45 would likely downgrade the stage at diagnosis however, its effect on overall survival has yet to be determined.


Intracorporeal Versus Extracorporeal Anastomosis in Minimally-Invasive Rectosigmoid Resection

Kasim Mirza, MD, Carey Wickham, MD, Andreas M Kaiser, MD, FACS, FASCRS; USC Colorectal Surgery

Introduction: Intracorporeal anastomosis (ICA) during minimally invasive colorectal resections (robotic/laparoscopic) has been thought to have advantages over extracorporeal anastomosis (ECA). It avoids exteriorization of the colon with room air exposure, traction, and manipulation in the resection and anastomosis phase and for placement of an EEA stapler anvil. We previously described the technique of a robotic single-dock intracorporeal anastomosis for rectosigmoid resections. The purpose of this study was to compare outcomes between robotic and laparoscopic ICA and ECA for sigmoid and low anterior rectal resections (LAR). We hypothesized that ICA was associated with decreased rates of ileus and LOS.

Methods: Patients who between 2015 and 2018 underwent a laparoscopic or robotic sigmoidectomy or LAR performed by a single surgeon at a tertiary referral center were retrospectively analyzed. Included were any minimally-invasive sigmoidectomy or LAR for benign or malignant disease with primary stoma-free anastomosis. ICA was defined as laparoscopic or single-dock robotic resection with intracorporeal colon resection and anvil placement, whereas ECA was defined as exteriorization of more than the specimen for resection, anvil placement, or anastomosis. Exclusion criteria included conversion from MIS to open surgery, creation of a stoma, or hand-sewn coloanal anastomosis.

The patients were grouped into ICA versus ECA. Data analyzed and compared included patient demographics, operative time, peri- and postoperative morbidity, and length of stay. Statistical analysis was performed on SAS software using 2-tailed t-test for continuous variables, and Chi squared or fisher exact test for categorical data.

Results: Of 64 patients identified, 40 met the criteria with 20 ICA (10 LARs and 10 sigmoidectomies) and 20 ECA (17 LARs and 3 sigmoidectomies). There were no significant differences between the groups for age, gender, ASA, or BMI. Average LOS was shorter in ICA (3.5 vs 5.3 days) without reaching statistical significance (p = 0.088). While the rate of prolonged postoperative ileus showed no difference, overall complications were significantly higher in ECA (8/20 vs 2/20, = p=0.029). Responsible for this difference was a significantly lower complication rate after ICA for LARs when compared to ECA (p = 0.026). Without reaching statistical significance, secondary outcomes such as operative time (254 vs 231 min,p = 0.24) and leak rate (2/20, 0/20,p = 0.49) favored ICA.

Conclusion: Minimally-invasive ICA was associated with favorable outcomes compared to ECA with significantly decreased overall post-operative complications and a trend to shorter LOS without an increase in operative time. ICA for rectosigmoid resections appears to offer an advantage and should be further evaluated


Transanal Extraction for Rectal Cancer After TME: Always, Never or Sometimes?

Jonathan Josse, MD, Brigitte Anderson, BS, Henry Schoonyoung, MD, John Marks, MD; Lankenau Medical Center

Introduction: TaTME has emerged as a new popular approach for rectal cancer surgery. An incision through the anus or rectum provides a natural orifice route to deliver the specimen and avoid an abdominal extraction site. Concerns regarding the applicability of this approach in patients with large tumors, or high BMI and possible oncologic risks of this approach have often limited the adoption of Transanal extraction (TAE). We examine our experience with the routine use of TAE for TaTME and TATA over a 10 year period, to identify its impact on TME grade, local recurrence (LR) and morbidity.

Methods: From a prospectively maintained laparoscopic and rectal cancer database, all patients with primary adenocarcinoma of the rectum, treated with neoadjuvant therapy and a TaTME/TATA between 2008-2018 were identified. Retrospective review of the operative notes determined the route of specimen extraction in these patients as either abdominal (abd) or Transanal (TAE). The TAE group was analyzed to determine overall TME completeness, LR and morbidity. Subclass analysis of these outcomes was carried out based on BMI ≥ 30, size, ≥ 5 cm, and circumferential versus non–circumferential cancers.

Results: Of the 128 eligible patients, 99.2% of specimens were extracted transanally, and comprise these results (N = 127). The mean age of our patients was 59 years old, with 28% being female. TME grade on final pathology was incomplete-2%, near complete-3%, and Complete-95%. Local recurrence was 1.6%. There was one case of carcinomatosis. Overall 60-day morbidity was 32.3% with 63.4% having a Clavien-Dindo score of ≤ 2. There was no mortality. The effect of BMI and size of the cancer, on TME, LR and morbidity are shown in Table 1.

Conclusion: This study establishes that the Transanal extraction of the specimen can be routinely used for TaTME, without impairing the quality of the TME, increasing LR rates, carcinomtosis or morbidity. Transanal extraction is shown as safe for morbidly obese patients with large cancers as well. The primary concerns of Transanal extraction of the rectal cancer specimen regarding the compromise of the TME specimens and/or increased morbidity appears unfounded.


Stoma Reversal and Postoperative Complications After Laparoscopic Intersphinteric Resection for Rectal Cancer

Nao Obara, Shigeki Yakaguchi, Yasumitsu Hirano, Toshimasa Ishii, Hiroka Kondo, Kiyoka Hara, Shintaro Ishikawa, Takuhisa Okada, Liming Wong; Saitama medical university International medical Center

Introduction: Recently, the opportunity to perform laparoscopic intersphincteric resection (ISR) has been increased to preserve the anus. Temporary feacal diversion reduces the consequences of anastomotic leakage, and resulted in the increasing numbers of patients with loop ostomy after laparoscopic ISR. The aim of this study was to clarify the rate of stoma reversal and the postoperative complications after laparoscopic ISR for rectal cancer.

