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The Use of a Suction Calibration System vs Endoscopy For Laparoscopic Sleeve Gastrectomy: A Comparative Analysis
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ASMBS E-Poster Abstracts / Surgery for Obesity and Related Diseases 13 (2017) S66–S226
concomitant hiatal hernia repair after incidental intraoperative diagnosis. Mean DI values increased significantly from induction to deinsufflation; 1.68 (1.16) and 2.74 (2.05) mm2/mmHg, respectively; p¼0.01. Three month GERD-Q scores were obtained in 27/33 (82%) patients; 3/27 (11%) patients developed de-novo GERD symptoms. The final DI (increase in DI) for the three patients who developed denovo GERD symptoms were 3.23 (2.18) mm2/mmHg, 3.09 (1.45) mm2/mmHg, and 0.65 (0.16) mm2/mmHg. Conclusion: In summary, LSG results in a significant increase in DI. We did not identify a consistent trend in final DI among patients who developed de-novo GERD and those who remained asymptomatic. Six month physiologic testing in symptomatic patients is currently ongoing. Our preliminary results highlight the multi-factorial nature of GERD in patients undergoing LSG.
A5098
ANATOMY-BASED LAPAROSCOPIC SLEEVE GASTRECTOMY REDUCES GASTROESOPHAGEAL REFLUX DISEASE COMPARED TO LAPAROSCOPIC SLEEVE GASTRECTOMY WITH BOUGIE Jonathan Thompson1; Vikrom Dhar1; Dennis Hanseman1; Brad Watkins2; John Morton3; Tayyab Diwan1; 1University of Cincinnati, Cincinnati OH; 2University of Cincinnati, West Chester OH; 3Stanford School of Medicine, Stanford CA Background: Sleeve gastrectomy pouches with narrowing at the incisura angularis, twists along the staple line, retained fundus or resection compromising the lower esophageal sphincter have been implicated in increased gastroesophageal reflux disease (GERD) rates following laparoscopic sleeve gastrectomy (LSG). Basing creation of sleeve gastrectomy pouches on anatomic landmarks may help produce more consistent sleeve anatomy and improve outcomes. The goal of this study was to evaluate rates of GERD for patients undergoing anatomy-based laparoscopic sleeve gastrectomy (ABLSG) compared to those undergoing traditional LSG with a bougie. Methods: A retrospective review of all patients undergoing LSG from January 2016 to November 2016 at a single institution specializing in bariatric surgery was performed. Patients underwent
either traditional LSG with use of a 40F suction bougie to guide creation of the sleeve or ABLSG. ABLSG was performed using a gastric clamp to maintain predetermined distances from key landmarks (1 cm from gastroesophageal junction, 3 cm from incisura angularis, 6 cm from pylorus) during stapling. Data regarding GERD was collected prospectively as a part of an ongoing quality improvement program (MBSAQIP). Patient demographics, perioperative characteristics, and post-operative outcomes were compared using Chi-square and Student’s t-tests as required. Results: Of 271 patients included during the study period, 156 (58%) underwent traditional LSG with use of a bougie and 115 (42%) underwent ABLSG. No significant difference in operative time was identified between groups (113 minutes vs. 109 minutes, p ¼ 0.30). Additionally, there were no intraoperative complications, reoperations, leaks, bleeds, or strictures in either cohort. While prevalence of pre-operative GERD was similar between groups (37% vs. 33%, p ¼ 0.51), patients undergoing ABLSG had a significantly lower rate of GERD post-operatively compared to the bougie group (19% vs. 34%, p ¼ o0.01). In patients without preoperative GERD, there was no significant difference in the rates of new-onset GERD following LSG (11% vs. 18%, p ¼ 0.27). At a median follow-up of 2.3 months, a significantly larger proportion of patients undergoing ABLSG achieved resolution of their GERD compared to the bougie group (67% vs. 32%, p o 0.01). Conclusion: When compared to traditional LSG with use of a bougie, ABLSG was shown to result in a significantly lower rate of post-operative GERD and a more than 100% improvement in early GERD resolution. These findings suggest that ABLSG may provide a substantial clinical benefit with regard to GERD following sleeve gastrectomy.
