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Adaptation of Robotic Sleeve Gastrectomy During Bariatric Surgical Fellowship
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
Conclusion: Rigorous patient selection, without band complications such as: slippage, erosion, or obstruction, allows for a significantly lower rate of operative complications for a onestage conversion of failed gastric banding to a LSG. A5280
EVALUATION OF SAFETY AND EFFECTIVENESS OF A NOVEL SUCTION CALIBRATION SYSTEM (SCS) COMPARED TO A BOUGIE IN LAPAROSCOPIC SLEEVE GASTRECTOMY (LSG) Leonardo Claros, MD1; Maher ElChaar, MD2; Rose Huang, MS3; George Ezeji, MD1; Jill Stoltzfus, PhD2; 1Allentown, PA, USA; 2 Bethlehem, PA, USA; 3Phoenixville, PA, USA Background: LSG consists of three steps: decompression, sleeve sizing, and leak testing. Using a different intraluminal tube for each step interrupts OR workflow and increases clinical risks. The aim of this study was to evaluate a SCS that integrates said steps in LSG compared to a bougie. Methods: Enrolled patients were randomly assigned to receive either the 36 Fr. SCS or bougie. Adenosine triphosphate (ATP) swab testing was performed prior to time-out. The insertion and removal times of tubes were recorded. Intraoperative pictures of stomachs before the first staple firing were recorded. The frequency of tube movements was documented. Results: Enrollment included 41 women and 11 men with mean age of 45.7 years and mean BMI of 41.1 kg/m2. ATP results identified 10 times more microbial activity on reusable bougie compared to SCS (p o 0.0001). With SCS, median total operating time decreased 39.8% (1960 sec vs. 1180.5 sec, p o 0.001); decompression time decreased 93.0% (301 sec vs. 21 sec, p o 0.001); greater curvature mobilization time decreased 14.1% (559 sec vs. 480 sec, p ¼0.01). The median number of tube movements was 8 for the bougie versus 4 for SCS (p o 0.0001). Conclusion: SCS integrates multiple steps in one device with controlled suction capability and significantly reduces operating time during LSG. Reduction in tube movement may potentially decrease the chance of risk in esophageal perforation. A5281
EARLY EFFECTS OF SLEEVE GASTRECTOMY ON RHEUMATOID ARTHRITIS Hideharu Shimizu, MD PhD; Fumihiko Hatao, MD, PhD; Kazuhiro Imamura, MD; Kijuro Takanishi, MD; Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan Introduction: The significant impact of obesity on the musculoskeletal system is associated with osteoarthritis (OA). Rheumatoid arthritis (RA) is an autoimmune disease that typically affects the small joints. A low grade inflammatory state related to obesity may play a role in OA and are also culprits in RA. There is some evidence that sleeve gastrectomy ameliorates chronic inflammation related to obesity through weight loss. It has been reported that in patients with RA who underwent bariatric surgery, significant weight loss was associated with improvement in disease activity, reductions in medication use, and a reduction in inflammatory markers. This time, we report the early effects of sleeve gastrectomy on a morbidly obese japanese female who had severe RA.