Patients and Methods: We retrospectively examined 139 patients who have underwent laparoscopic ISR for rectal cancer with defunctioning ostomy in our hospital between 2010 and 2017 with a follow-up period of at least one year.

Results: The median age at the time of creation of the stoma was 65-years old, and median BMI was 22.8 kg/m2. Of these, 102 were male and 37 were female. The preoperative comorbidities were 34 hypertensions, 25 diabetes, 11 respiratory diseases, 9 ischemic heart diseases, 8 cerebrovascular diseases, 5 arrhythmias and 4 hepatitis. The treatment performed before laparoscopic ISR included 18 chemo-radio therapies, 13 endoscopic tumor resections, 2 trans-anal tumor resections and one chemotherapy. The positions of defunctioning ostomy were 131 ileums and 8 transverse colons. Postoperative complications after laparoscopic ISR were 18 anastomotic leakages, 9 anastomotic strictures, 8 stoma outlet obstructions, 6 rectal prolapses, 5 bowel obstructions, 3 dysuria and one peri-stomal fistula. One hundred and twenty three patients (88%) had stoma reversal, and median time to reversal was 4.2 months. In 16 patients (12%), stoma reversal was not performed. The reasons were 10 tumor metastasis or recurrence of rectal cancer, 3 anastomotic leakage or stricture and 3 patients’ reques. In 16 patients (13%) after stoma reversal, reconstructions of ostomy were performed because of 6 anastomotic recurrences of cancer, 3 anastomotic strictures, 2 late anastomotic leakages, 2 poor anal function, one recto-seminal vesicle fistula, one perforation of colon and one perforation of small intestine. In 110 patients (79%), stoma reversal was performed in the follow-up period of at least one year.

Conclusion: Twenty nine patients (21%) undergone laparoscopic ISR with defuntioning ostomy did not have stoma reversal or had stoma recreation after reversal in the follow-up period. It is important to detect the patient who may not have stoma reversal preoperatively and should be considered for permanent stoma.


The Current Status of TaTME-ISR and Robot-LAR for Rectal Cancer in Comparison with Lap-ISR and Lap-LAR

Takuya Miura, Yoshiyuki Sakamoto, Hajime Morohashi, Hayato Nagase, Tatsuya Yoshida, Kentaro Sato, Yutaro Hara, Kenichi Hakamada; Hirosaki university

Background/Aim: Laparoscopic-Intersphincteric resection (ISR) and Low anterior resection (LAR) for rectal cancer is widely accepted, but the usefulness and problems of TaTME and Robot remained unclear. By comparing with Lap, we will examine the current status of TaTME-ISR and Robot-LAR.

Methods: We compared 13 patients of Lap-ISR + diverting stoma (DS) with 15 patients of TaTME-ISR + DS and 19 patients of Lap-LAR + DS with 7 patients of robot-LAR + DS retrospectively. In our hospital, TaTME was only introduced to ISR. LLND cases were excluded in the comparison between Robot and Lap, because Robot-lateral lymph node dissection (LLND) was only performed in one patient. The patients who underwent a partial resection of adjacent organs, pelvic exenteration, and simultaneous resection other than pelvic organs were excluded.


1. Lap vs TaTME-ISR. In the characteristics, distance from tumor margin to anal verge was statistically longer in TaTME (3 cm/5 cm) but gender (male, 69%/82%), BMI (22.8/22.4), preoperative chemotherapy (23%/46%), tumor diameter (3 cm/4 cm), T3 (15%/21%), lymph node metastasis (7%/6%) and lateral lymph node dissection (61%/46%) were not obviously different. Postoperative complications in Lap were 15% of anastomotic leakage (Grade A 1, B 1), 15% of intracorporeal SSI, 15% of stoma related complications and 7% of urinary retention (Grade 2). TaTME had 20% of anastomotic leakage (GradeA 1, B 2), 53% of intracorporeal SSI, 46% of stoma related complications and 6% of urinary retention (Grade 1). The definitive stoma was created in 7% after Lap-ISR and 33% after TaTME.

2. Lap-LAR vs Robot-LAR. In the characteristics, Lap group had more advanced tumor such as size (15 mm/35 mm), T3 (52%/14%), and lymph node metastasis (42%/0%). Gender (male, 100%/100%), BMI (22.5/24.0), preoperative chemotherapy (5%/0%), and distance from tumor margin to anal verge (9 cm/7 cm) were not obviously different. Operative time was longer in Robot (260 min/404 min) but blood loss was not different (15 ml/20 ml). Postoperative complications in Lap-LAR were 31% of anastomotic leakage (Grade A 1, B 3, C 2), 21% of stoma related complications and 5% of urinary retention (Grade 2). Robot-LAR had 0% of anastomotic leakage, 28% of stoma related complications and 14% of urinary retention (Grade 1).

Conclusions: Compared to Lap-ISR, TaTME-ISR in the early stage of introduction had many intracorporeal SSI, stoma-related complications and definitive stoma. Robot-LAR can reduce anastomotic insufficiency as compared with Lap-LAR.