A5099
THE USE OF A SUCTION CALIBRATION SYSTEM VS ENDOSCOPY FOR LAPAROSCOPIC SLEEVE GASTRECTOMY: A COMPARATIVE ANALYSIS Michael McCoy1; Vinay Singhal2; David Livert2; Charles Hopley3; 1 Easton Hospital, Easton PA; 2Easton Hospital, Easton PA; 3 Easton Hospital, Aurora Colorado Background/Objectives: ViSiGi3D™, a suction calibration system, and endoscopy are two devices utilized for sleeve sizing during laparoscopic sleeve gastrectomy. No studies have compared these two approaches. Our objective was to compare safety and efficacy between the two devices. Methods: This was a single institution, retrospective chart review investigating laparoscopic sleeve gastrectomies performed from August 2013 to January 2016. Primary outcome assessed was 6 and 12-month postoperative BMI loss (ΔBMI; kg/m2). Secondary outcomes included operative time, intraoperative leak testing results, length of stay and cost analysis. Results: A total of 83 patients were analyzed (46 in endoscopy group, 37 in ViSiGi3D™ group), after 6 met our exclusion criteria and 13 were lost to follow-up. Mean preoperative BMI in the endoscopy group was 46.2 kg/m2 (35.3-69.9 kg/m2), compared to 46.1 kg/m2 (37.1-67.0 kg/m2) in the ViSiGi3D™ group. In comparing endoscopy vs. ViSiGi3D™, there was significant difference in operative time (145.9 vs 133.4 minutes, p ¼ .0239), 6 month
ASMBS E-Poster Abstracts / Surgery for Obesity and Related Diseases 13 (2017) S66–S226
postoperative BMI loss (-11.27 vs -8.80 kg/m2, p ¼ .0379) and 12 month postoperative BMI loss (-13.57 vs -9.07 kg/m2, p ¼ .0018). The endoscopy group had higher OR costs ($84,405 vs $79,453). No significant difference in length of stay (2.06 days in endoscopy group vs. 2.05 days in ViSiGi3D™ group) or intraoperative leak testing (0 leaks) was appreciated. A series of generalized linear models were run to assess if the effects of using endoscopy or ViSiGi3D™ changed when taking into account preoperative BMI, age and gender. Post-analysis confirmed that use of endoscopy was still associated with higher loss of BMI postoperatively at 6 and 12 months. Conclusion: Use of endoscopy was associated with significantly higher postoperative BMI loss along with longer operative time which contributed to higher OR costs. Regarding safety, neither was associated with gastric leak. Ultimately, it is at the discretion of the surgeon to decide which calibration device to utilize while performing laparoscopic sleeve gastrectomy. The surgeon must determine whether risk of longer OR time (and potentially greater costs) are outweighed by the potential for greater BMI reduction as demonstrated in the endoscope arm. Keywords: ViSiGi 3D™, Endoscopy, laparoscopic sleeve gastrectomy
A5100
ROBOTIC VS. LAPAROSCOPIC SURGERY FOR SLEEVE GASTRECTOMY; A COMPARATIVE STUDY Samer Alharthi; Mohammed Ageel; WEIKAI QU; Jorge Ortiz; Munier Nazzal; university of Toledo, Toledo OH Background: Obesity is a global health problem. Sleeve gastrectomy has gained popularity because of its good result. Robotic technology has recently appeared in different surgical fields. In this study we seek to compare the outcomes of robotic and laparoscopic approaches to sleeve gastrectomy. Methods: We analyzed data of patients who underwent sleeve gastrectomy using the National Inpatient Sample database between 2011-2013. Utilization and outcome measures including demographics, primary expected payer, in-hospital mortality, pre-existing comorbidities, complications, length of hospital stay, and total hospital cost were compared between the two different surgical approaches. Analyzed by Chi-square, Non-Parametric tests and Multivariate linear regression. Results: A total of 26,195 patients who underwent elective sleeve gastrectomy for morbid obesity were included in this study. Of these, 25,391 (96.9%) were done via a laparoscopic approach while 804 (3.1%) via robotic approach. The mean age at the time of procedure were 44.11þ 11.6 and 43.67 þ 11.3 in laparoscopic and robotic approaches respectively (p ¼0.29). The majority of patients