S207
Presentation of case: We report a 34 year old female with a BMI of 44 kg/m2(103 kg), type 2 diabetes, hypertension, and 10- yearlong RA. She had pain in her feet, hip, knees, back, and hands and could not endure physical therapy and exercise due to pain. She was taking three kinds of DMARDS (MTX, sulfasalazine, and bucillamine), and two kinds of NSAIDS to control her symptoms. Her symptoms related to RA improved greatly within a week after sleeve gastrectomy before significant weight loss occured. All of medications she took before surgery for RA became unnecessary after surgery except for bucillamine. Matrix Metalloproteinase-3 (MMP-3), monitoring her disease activity, showed a reduction from 285.5 to 85.3 within a month after surgery with -8 kg body weight change. Leptin and hs-CRP also decreased. She has been in good condition for 3 months after surgery. The other comorbidities were improved after surgery. Discussion: The pathophysiology of obesity-related OA and RA is multi-factorial. Sleeve gastrectomy appears to contribute to significant improvement of the joint pains and the inflammatory markers related to RA, which happened soon after surgery. Conclusion: Obesity might contribute to progression of RA. Sleeve gastrectomy can be a good treatment option for RA with morbid obesity. A5282
ADAPTATION OF ROBOTIC SLEEVE GASTRECTOMY DURING BARIATRIC SURGICAL FELLOWSHIP Gregory Johnston, DO; Lindsey Berbiglia, DO; Adrian Dan, MD; Mark Pozsgay, DO; John Zografakis, MD, FACS; Summa Akron City Hospital, Akron, OH, USA Introduction: Laparoscopic Sleeve Gastrectomy (LSG) quickly gained acceptance in the treatment of morbid obesity. Furthermore indications and applications for robotic bariatric surgery continue to evolve. Little data exists about the clinical outcomes of bariatric surgery fellowship programs implementing robotic surgery. A retrospective review was completed to determine the feasibility, safety and outcomes of patients undergoing robotic sleeve gastrectomy (RSG) in an advanced laparoscopic and bariatric accredited fellowship training program. Methods: An IRB approved comparison of consecutive patients undergoing RSG versus LSG was performed. Data was collected in each group for age, sex, type of procedure, concomitant procedure, BMI, blood loss, intraoperative complications, postoperative complications, 6, 12 and 18 month percent excess body weight loss (EBWL). Patients were excluded if they had a BMI greater than or equal to 65 kg/m2. Initially the attending surgeon incorporated RSG for weight loss during the first 10 procedures and thereafter the trainee performed as surgeon at the robotic console. Statistical analysis was performed using a T-test with p value o 0.05 as significant. Results: 63 patients underwent RSG and 70 underwent LSG. Average age and female to male ratio was 49 vs. 51.4 years and 50:13 vs. 54:16 in the RSG and LSG groups respectively. Preoperative BMI was 44.3 in RSG vs. 46.4 in LSG patients. Length of stay was 1.2 days versus 1.6 days in RSG and LSG groups respectively. Estimated blood loss was 60.7ml in LSG versus 58.8 in RSG. The 6, 12 and 18 month EBWL was 52.9%, 59.6% and 59.6% in RSG versus 52.4%, 57.6% and 57.4% in
S208
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
LSG. Intraoperative complications included one patient during RSG with esophageal injury during boogie placement and one patient during LSG with a large liver laceration. Two patients undergoing LSG developed a stricture at the incisura versus one undergoing RSG. One anastomotic leak was noted in the LSG group versus zero in the RSG group. A single mortality occurred in the RSG cohort due to a myocardial infarction on postoperative day 3, with no mortalities in the LSG group. In 28 trainee performed cases, excluding the ten cases where the attending performed the procedure, and excluding cases where a concomitant procedure was performed; the first 14 of the 28 cases had an average time of 189 minutes versus 171 minutes (p¼0.03) in the last 14 cases. Conclusions: Implementing RSG into bariatric surgical fellowship training appears safe, feasible and successful with equivalent outcomes. Robotic sleeve gastrectomy was associated with few perioperative complications. Patients who underwent RSG had equivalent weight loss when compared with LSG. There may be a learning curve around 15 cases for RSG during adaptation of robotic training as shown by decreased operative times after an initial 15 cases. As robotic technology improves, robotic training should be considered during bariatric surgical fellowship programs. A5283
INFLUENCE OF BARIATRIC SURGERY ON PREGNANCY Ramona Sanani, MD; Ahmed Abrahim, MD; Christoph Sperker, MD; Martin Schermann, MD; Anton Landsiedl, MD; KA Rudolfstiftung, Vienna, Austria Background: Obese women are known to suffer from gestational pathologies like gestational diabetes, miscarriage and as well as fetal complications such as high birth weight and larger birth size, which might lead to delivery difficulties. Setting: Non-University General Hospital Materials and Methods: During a period of 8 years all patients, who gave birth to at least one child pre and post sleeve gastrectomy, were included into this study. Data concerning weight parameters, obesity associated comorbidities as well as gestational complications and birth related parameters were recorded prospectively and analyzed retrospectively. Results: A total of 16 patients could be identified to meet the criteria to be included in this study. Pre OP BMI showed a mean value of 47.43 kg/m2 while the mean BMI post OP was 31.19 kg/ m2 (po0.001). Two patients showed pathologic blood glucose levels preoperatively, while there were no pathologies concerning diabetes postoperatively. Babies showed a mean birth weight of 3827g and a mean size of 52.5cm preoperatively, while postoperative values where 3341g (p¼0.02) and 50.3cm (p¼0.03). Two patients showed delayed birth pre OP, while there were no difficulties post OP. Preoperatively a total of 20 miscarriages was recorded, while postoperatively only three miscarriages could be observed (p¼0.02). Conclusion: Bariatric surgery shows direct effects on pregnancy and gestational pathologies as well as on incidence of miscarriage. For obese patients with unfulfilled desire to have child, sleeve gastrectomy might be a considerable option.