Impact of Perioperative Variables According to the Start Time of Laparoscopic Colorectal Surgery

Mariana Matzner Perfumo, MD, Maria Elena Peña, MD, Jose Piatti, MD, Maximiliano Bun, MD, Nicolás Rotholtz, MD; Hospital Aleman

Introduction: The operation start time might be one of the many factors that can contribute to the patient´s outcomes. The aim of this study was to evaluate the relationship between operation start time and patient outcomes in laparoscopic colorectal surgery.

Methods and Procedures: A series of patients who underwent elective colorectal surgery was analyzed from a prospective data base since January 2005 from June 2018. Patients were divided in two groups according to the start time of surgery. G1: 8am-12am and G2: 12:01 am-20 pm. At the same time the procedures were categorized in: Simple procedures (segmental resections and anterior resection) and complex procedures (total colectomies, total proctocolectomy, low anterior resection, abdominoperineal resection). Demographic data, hospital stay, type of complication, number of reoperations morbidity and mortality were analyzed.

Results: A total of 1339 patients underwent laparoscopic elective colorectal surgery. 715 (54%) Were included in G1 and 624 (46%) in G2. The media age was 61 years. No differences between both groups were identified in demographic data. Time of surgery was lower in G2 with no statistically significant differences. Although simple procedures were performed more frequently in G2 (460 (73,7%) vs G1 (491 (68,7%)) p < 0,04) the rate of intraoperative complications was higher in this group (G2 (67 (10.7%)/G1:54 (7,6%) p < 0.04). However there no differences in conversion rate. The length of hospital stay was less in G1 (G1: 4,6, G2:5,5 p < 0.001). The most common complication was Clavien I in G1 (G1:135 (19%), G2:92 (14,7%), p < 0,04). Reoperations were more often in G2 (77(12,3%/G1:63 (9%)); p < 0.03. Mortality rates were higher in G2 (15 (2,4%)/G1 7 (1%) p < 0.04).

Conclusion: Start time of surgery after 12 am generates an impact on patient´s outcomes in laparoscopic colorectal surgery as the increased morbidity and mortality.


Perioperative Nutrition-Focused Intervention in Enhanced Recovery After Surgery

Zhigang Xue, MD, Jianchun Yu, MD, Weiming Kang, MD, Zhiqiang Ma, MD, PhD, Xin Ye, MD, Yuguang Huang, MD, Lijian Pei, MD; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences

Aim: Enhanced recovery after surgery (ERAS) program focusing on nutritional risk assessment and comprehensive perioperative nutritional intervention is limited. We aimed to study the safety and efficacy of ERAS program focusing on the integrative clinical nutrition concept.

Methods: Our study was a single-center, prospective cohort study. The ERAS group included special focus on preoperative nutritional assessment, nutritional supplements by oral or tube feeding, early postoperative enteral nutrition (EN), combined with other series of ERAS items including no routine mechanical bowel preparation, preoperative carbohydrate loading, NSAIDs as analgesic meditation, no routine of gastric tube, no routine or early removal of peritoneal drainage and so on. The control group was under traditional perioperative management including routine mechanical bowel preparation, preoperative fasting and fluids limitation for 6-8 h prior to induction of anesthesia, opioid analgesia, routine placement of gastric tube and peritoneal drainage, postoperative parenteral nutrition (PN) and so on. The primary outcome was postoperative length of hospital stay (LOS), and secondary outcomes included total hospitalization cost, postoperative complication rate, readmission rate within postoperative 60 days.

Results: From December 2015 to April 2018, we enrolled 204 patients with GI surgery in the Department of General Surgery, Peking Union Medical College Hospital, and Chinese Academy of Medical Sciences. 102 patients in the ERAS process group, and 102 patients in the traditional process group. The postoperative LOS in the ERAS group was significantly lower than that in the traditional group (7.2 ± 4.5 days vs. 9.8 ± 4.8 days, p < 0.001). Total hospitalization cost in the ERAS group was significantly lower than that in the traditional process group (41 125 ± 18 593 RMB vs. 51 512 ± 19 453 RMB, p < 0.001) as well. The postoperative EN start time in ERAS group was on 2.4 ± 1.8 days after surgery (POD), and the traditional group was on POD 5.1 ± 1.2 (p < 0.001). There was no significant difference in the incidence of postoperative complications between the two groups (ERAS group: 9.8% vs. traditional group 13.7%, p = 0.646), and readmission rate within postoperative 60 days were 2.9% and 2.0% respectively.

Conclusion: Perioperative Nutrition-focused Intervention including preoperative nutritional assessment and intervention and early postoperative EN as well as other ERAS programs are safe and effective in GI surgery. Nutrition-enhanced ERAS program helps to reduce postoperative hospitalization and total cost significantly, while showing no increase of postoperative complications and readmission rate within POD 60. Integrative clinical nutrition-focused program may be more reasonable and feasible when achieving enhanced recovery after GI surgery.


Short Term Outcomes of Laparoscopic Ventral Mesh Rectopexy in the Management of Complete Rectal Prolapse

Anwar Zeb Khan, Muhammad Adeel Kaiser, Danish Ali, Muhammad Farooq Afzal; Lahore General hospital, Lahore

Purpose: To analyze the short outcome of laparoscopic mesh rectpexy in the management of rectal prolapse.

Methods and Material: This is a case series of 6 patients with rectal. Prolapse who was admitted through Opd. They have been subjected to clinical examination and sigmoidoscopy. They have underwent laparoscopic ventral mesh rectpexy. Post of bowel functions and complications have been documented.