were over 40 years in both groups (p¼0.55). Female represented most of the patients (78.2% and 79.9% in laparoscopic and robotic groups respectively, p ¼ 0.26). There were no significant differences between both groups when compared in respect to race, diabetes mellitus, hypertension, ischemic heart disease, chronic kidney disease, and COPD. Post-operative complications were comparable between groups in respect to DVT, pain, bleeding, bowel obstruction, ileus, abscess, adhesion, atelectasis, leak, and nausea The in-hospital mortality was similar between both groups. Length of hospital stay was statistically significant different with a mean of 1.88 in laparoscopic vs. 2.08 days in robotic (po 0.001). Patient who
S111
underwent robotic surgery had a significant higher total hospital charge compared to patient who underwent laparoscopic surgery (median $38,569 vs. $54,658 USD, po0.001). The total hospital charges were higher in robotic surgery after adjusting of confounding factors; wound infection, atelectasis, bowel obstruction, pneumonia, bowel obstruction, and length of hospital stay (p o0.001). Conclusions: Nationwide, most of sleeve gastrectomy done via laparoscopic approach. Compared to laparoscopic approach, Robotic approach has no clinical advantages observe in relation to morbidity and mortality. However, Robotic procedure has a significantly higher total charge.
A5101
LAPAROSCOPIC SLEEVE GASTRECTOMY AND OMENTOPEXY IN MORBID OBESE PATIENT WITH SITUS INVERSUS TOTALIS Syed Saif Rizvi; Leaque Ahmed; Harlem Hospital Center, New York NY Introduction: Situs inversus totalis is a rare condition in which there is a reversal of placement of the abdominal and thoracic structures. Laparoscopic surgery is technically challenging in these patients due to mirror-image anatomy. 27 y/o female with morbid obesity (BMI 40.4 Kg/m2) presented with failure to lose weight despite diet and exercise regimes. Medical history included well-controlled HTN. Laboratory and psychological evaluations were unremarkable. However, a CXR showed dextrocardia and a 7mm nodule within the right lower lobe, and a CT scan revealed a benign lung granuloma and situs inversus totalis. Technical details of a laparoscopic sleeve gastrectomy with minimum port placement is presented. Method: Peritoneal entry was done using 5mm Optiview trocar in the right midclavicular line below the costal margin. Pneumoperitoneum was created. Below the costal margins, a second 5mm trocar was placed in left midclavicular line, a third 5mm trocar in the right anterior axillary line. A 12mm trocar was placed about 10cm below the xiphoid. Nathanson liver retractor was placed below the xiphoid and tunneled to the right side of falciform to reach the left segment of the liver with the hook facing downward and handle facing upward. Pylorus was identified by locating the vein of mayo and lesser sec was opened using LigaSure 5cm proximally. The direction of liver retractor was changed, with the tip of the hook facing upward and handle facing down toward the right lower quadrant, enabling good fundus and angle of His views. Omentum was separated off the stomach. The greater curvature was transected over 38Fr bougie 5cm above the pylorus using 2 black followed by 3 purple loads. The liver retractor was replaced with a bowel clamp lifting the liver for visualization. Greater omentum sutured to the staple line using 2-0 Tricon sutures was done and fibrin sealant was applied. The specimen was removed via the midline 12mm trocar site. The fiscal defect was closed using #2 Vicryl sutures. Result: The was no complication postoperatively. Barium swallow postoperative day one was normal. On follow-up, the patient lost 39lbs in a one month period and has a BMI of 33.4 Kg/m2. Conclusion: Laparoscopic sleeve gastrectomy with situs inversus totalis can be successfully performed with minimum port placement. The direction of Liver retractor hook can be changed to expose entire stomach up to angle of His and a bowel clamp to retract liver may be substituted.