A5284
ROUTINE INTRAOPERATIVE STAPLE LINE TESTING AND POSTOPERATIVE UPPER GASTROINTESTINAL STUDIES ARE NOT NECESSARY: A COMMUNITYBASED SURGEON’S INITIAL EXPERIENCE Mariana Chavez, MD; Nathaniel Stoikes, Md; David Webb, MD; Guy Voeller, MD; George Woodman, MD; University of Tennessee Health Science Center, MemphisTN, USA Introduction: Laparoscopic Sleeve Gastrectomy (LSG) is emerging as a safe and durable bariatric surgical option with proven weight loss outcomes and comorbidities resolution. It is a common practice to routinely perform intraoperative staple line tests for integrity and postoperative Upper Gastrointestinal (UGI) studies to screen for technical complications such as leak, obstruction or stenosis. However, these tests increase time and costs of the procedure and hospital stay. Objective: To determine if routine intraoperative and postoperative testing is cost effective in a high volume single surgeon community practice. We tested the hypothesis that these routine practices after LSG result in increased length and cost of stay, without impacting patient outcomes. Methods: A retrospective chart review of patients that underwent LSG by a single surgeon at two community hospitals in Memphis, TN from April 2008 to March 2015 was performed. Two groups were identified: those who underwent routine UGI study (UGI) and those who did not (non-UGI). Characteristics evaluated included age, sex, race, preoperative BMI, length of stay, cost of stay per day, complication and readmission rates. Results: A total of 565 patients were included, 210 in the UGI and 355 in the non-UGI group. Intraoperative staple line test was not performed in any patient. There were no postoperative leaks or bleeding in either group. There were 4 re-hospitalizations, none of which were related to the staple line. The cost of an UGI study at these institutions was $1,080 and on average delayed discharge for 3 hours. Also, intraoperative testing takes an average of 10 minutes to perform, resulting in prolonged OR time, anesthesia time and hospital charges. Conclusions: After LSG, routine use of intraoperative testing and postoperative UGI studies is not cost effective. Furthermore, surgeon experience and visual evaluation are sufficient to ensure adequate staple line integrity. We recommend that these studies only be performed when clinically indicated. A5285
IDIOPATHIC COMPLETE HEART BLOCK IN A PATIENT AFTER UNEVENTFUL LAPAROSCOPIC SLEEVE GASTRECTOMY (LSG) Anish Nihalani, MD, FACS; JFK Medical Center, Edison, NJ, USA Introduction: Laparoscopic Sleeve Gastrectomy (LSG) is a widely acccepted weight loss procedure in the United States. The greater curvature is mobilized and then 70% of the stomach is resected leaving a tubular stomach which is supplied by the left and right gastric vessels. The vagus nerve is preserved. An EGD is performed and usually on postoperative day 1, an upper gastrointestinal study is done using gastrograffin to rule out staple line leakage. A bariatric clear liquid diet is subsequently initiated.