Results: Median age was 38.male into female ratio was 1:1. Median operation time was 130 min. Their hospital stay was 3 days. They have been observed in follow up and no complication has been documented.

Conclusion: We suggest that laparoscopic ventral mesh rectpexy is a safe technique and nerve sparing method is good and result in less complication and less recurrence.


Laparoscopic Low Anterior Resection for Diverticular Disease on a Patient with Situs Inversus Totalis

Lucia Collar Yagas, MD 1, Nicolas M Cordoba, MD2, Jan P Kamiski, MD, MBA1, Joaquin J Estrada, MD, FACS, FACRS11Advocate Illinois Masonic Medical Center, 2Private Practice

Situs inversus totalis (SIT) is a rare condition with an approximate incidence of 1:10,000 live births, in which the position of the thoracic and abdominal organs is inverted presenting as a mirror image of the normal anatomic layout called situs solitus. Colonic diverticulosis is, on the other hand, a common clinical condition with a prevalence that increases with age, being 1 to 2% in patients under the age of 30 and over 40% after age 60. Approximately a quarter of such patients will develop acute diverticulitis.

We present a case of SIT and recent history of complicated acute diverticulitis, and our experience performing a laparoscopic low anterior resection. To our knowledge, there have been no similar cases previously reported in the literature.

A 29-year-old male with SIT and polysplenia presented after an episode of acute sigmoid diverticulitis complicated by an intra-abdominal abscess. He had a previous episode of uncomplicated diverticulitis.

Due to the recurrent episodes of diverticulitis, the complicated course of the last one, and the patient’s abnormal topography, a sigmoid colon resection was recommended, as well as an appendectomy in view of the atypical location of the appendix.

A laparoscopic low anterior resection (LAR) with primary anastomosis and an appendectomy were performed. Special consideration regarding port placement and position of the surgeon and assistant were taken. The operator was situated at the left side of the patient and the assistant at the right, which is opposite to a conventional laparoscopic LAR. Ports were placed in a mirrored fashion to their regular placement. The surgeon used his left hand as the main working hand for most of the procedure. Extra care was taken due to the presence of multiple accessory spleens. The surgery was completed safely with an operating time of 180 min and minimal blood loss.

Conclusion: In a patient with SIT and history of diverticulitis, surgery should be indicated to avoid future problems such as misdiagnosis, delay in treatment and the possible complications that these might bring. Similarly, a prophylactic appendectomy should be performed at the time of a laparoscopy for any other indication.

SIT represents a technical challenge for the surgeon. A laparoscopic approach is feasible and safe in the hands of an experienced surgeon. Understanding the aberrant anatomy and being able to adjust technical aspects of the surgery to this condition are key elements for the success of a laparoscopic LAR.


Efficacy and Safety of Laparoscopic-Assisted Versus Traditional Open Surgery for Synchronous Multiple Primary Colorectal Cancers

Ziming Cui, Xiaoyu Dong, Weisheng Chen, Dexin Chen, Wei Jiang, Kai Li, Jun Yan; Department of General Surgery, Nanfang Hospital, Southern Medical University

Background: There is still no consensus on the treatment of synchronous multiple primary colorectal cancers (CRCs). In this study, we aimed to compare the efficacy and safety of laparoscopic-assisted versus traditional open surgery for multiple primary CRCs.

Methods: Between March 2006 and March 2018, 115 patients who suffered from synchronous multiple primary CRC with clinical stage among T1-4N0-2M0 were included. Efficacy and safety of laparoscopic-assisted group (n = 75) and traditional open group (n = 40) were compared. All patients were followed up every 6 months and were recorded the survival.

Results: Two patients were converted to open surgery in the laparoscopic-assisted group. Both length of total and postoperative hospital stay were significantly shorter in the laparoscopic-assisted group than the traditional open group (median 16 vs 19 days, p = 0.004; median 10 vs 12 days, p = 0.006, respectively). The laparoscopic-assisted group yielded less blood loss (median 100 vs 125 mL, p = 0.003), shorter postoperative exhaust time but longer operation time (median 230 vs 197 min, p = 0.031) than the traditional open group. There was no significant difference on the overall survival and disease-free survival between two groups.

Conclusion: Our results suggested that laparoscopic-assisted surgery is a more efficacious, relatively safer and minimally invasive treatment for synchronous multiple primary CRCs. Further randomized controlled trials with larger sample sizes are needed to strengthen the conclusion of this study.


Early Discharge with Transversus Abdominis Plane (TAP) Block as Component of Colon Resection Protocol

Natalie Pozzi, Landon Guntman, MD, Logan Brady, Phillip Corvo; Saint Mary’s Hospital

Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to optimize recovery and reduce hospital length of stay. Adverse effects from long-acting medications such as opioids, sedatives, and hypnotics slow recovery. This study aims to assess the impact of the addition of the Transversus Abdominis Plane (TAP) block as a component of non-opioid pain management for elective colorectal surgery patients at a community hospital.

Method(s): A retrospective chart review was performed from October 2015 – December 2016 for all adult patients undergoing general anesthesia and elective colon resection. Patients who received TAP blocks in addition to general anesthesia were compared to patients who received general anesthesia alone. Length of stay was calculated for each patient from time of admission to discharge from the hospital.

Results: Thirty-four patients who were treated with TAP block were compared to 32 patients who received conventional care. Length of stay was 25 h shorter (P = 0.02) for patients who received general anesthesia with a TAP block compared to patients who received general anesthesia only. Additionally, compared with other surgeons at our institution, those following the established ERAS protocol with the addition of TAP block had an average length of stay shortened by 31 h (P = 0.07).