ASMBS E-Poster Abstracts / Surgery for Obesity and Related Diseases 13 (2017) S66–S226
concomitant hiatal hernia repair after incidental intraoperative diagnosis. Mean DI values increased significantly from induction to deinsufflation; 1.68 (1.16) and 2.74 (2.05) mm2/mmHg, respectively; p¼0.01. Three month GERD-Q scores were obtained in 27/33 (82%) patients; 3/27 (11%) patients developed de-novo GERD symptoms. The final DI (increase in DI) for the three patients who developed denovo GERD symptoms were 3.23 (2.18) mm2/mmHg, 3.09 (1.45) mm2/mmHg, and 0.65 (0.16) mm2/mmHg. Conclusion: In summary, LSG results in a significant increase in DI. We did not identify a consistent trend in final DI among patients who developed de-novo GERD and those who remained asymptomatic. Six month physiologic testing in symptomatic patients is currently ongoing. Our preliminary results highlight the multi-factorial nature of GERD in patients undergoing LSG.
A5098
ANATOMY-BASED LAPAROSCOPIC SLEEVE GASTRECTOMY REDUCES GASTROESOPHAGEAL REFLUX DISEASE COMPARED TO LAPAROSCOPIC SLEEVE GASTRECTOMY WITH BOUGIE Jonathan Thompson1; Vikrom Dhar1; Dennis Hanseman1; Brad Watkins2; John Morton3; Tayyab Diwan1; 1University of Cincinnati, Cincinnati OH; 2University of Cincinnati, West Chester OH; 3Stanford School of Medicine, Stanford CA Background: Sleeve gastrectomy pouches with narrowing at the incisura angularis, twists along the staple line, retained fundus or resection compromising the lower esophageal sphincter have been implicated in increased gastroesophageal reflux disease (GERD) rates following laparoscopic sleeve gastrectomy (LSG). Basing creation of sleeve gastrectomy pouches on anatomic landmarks may help produce more consistent sleeve anatomy and improve outcomes. The goal of this study was to evaluate rates of GERD for patients undergoing anatomy-based laparoscopic sleeve gastrectomy (ABLSG) compared to those undergoing traditional LSG with a bougie. Methods: A retrospective review of all patients undergoing LSG from January 2016 to November 2016 at a single institution specializing in bariatric surgery was performed. Patients underwent
either traditional LSG with use of a 40F suction bougie to guide creation of the sleeve or ABLSG. ABLSG was performed using a gastric clamp to maintain predetermined distances from key landmarks (1 cm from gastroesophageal junction, 3 cm from incisura angularis, 6 cm from pylorus) during stapling. Data regarding GERD was collected prospectively as a part of an ongoing quality improvement program (MBSAQIP). Patient demographics, perioperative characteristics, and post-operative outcomes were compared using Chi-square and Student’s t-tests as required. Results: Of 271 patients included during the study period, 156 (58%) underwent traditional LSG with use of a bougie and 115 (42%) underwent ABLSG. No significant difference in operative time was identified between groups (113 minutes vs. 109 minutes, p ¼ 0.30). Additionally, there were no intraoperative complications, reoperations, leaks, bleeds, or strictures in either cohort. While prevalence of pre-operative GERD was similar between groups (37% vs. 33%, p ¼ 0.51), patients undergoing ABLSG had a significantly lower rate of GERD post-operatively compared to the bougie group (19% vs. 34%, p ¼ o0.01). In patients without preoperative GERD, there was no significant difference in the rates of new-onset GERD following LSG (11% vs. 18%, p ¼ 0.27). At a median follow-up of 2.3 months, a significantly larger proportion of patients undergoing ABLSG achieved resolution of their GERD compared to the bougie group (67% vs. 32%, p o 0.01). Conclusion: When compared to traditional LSG with use of a bougie, ABLSG was shown to result in a significantly lower rate of post-operative GERD and a more than 100% improvement in early GERD resolution. These findings suggest that ABLSG may provide a substantial clinical benefit with regard to GERD following sleeve gastrectomy.