Conclusion: Rigorous patient selection, without band complications such as: slippage, erosion, or obstruction, allows for a significantly lower rate of operative complications for a onestage conversion of failed gastric banding to a LSG. A5280
EVALUATION OF SAFETY AND EFFECTIVENESS OF A NOVEL SUCTION CALIBRATION SYSTEM (SCS) COMPARED TO A BOUGIE IN LAPAROSCOPIC SLEEVE GASTRECTOMY (LSG) Leonardo Claros, MD1; Maher ElChaar, MD2; Rose Huang, MS3; George Ezeji, MD1; Jill Stoltzfus, PhD2; 1Allentown, PA, USA; 2 Bethlehem, PA, USA; 3Phoenixville, PA, USA Background: LSG consists of three steps: decompression, sleeve sizing, and leak testing. Using a different intraluminal tube for each step interrupts OR workflow and increases clinical risks. The aim of this study was to evaluate a SCS that integrates said steps in LSG compared to a bougie. Methods: Enrolled patients were randomly assigned to receive either the 36 Fr. SCS or bougie. Adenosine triphosphate (ATP) swab testing was performed prior to time-out. The insertion and removal times of tubes were recorded. Intraoperative pictures of stomachs before the first staple firing were recorded. The frequency of tube movements was documented. Results: Enrollment included 41 women and 11 men with mean age of 45.7 years and mean BMI of 41.1 kg/m2. ATP results identified 10 times more microbial activity on reusable bougie compared to SCS (p o 0.0001). With SCS, median total operating time decreased 39.8% (1960 sec vs. 1180.5 sec, p o 0.001); decompression time decreased 93.0% (301 sec vs. 21 sec, p o 0.001); greater curvature mobilization time decreased 14.1% (559 sec vs. 480 sec, p ¼0.01). The median number of tube movements was 8 for the bougie versus 4 for SCS (p o 0.0001). Conclusion: SCS integrates multiple steps in one device with controlled suction capability and significantly reduces operating time during LSG. Reduction in tube movement may potentially decrease the chance of risk in esophageal perforation. A5281
EARLY EFFECTS OF SLEEVE GASTRECTOMY ON RHEUMATOID ARTHRITIS Hideharu Shimizu, MD PhD; Fumihiko Hatao, MD, PhD; Kazuhiro Imamura, MD; Kijuro Takanishi, MD; Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan Introduction: The significant impact of obesity on the musculoskeletal system is associated with osteoarthritis (OA). Rheumatoid arthritis (RA) is an autoimmune disease that typically affects the small joints. A low grade inflammatory state related to obesity may play a role in OA and are also culprits in RA. There is some evidence that sleeve gastrectomy ameliorates chronic inflammation related to obesity through weight loss. It has been reported that in patients with RA who underwent bariatric surgery, significant weight loss was associated with improvement in disease activity, reductions in medication use, and a reduction in inflammatory markers. This time, we report the early effects of sleeve gastrectomy on a morbidly obese japanese female who had severe RA.