Conclusions: As part of the ERAS protocol, TAP blocks using liposomal bupivacaine significantly reduce hospital length of stay in patients undergoing elective colorectal surgery.


Transanal Total Mesorectal Excision for Low Rectal Cancer: A Case-Matched Study Comparing TaTME Versus Standard Laparoscopic TME

Magdalena Mizera, Grzegorz Torbicz, Natalia Gajewska, Jan Witowski, Mateusz Rubinkiewicz, MD, PhD, Mateusz Wierdak, MD, Magdalena Pisarska, MD, Piotr Major, MD, PhD, Piotr Malczak, MD, Michal Pedziwiatr, MD, PhD; 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland

Background: Transanal total mesorectal excision (TaTME) is emerging as a novel alternative to laparoscopic total mesorectal excision (LaTME). The aim of this study was to compare clinical and pathological results from these two techniques in patients undergoing rectal resections for low rectal cancer.

Materials and Methods: Thirty-five patients undergoing TaTME were matched with 35 patients operated on using LaTME. Composite primary endpoint (complete TME, negative circumferential resection margin [pCRM], and distal resection margin [pDRM]) was used to assess pathological quality specimens. Secondary outcomes included operative and postoperative parameters (operative time, total blood loss, postoperative morbidity, length of stay, 30-day mortality).

Results: Composite primary endpoint was achieved by 85% of subjects in the TaTME group and 82% of subjects in the LaTME group (p = 0.66). Mean pCRM was 1.1 ± 1.29 mm vs. 0.99 ± 0.78 mm (p = 0.25). Distal pDRM was 1.57 ± 0.92 cm and 1.98 ± 1.22 cm (p = 0.15). In the TaTME and LaTME groups, respectively. Complete mesorectal excision was achieved in 89% and 83% of subjects, while excision was nearly complete for the remaining 11% and 17% (p = 0.23). Secondary outcomes were not significantly different.

Conclusions: TaTME appears to be a non-inferior alternative to laparoscopic surgery. In comparison to LaTME, TaTME allows for similar quality of specimens with comparable clinical outcomes.


Standarding Nursing Care to Ehnance Recovery After Colorectal Surgery

Lauren Charles-Johnson, BS, RN, BSN, Miranda Aigeldinger, RN, BSN, PCCN; Lankenau Medical Center

Standardizing nursing care for colorectal surgical patients will enhance recovery by reducing physiologic and psychological stress, improve patient post op pain, expedite bowel function, and decrease cost by a shorter hospital stay and reduced post op complications.

The Enhanced Recovery after Surgery (ERAS) pathway involves continuous teaching and nursing interventions at all stages of care. When a patient comes to the hospital for pre-admission testing (PATs) the nurse discusses with them their plan of care including what to do the night before surgery, realistic postoperative pain expectations, the effects of early ambulation on the healing process, and the negative effects of opioid medication on bowel function. Instructions include drinking a carbohydrate load (12 oz) or clear fluids up to 2 h prior to surgery and taking Entereg the night before. Upon admission, Entereg is administered with a small sip of water if needed, along with Tylenol, Gabapentin, and Celebrex by the preoperative nurse. Teaching done in PATs is reiterated.

Once in the OR the CRNA uses a Clearsite to monitor fluid volumes, propofol to reduce postoperative nausea and vomiting, a ketamine or lidocaine drip are administered for the duration of the case, and a local nerve block using bupivacaine to the anterior abdominal wall is administered once the procedure is complete. The intraoperative goal is euvolemia, defined as having the total fluid volume less than 2L above total losses. In the PACU the nurse assesses pain and administers pain medication as ordered or uses integrative therapy (Reiki, positioning, music, and guided imaginary). The PACU nurse assesses the IV fluid rate, questions the use of an NG tube or Foley catheter, and continues to educate the patient about pain management and the importance of day of surgery ambulation.

Upon arrival to the inpatient unit the nurse maintains the use of multimodel pain management converting to oral medications, uses aggressive antiemetic therapy (Dexamethasone 4-10 mg and Ondansetron 4 mg), removes the Foley or nasogastric tube, promotes chewing gum, and begins an ambulation schedule. The nurse ambulates the patient as soon as possible the day of surgery setting specific goals.

Since being implemented the average length of stay (5-7 days) is declining with a few patients leaving as early as post op day 2. Many patients have shown enhanced recovery which is a patient who is eating, drinking, and mobilizing well. The newly standardized ERAS pathway is largely the reason for these patients’ success.


Robotic Right Colectomy with Complete Mesocolic Excision and Suprapubic Approach: Clinical and Oncologic Results of a Consecutive Single-Centre Experience

Wanda Petz, MD, Emilio Bertani, MD, Simona Borin, MD, Alessandra Piccioli, Uberto Fumagalli Romario, Giuseppe Spinoglio, MD, FACS; European Institute of Oncology

Background: Single-center non randomized series have shown that D3 lymphadenectomy and complete mesocolic excision (CME) in the surgical treatment of colon cancer can provide better oncologic results in comparison with conventional technique in which integrity of mesocolon is not preserved and central lymph nodes are not removed.

However, this technique is technically demanding, particularly with a laparoscopic approach.

Aim of this study is to describe a robotic suprapubic approach to right colectomy with CME and D3 lymphadenectomy and to report oncologic safety and short term outcomes.

Methods: Data from 57 consecutive patients who received a robotic right colectomy with suprapubic approach for right colon cancer are presented.