A5099
THE USE OF A SUCTION CALIBRATION SYSTEM VS ENDOSCOPY FOR LAPAROSCOPIC SLEEVE GASTRECTOMY: A COMPARATIVE ANALYSIS Michael McCoy1; Vinay Singhal2; David Livert2; Charles Hopley3; 1 Easton Hospital, Easton PA; 2Easton Hospital, Easton PA; 3 Easton Hospital, Aurora Colorado Background/Objectives: ViSiGi3D™, a suction calibration system, and endoscopy are two devices utilized for sleeve sizing during laparoscopic sleeve gastrectomy. No studies have compared these two approaches. Our objective was to compare safety and efficacy between the two devices. Methods: This was a single institution, retrospective chart review investigating laparoscopic sleeve gastrectomies performed from August 2013 to January 2016. Primary outcome assessed was 6 and 12-month postoperative BMI loss (ΔBMI; kg/m2). Secondary outcomes included operative time, intraoperative leak testing results, length of stay and cost analysis. Results: A total of 83 patients were analyzed (46 in endoscopy group, 37 in ViSiGi3D™ group), after 6 met our exclusion criteria and 13 were lost to follow-up. Mean preoperative BMI in the endoscopy group was 46.2 kg/m2 (35.3-69.9 kg/m2), compared to 46.1 kg/m2 (37.1-67.0 kg/m2) in the ViSiGi3D™ group. In comparing endoscopy vs. ViSiGi3D™, there was significant difference in operative time (145.9 vs 133.4 minutes, p ¼ .0239), 6 month
ASMBS E-Poster Abstracts / Surgery for Obesity and Related Diseases 13 (2017) S66–S226
postoperative BMI loss (-11.27 vs -8.80 kg/m2, p ¼ .0379) and 12 month postoperative BMI loss (-13.57 vs -9.07 kg/m2, p ¼ .0018). The endoscopy group had higher OR costs ($84,405 vs $79,453). No significant difference in length of stay (2.06 days in endoscopy group vs. 2.05 days in ViSiGi3D™ group) or intraoperative leak testing (0 leaks) was appreciated. A series of generalized linear models were run to assess if the effects of using endoscopy or ViSiGi3D™ changed when taking into account preoperative BMI, age and gender. Post-analysis confirmed that use of endoscopy was still associated with higher loss of BMI postoperatively at 6 and 12 months. Conclusion: Use of endoscopy was associated with significantly higher postoperative BMI loss along with longer operative time which contributed to higher OR costs. Regarding safety, neither was associated with gastric leak. Ultimately, it is at the discretion of the surgeon to decide which calibration device to utilize while performing laparoscopic sleeve gastrectomy. The surgeon must determine whether risk of longer OR time (and potentially greater costs) are outweighed by the potential for greater BMI reduction as demonstrated in the endoscope arm. Keywords: ViSiGi 3D™, Endoscopy, laparoscopic sleeve gastrectomy
A5100
ROBOTIC VS. LAPAROSCOPIC SURGERY FOR SLEEVE GASTRECTOMY; A COMPARATIVE STUDY Samer Alharthi; Mohammed Ageel; WEIKAI QU; Jorge Ortiz; Munier Nazzal; university of Toledo, Toledo OH Background: Obesity is a global health problem. Sleeve gastrectomy has gained popularity because of its good result. Robotic technology has recently appeared in different surgical fields. In this study we seek to compare the outcomes of robotic and laparoscopic approaches to sleeve gastrectomy. Methods: We analyzed data of patients who underwent sleeve gastrectomy using the National Inpatient Sample database between 2011-2013. Utilization and outcome measures including demographics, primary expected payer, in-hospital mortality, pre-existing comorbidities, complications, length of hospital stay, and total hospital cost were compared between the two different surgical approaches. Analyzed by Chi-square, Non-Parametric tests and Multivariate linear regression. Results: A total of 26,195 patients who underwent elective sleeve gastrectomy for morbid obesity were included in this study. Of these, 25,391 (96.9%) were done via a laparoscopic approach while 804 (3.1%) via robotic approach. The mean age at the time of procedure were 44.11þ 11.6 and 43.67 þ 11.3 in laparoscopic and robotic approaches respectively (p ¼0.29). The majority of patients