S207
Presentation of case: We report a 34 year old female with a BMI of 44 kg/m2(103 kg), type 2 diabetes, hypertension, and 10- yearlong RA. She had pain in her feet, hip, knees, back, and hands and could not endure physical therapy and exercise due to pain. She was taking three kinds of DMARDS (MTX, sulfasalazine, and bucillamine), and two kinds of NSAIDS to control her symptoms. Her symptoms related to RA improved greatly within a week after sleeve gastrectomy before significant weight loss occured. All of medications she took before surgery for RA became unnecessary after surgery except for bucillamine. Matrix Metalloproteinase-3 (MMP-3), monitoring her disease activity, showed a reduction from 285.5 to 85.3 within a month after surgery with -8 kg body weight change. Leptin and hs-CRP also decreased. She has been in good condition for 3 months after surgery. The other comorbidities were improved after surgery. Discussion: The pathophysiology of obesity-related OA and RA is multi-factorial. Sleeve gastrectomy appears to contribute to significant improvement of the joint pains and the inflammatory markers related to RA, which happened soon after surgery. Conclusion: Obesity might contribute to progression of RA. Sleeve gastrectomy can be a good treatment option for RA with morbid obesity. A5282
ADAPTATION OF ROBOTIC SLEEVE GASTRECTOMY DURING BARIATRIC SURGICAL FELLOWSHIP Gregory Johnston, DO; Lindsey Berbiglia, DO; Adrian Dan, MD; Mark Pozsgay, DO; John Zografakis, MD, FACS; Summa Akron City Hospital, Akron, OH, USA Introduction: Laparoscopic Sleeve Gastrectomy (LSG) quickly gained acceptance in the treatment of morbid obesity. Furthermore indications and applications for robotic bariatric surgery continue to evolve. Little data exists about the clinical outcomes of bariatric surgery fellowship programs implementing robotic surgery. A retrospective review was completed to determine the feasibility, safety and outcomes of patients undergoing robotic sleeve gastrectomy (RSG) in an advanced laparoscopic and bariatric accredited fellowship training program. Methods: An IRB approved comparison of consecutive patients undergoing RSG versus LSG was performed. Data was collected in each group for age, sex, type of procedure, concomitant procedure, BMI, blood loss, intraoperative complications, postoperative complications, 6, 12 and 18 month percent excess body weight loss (EBWL). Patients were excluded if they had a BMI greater than or equal to 65 kg/m2. Initially the attending surgeon incorporated RSG for weight loss during the first 10 procedures and thereafter the trainee performed as surgeon at the robotic console. Statistical analysis was performed using a T-test with p value o 0.05 as significant. Results: 63 patients underwent RSG and 70 underwent LSG. Average age and female to male ratio was 49 vs. 51.4 years and 50:13 vs. 54:16 in the RSG and LSG groups respectively. Preoperative BMI was 44.3 in RSG vs. 46.4 in LSG patients. Length of stay was 1.2 days versus 1.6 days in RSG and LSG groups respectively. Estimated blood loss was 60.7ml in LSG versus 58.8 in RSG. The 6, 12 and 18 month EBWL was 52.9%, 59.6% and 59.6% in RSG versus 52.4%, 57.6% and 57.4% in
S208
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
LSG. Intraoperative complications included one patient during RSG with esophageal injury during boogie placement and one patient during LSG with a large liver laceration. Two patients undergoing LSG developed a stricture at the incisura versus one undergoing RSG. One anastomotic leak was noted in the LSG group versus zero in the RSG group. A single mortality occurred in the RSG cohort due to a myocardial infarction on postoperative day 3, with no mortalities in the LSG group. In 28 trainee performed cases, excluding the ten cases where the attending performed the procedure, and excluding cases where a concomitant procedure was performed; the first 14 of the 28 cases had an average time of 189 minutes versus 171 minutes (p¼0.03) in the last 14 cases. Conclusions: Implementing RSG into bariatric surgical fellowship training appears safe, feasible and successful with equivalent outcomes. Robotic sleeve gastrectomy was associated with few perioperative complications. Patients who underwent RSG had equivalent weight loss when compared with LSG. There may be a learning curve around 15 cases for RSG during adaptation of robotic training as shown by decreased operative times after an initial 15 cases. As robotic technology improves, robotic training should be considered during bariatric surgical fellowship programs. A5283
INFLUENCE OF BARIATRIC SURGERY ON PREGNANCY Ramona Sanani, MD; Ahmed Abrahim, MD; Christoph Sperker, MD; Martin Schermann, MD; Anton Landsiedl, MD; KA Rudolfstiftung, Vienna, Austria Background: Obese women are known to suffer from gestational pathologies like gestational diabetes, miscarriage and as well as fetal complications such as high birth weight and larger birth size, which might lead to delivery difficulties. Setting: Non-University General Hospital Materials and Methods: During a period of 8 years all patients, who gave birth to at least one child pre and post sleeve gastrectomy, were included into this study. Data concerning weight parameters, obesity associated comorbidities as well as gestational complications and birth related parameters were recorded prospectively and analyzed retrospectively. Results: A total of 16 patients could be identified to meet the criteria to be included in this study. Pre OP BMI showed a mean value of 47.43 kg/m2 while the mean BMI post OP was 31.19 kg/ m2 (po0.001). Two patients showed pathologic blood glucose levels preoperatively, while there were no pathologies concerning diabetes postoperatively. Babies showed a mean birth weight of 3827g and a mean size of 52.5cm preoperatively, while postoperative values where 3341g (p¼0.02) and 50.3cm (p¼0.03). Two patients showed delayed birth pre OP, while there were no difficulties post OP. Preoperatively a total of 20 miscarriages was recorded, while postoperatively only three miscarriages could be observed (p¼0.02). Conclusion: Bariatric surgery shows direct effects on pregnancy and gestational pathologies as well as on incidence of miscarriage. For obese patients with unfulfilled desire to have child, sleeve gastrectomy might be a considerable option.