Surgery is realized with the Da Vinci Xi® system and all trocars are placed along a horizontal line 3-6 cm above the pubis. CME with fluorescence-guided D3 lymphadenectomy is performed.

After Indocyanine Green intravenous injection, bowel stumps perfusion is assessed, and an intracorporeal isoperistaltic side-to-side mechanical anastomosis with robotic linear stapler and manual closure of insertion holes is realized.

The specimen is extracted through a Pfannenstiel incision.

Results: Patients median age was 69 years, median body mass index was 27 kg/m2. Median operative time was 228 min, blood loss was negligible, no conversions to open or laparoscopic surgery occurred. Median hospital stay was six days; two postoperative grade IIIa Clavien-Dindo complications occurred, no 30-days postoperative death was registered. Resection margins were negative in all patients; median tumour diameter was 3.6 cm, median specimen length was 40 cm, median number of harvested lymph nodes was 37.

Conclusions: Robotic right colectomy with cme using a suprapubic approach is a feasible and safe technique that allows for an extended lymphadenectomy and provides high quality surgical specimens.


Current Status of taTME in China

Liang Kang; the sixth affiliated hospital of Sun Yat-sen University

Methods: A questionnaire survey was conducted in 71 large medical centers in 23 provinces of China. The survey included the time to launch taTME, the number of taTME cases completed, the occurrence of complications and the difficulties encountered at present.

Results: A total of 71 units completed the questionnaires, of which 2/3 units have begun to carry out taTME, a total of 915 taTME cases were counted, of which 211 completed the most cases, 10 units completed more than 30 cases (14.1%). The total complication rate was 138 (15%). Among them, anastomotic leakage was found in 75 cases (8.2%), urinary retention in 21 cases (2.3%), fecal incontinence and anastomotic stenosis in 8 cases (0.9%) and urethral injury in 6 cases (0.6%). Other complications included intestinal obstruction in 5 cases, anastomotic bleeding in 4 cases, diffuse peritonitis in 3 cases, vaginal injury in 2 cases, ureteral injury in 1 case. Surveys of technical difficulty showed that 50% of the surgeons thought lateral dissociation was more difficult, 43% thought anterior dissociation was more difficult, and 35% thought purse suture was more difficult. Analysis of the factors affecting the development of taTME showed that 70.4% of the surgeons believed that there was a lack of professional equipment, 35% of the surgeons believed that the anatomical structure was unclear, 29% of the surgeons believed that the transanal operation was inexperienced and they were not confident to carry out it for the time being.

Conclusion: At present, the development of taTME in China is still in its infancy, and there are still many technical problems to be solved. The lack of professional instruments and equipment is the main problem for this operation.


Postpolypectomy Electrocoagulation Syndrome: A Rare Imitator of Perforation after Colonoscopy

Shinban Liu, DO 1, Nicholas Morin, DO1, Vadim Meytes, DO21NYU Langone Medical Center, 2Vassar Brothers Medical Center

Case Description: A 78-year-old woman presents to the emergency department with complaints of abdominal pain. Earlier that day she had undergone a routine screening colonoscopy with polypectomy of 3 sessile polyps removed from the transverse colon. She was hemodynamically stable but febrile (101.3?). Laboratory values were significant for white blood cell count of 16.3 K/uL but otherwise grossly within normal limits. A computed tomography of the abdomen and pelvis demonstrated no free intraperitoneal air and focal wall thickening of the mid transverse colon containing biopsy clips. Due to her clinical presentation with localized peritonitis, laboratory workup, and imaging studies the patient was brought urgently to the operating room for diagnostic laparoscopy. Upon insertion of the laparoscope, no perforation or gross spillage was identified after examination of the bowel. The prior polypectomy site in the mid transverse colon was located with identification of colonoscopic tattoo and noted to have surrounding hyperemia and edema consistent with transmural burn without perforation. The remainder of her hospital course was unremarkable and was ultimately discharged home with suspected postpolypectomy electrocoagulation syndrome.

Discussion: Postpolypectomy electrocoagulation syndrome (also known as polypectomy syndrome and transmural burn syndrome) is a rare condition with an incidence of 0.07% following colonoscopic polypectomy. Development of this syndrome is associated with large amounts of thermal energy over extended periods of time when performing extensive endoscopic submucosal dissection. The electrical current is theorized to extend past the targeted mucosa into the muscularis propria and serosa creating a transmural burn without associated perforation. Clinically this may manifest as localized peritonitis secondary to serosal irritation and subsequent inflammatory response. Patients may also present with symptoms of fever, leukocytosis, and imaging demonstrating inflammation with or without microperforation such as in this case– all of which are concerning for an acute surgical abdomen. This diagnosis should be suspected in patients following polypectomy with electrocautery but should be confirmed with imaging to evaluate for frank perforation and free air rather than focal wall thickening and inflammatory changes as seen in this syndrome. Treatment of this syndrome consists of conservative management with nothing by mouth, antibiotics, and intravenous fluids until symptoms improve with the majority of patients fully recovering. Recognition of this condition is important as unnecessary surgery can be avoided.


Adoption of Laparoscopic Colorectal Surgery in the Elderly Population: Current State and Value Proposition

Deborah S Keller, MS, MD, James M Kiely, MD, Daniel P Geisler, MD, Ravi P Kiran, MD; Columbia University Medical Center

Background: The economic and clinical benefits of laparoscopic colorectal surgery are proven, yet laparoscopy remains underutilized in appropriate cases in the United States. Use of laparoscopy in the elderly may remain specifically underutilized, despite reports of safety and feasibility. Since the elderly constitute the greatest surgical colorectal volume, our goal was to identify trends in utilization and outcomes for laparoscopic colorectal surgery in this cohort.