were over 40 years in both groups (p¼0.55). Female represented most of the patients (78.2% and 79.9% in laparoscopic and robotic groups respectively, p ¼ 0.26). There were no significant differences between both groups when compared in respect to race, diabetes mellitus, hypertension, ischemic heart disease, chronic kidney disease, and COPD. Post-operative complications were comparable between groups in respect to DVT, pain, bleeding, bowel obstruction, ileus, abscess, adhesion, atelectasis, leak, and nausea The in-hospital mortality was similar between both groups. Length of hospital stay was statistically significant different with a mean of 1.88 in laparoscopic vs. 2.08 days in robotic (po 0.001). Patient who
S111
underwent robotic surgery had a significant higher total hospital charge compared to patient who underwent laparoscopic surgery (median $38,569 vs. $54,658 USD, po0.001). The total hospital charges were higher in robotic surgery after adjusting of confounding factors; wound infection, atelectasis, bowel obstruction, pneumonia, bowel obstruction, and length of hospital stay (p o0.001). Conclusions: Nationwide, most of sleeve gastrectomy done via laparoscopic approach. Compared to laparoscopic approach, Robotic approach has no clinical advantages observe in relation to morbidity and mortality. However, Robotic procedure has a significantly higher total charge.
A5101
LAPAROSCOPIC SLEEVE GASTRECTOMY AND OMENTOPEXY IN MORBID OBESE PATIENT WITH SITUS INVERSUS TOTALIS Syed Saif Rizvi; Leaque Ahmed; Harlem Hospital Center, New York NY Introduction: Situs inversus totalis is a rare condition in which there is a reversal of placement of the abdominal and thoracic structures. Laparoscopic surgery is technically challenging in these patients due to mirror-image anatomy. 27 y/o female with morbid obesity (BMI 40.4 Kg/m2) presented with failure to lose weight despite diet and exercise regimes. Medical history included well-controlled HTN. Laboratory and psychological evaluations were unremarkable. However, a CXR showed dextrocardia and a 7mm nodule within the right lower lobe, and a CT scan revealed a benign lung granuloma and situs inversus totalis. Technical details of a laparoscopic sleeve gastrectomy with minimum port placement is presented. Method: Peritoneal entry was done using 5mm Optiview trocar in the right midclavicular line below the costal margin. Pneumoperitoneum was created. Below the costal margins, a second 5mm trocar was placed in left midclavicular line, a third 5mm trocar in the right anterior axillary line. A 12mm trocar was placed about 10cm below the xiphoid. Nathanson liver retractor was placed below the xiphoid and tunneled to the right side of falciform to reach the left segment of the liver with the hook facing downward and handle facing upward. Pylorus was identified by locating the vein of mayo and lesser sec was opened using LigaSure 5cm proximally. The direction of liver retractor was changed, with the tip of the hook facing upward and handle facing down toward the right lower quadrant, enabling good fundus and angle of His views. Omentum was separated off the stomach. The greater curvature was transected over 38Fr bougie 5cm above the pylorus using 2 black followed by 3 purple loads. The liver retractor was replaced with a bowel clamp lifting the liver for visualization. Greater omentum sutured to the staple line using 2-0 Tricon sutures was done and fibrin sealant was applied. The specimen was removed via the midline 12mm trocar site. The fiscal defect was closed using #2 Vicryl sutures. Result: The was no complication postoperatively. Barium swallow postoperative day one was normal. On follow-up, the patient lost 39lbs in a one month period and has a BMI of 33.4 Kg/m2. Conclusion: Laparoscopic sleeve gastrectomy with situs inversus totalis can be successfully performed with minimum port placement. The direction of Liver retractor hook can be changed to expose entire stomach up to angle of His and a bowel clamp to retract liver may be substituted.