A5284
ROUTINE INTRAOPERATIVE STAPLE LINE TESTING AND POSTOPERATIVE UPPER GASTROINTESTINAL STUDIES ARE NOT NECESSARY: A COMMUNITYBASED SURGEON’S INITIAL EXPERIENCE Mariana Chavez, MD; Nathaniel Stoikes, Md; David Webb, MD; Guy Voeller, MD; George Woodman, MD; University of Tennessee Health Science Center, MemphisTN, USA Introduction: Laparoscopic Sleeve Gastrectomy (LSG) is emerging as a safe and durable bariatric surgical option with proven weight loss outcomes and comorbidities resolution. It is a common practice to routinely perform intraoperative staple line tests for integrity and postoperative Upper Gastrointestinal (UGI) studies to screen for technical complications such as leak, obstruction or stenosis. However, these tests increase time and costs of the procedure and hospital stay. Objective: To determine if routine intraoperative and postoperative testing is cost effective in a high volume single surgeon community practice. We tested the hypothesis that these routine practices after LSG result in increased length and cost of stay, without impacting patient outcomes. Methods: A retrospective chart review of patients that underwent LSG by a single surgeon at two community hospitals in Memphis, TN from April 2008 to March 2015 was performed. Two groups were identified: those who underwent routine UGI study (UGI) and those who did not (non-UGI). Characteristics evaluated included age, sex, race, preoperative BMI, length of stay, cost of stay per day, complication and readmission rates. Results: A total of 565 patients were included, 210 in the UGI and 355 in the non-UGI group. Intraoperative staple line test was not performed in any patient. There were no postoperative leaks or bleeding in either group. There were 4 re-hospitalizations, none of which were related to the staple line. The cost of an UGI study at these institutions was $1,080 and on average delayed discharge for 3 hours. Also, intraoperative testing takes an average of 10 minutes to perform, resulting in prolonged OR time, anesthesia time and hospital charges. Conclusions: After LSG, routine use of intraoperative testing and postoperative UGI studies is not cost effective. Furthermore, surgeon experience and visual evaluation are sufficient to ensure adequate staple line integrity. We recommend that these studies only be performed when clinically indicated. A5285
IDIOPATHIC COMPLETE HEART BLOCK IN A PATIENT AFTER UNEVENTFUL LAPAROSCOPIC SLEEVE GASTRECTOMY (LSG) Anish Nihalani, MD, FACS; JFK Medical Center, Edison, NJ, USA Introduction: Laparoscopic Sleeve Gastrectomy (LSG) is a widely acccepted weight loss procedure in the United States. The greater curvature is mobilized and then 70% of the stomach is resected leaving a tubular stomach which is supplied by the left and right gastric vessels. The vagus nerve is preserved. An EGD is performed and usually on postoperative day 1, an upper gastrointestinal study is done using gastrograffin to rule out staple line leakage. A bariatric clear liquid diet is subsequently initiated.