Methods: Review of the Premier Inpatient Database was performed for elective inpatient colorectal resections between 1/1/2010 and 9/30/2015. Patients were stratified into elderly (≥ 65 years) and non-elderly cohorts (< 65 years), then grouped into open or laparoscopic procedures. The main outcome measures were the trends in utilization by approach and total costs for the episode of care (considering the inpatient and 30-day post-discharge periods), hospital length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models were used to control for differences across the platforms, adjusting patient demographic, comorbidities and hospital characteristics.

Results: Laparoscopic adoption was greater and steadily increased in the non-elderly, while in the elderly, laparoscopy rates increased until 2013, then declined, with increasing rates of open surgery. In the elderly, laparoscopy was associated with significantly lower mean total costs ($4,012 less/case), complications and readmissions less likely (36% and 33% less, respectively), and shorter LOS (2.59 less days) than open cases (all p < 0.0001). When complications occurred, they were less severe and the readmission episodes were less costly with laparoscopy than open colorectal surgery.

Conclusion: The adoption of laparoscopic colorectal surgery in the elderly has lagged behind that of younger patients and has even declined slightly in recent years. Considering the reduced overall cost with improved clinical outcomes, there is a tremendous value proposition, in addition to the clinical benefits, for patients and hospitals with increased use of laparoscopic colorectal surgery in the elderly.


Incidence of Colon Resections is Increasing in the Younger Populations: Should an Early Initiation of Colon Cancer Screening be Implemented?

Maria S Altieri, MD, MS 1, Hannah Thompson, MD2, Aurora Pryor, MD1, Jie Yang, MD2, Siao Sun, BS2, Konstantinos Spaniolas, MD2, Mark Talamini, MD, MBA2, Jill Genua, MD21Washington University School of Medicine, 2Stony Brook University Hospital

Introduction: The American Cancer Society recently lowered the recommended age for screening of colorectal cancer (CRC) to age 45 due to recent data showing increased incidence of CRC in younger populations. The purpose of this study was to evaluate if younger patients have increased likelihood of resection for CRC (CRR) through the use of a statewide longitudinal database.

Methods: The New York SPARCS administrative database was used to identify all patients with diagnosis of colon cancer from 2000-2016. Through the use of ICD-9 and ICD-10 procedure codes, patients undergoing colorectal resections were identified. Patients were divided into seven age groups: 21-30, 31-40, 41-50, 51-60, 61-70, 71-80 and > 80. Patients’ characteristics, demographics, co-morbidities, and complications were evaluated. Duplicate records, missing information, and age < 21 were excluded from analysis. For multiple procedures, only the first procedure was included in the analysis. Chi square test was used to compare patients’ characteristics, comorbidities and complications among age groups. The linear trend of colon resection in different age groups over years was examined using log-linear Poisson regression models with year as an explanatory variable. Relative risks (RR) with 95% confidence interval were reported.

Results: Following inclusion and exclusion criteria, there were 73,697 colon resection surgeries extracted from 2000 to 2016. Trends are shown on Figure 1. Younger age was significantly associated with increased CRR over time. Patients age 21-70 had a significantly increasing trend over the years (age group 21-30: RR = 1.06, p-value < 0.0001; age group 31-40: RR 1.04, p < 0.0001; age group 41-50: RR 1.04, p < 0.0001; age group 51-60: RR 1.02. p < 0.0001); age group 61-70: RR 1.01, p = 0.0012). Patient age > 70 was significantly associated with decreasing trend of CRR over the years (age group 71-80: RR0.98, p < 0.0001 an age group > 80: RR 0.99, p-value < 0.0001).

Conclusion: Over the years, younger patients have an increased trend of undergoing colorectal resections, with up to a 6% yearly increase over the studied period. New screening initiation guidelines should be considered and awareness among clinicians and the general public should be increased.


Laparoscopic Management Of A Rare Adult Patent Urachus Presenting as a Colovesical Fistula

Esther H Cha, MD, David Lisle, MD, P. Jeffrey Ferris, MD; Medstar Health Baltimore

Introduction: Urachal ramnants result from a failure in the obliteration of the allantois at 4 – 5th week of gestation which connects the bladder to the umbilicus. This congenital anomaly occurrence is rare occurring about 1.6% in children and less than 1% in adults. We present a rare case of adult patent urachus presenting as a colovesical fistula complicated by chronic sigmoid diverticulitis managed by laparoscopy.

Case Presentation: A 63-year-old gentleman referred to a colorectal surgeon’s office from his urologist for evaluation of symptoms consistent with pneumaturia. He described passing occasional gas during urination and feculent urine. However, he denied having any night sweats, fever, chills, or unintentional weight loss. As his preoperative work-up, patient obtained contrast-enhanced computed tomographic (CT) cystogram which revealed thickened bladder dome and adjacent sigmoid colon inflammation, and air in the bladder concerning for colovesical fistula. Subsequently, he underwent colonoscopy which had to be aborted due to severe inflammation at the proximal sigmoid colon due to diverticular disease. Then the patient was taken to the operating room for a laparoscopic resection. Once splenic flexure was mobilized laparascopically, it was noted that the thickened sigmoid colon was adherent to the lower mid-abdomen entering a triangular structure located superior to the dome of bladder. This patent urachus along with the segment of adherent sigmoid colon were resected and extracted with small midline incision. Final surgical pathology revealed chronic diverticulitis of the sigmoid colon and colo-urachus fistula without any malignancy. Patient had uncomplicated postoperative recovery course and was discharged home on postoperative day 7.

Discussion: The persistent urachal lumen has variety of clinical presentations, most commonly as periumbilical skin infection. Involution of this allantoic duct and cloaca becomes fibrotic cord known as the median umbilical ligament. There are four variants of urachal anomalies: cysts, sinus, diverticulum or a patent urachus. Urachal remnants progressing to malignancy are rare, less than 1%, and most common malignancy type is urachal adenocarcinoma. Surgery remains as the primary treatment option. The traditional surgical approach to resection involves excision with low midline laparotomy or semicircular infraumbilical incision. Few reports include laparoscopic and robotic approaches with safe, successful outcomes.

Conclusion: Adult urachal remnant is rare and surgery is the treatment of choice as it prevents both recurrence of symptoms and malignant transformation. Laparoscopy is a useful and safe technique for the management of persistent or complicated urachus.


Transanal Total Mesorectal Excision for Diffuse Cavernous Hemangioma of the Rectum

Ziwei Zeng, Shuangling Luo, Liang Kang; the Sixth Affiliated Hospital, Sun Yat-sen University

Aims: To evaluate the safety and feasibility of transanal total mesorectal excision (TaTME) for diffuse cavernous hemangioma of the rectum (DCHR).

Methods: All DCHR patients who underwent TaTME in our hospital between January 2014 and June 2018 were reviewed.

Results: A total of 7 patients with a diagnosis of DCHR underwent TaTME during the study period. Four patients (57.1%) were male, with a mean age at surgery of …years.. Recurrent painless rectal bleeding was the chief symptom in all patients. The mean age was 32 years old (range 21-54). The median duration of symptoms was 10 years (range 1 month-50 years). The level of hemoglobin at admission ranged from 59.0 to 148.0 g/L (mean 106.6 g/L), and the level of MCV ranged from 75.1 fl to 93.5 fl (mean 83.7 fl). Colonoscopy, CT and MRI were important in the diagnosis of DCHR because of their high positive rates and accurate features. All of the lesions are between the anal tube and the descending colon. Two patients could be found enlarged serpentine vessel in other tissues and organs. After admission, all the patients underwent TaTME and four patients had simultaneous loop ileostomy. The mean operative time was 278 min (range 168-400 min). The median amount of intraoperative blood loss was 50 ml (range 10-300 ml). The mean distance from anal verge to anastomosis 2.2 ± 0.2 cm. The anastomosis was fashioned with a stapler in two patients (28.6%). There were no intraoperative and postoperative complication happened. All the patients continued to recover well from the surgery, and nobody needed postoperative blood transfusion.

Conclusions: The definite diagnosis rate of DCHR is low. Preoperative MRI and CT examination can make a definitely diagnosis and determine the extent of the lesions. DCHR mostly restricts to the rectum, sigmoid colon, anal wall and mesorectum. The best treatment for DCHR is completely lesions resection. It is safety and feasibility to therapy DCHR by TaTME. Moreover, transanal procedure (TaTME) might have huge potential in other rectal diseases.


Fitway Alabama Colorectal Cancer Prevention Program: Analysis of Results

Greg S Thompson, MD, Lee West, MD, Mark A Parker, MD; Brookwood Baptist Health

Colorectal cancer is the 4th most common cancer and 2 most common COD. In Alabama, it is among the top 6 in regards to mortality. There are several methods of screening for CRC but the most widely used are stool tests and colonoscopy. Stool tests include the FIT and FOBT which require samples with low sensitivity and will miss polyps. These are recommended as annual screening in conjunction with flexible sigmoidoscopy. Ultimately statistics have shown a 67% reduction in risk of death for CRC compared to no endoscopy.

The FITWAY program is a statewide program of the ADPH aimed at providing colorectal screening to AL residents. Patients receive a FIT test at their local clinic at age 50 and would be referred to have a colonoscopy if positive or recommended under current screening guidelines. Our study looked at the results a specific practice which is made up of 3 experienced colorectal surgeons who have participated in the program since May 2016. Data from 265 patients spanning 15 months was reviewed concentrating on age, gender, comorbidities, FIT results, prep adequacy and each of those associated ADR.

265 patients were examined and of the 19% who had a positive FIT, 45% had an adenoma found on endoscopy. Of the 26 pts w/negative FIT, 30% had an adenoma detected on endoscopy. The average age of patients screened was 56 and this was the first colonoscopy for 85% of them. 2/3 of patients screened were women. Overall patient prep was acceptable with 93% having adequate prep and only 3% having to be aborted. The ADR was equivalent to the national rate for endoscopists at 37% and well above the accepted rate of > 25%. Of the comorbidities assessed for patients w/adenomas detected, 71% had HTN and 56% had history of smoking. 35% of those with hypertension had an adenoma found and 55% of smokers had an adenoma detected. 1 cancer was detected throughout all these.

We estimate 6 colorectal cancers prevented and 325 thousand dollars saved in the small study thus far. FITWAY has provided a cost effective screening and prevention service to the underserved population of Alabama. With adequate funding, a strong referral base of PCP’s, and sufficient amount of gastroenterologists and colorectal surgeons we could begin to chip away at the national statistics and bring down Alabama’s incidence rate of colorectal cancer.


Accuracy of Preoperative Endoscopic Localization of