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Background: Biosynthetic meshes afford the cost advantages of being made from fully synthetic material, but are also biodegradable, making them a versatile option that can be used in both clean and contaminated cases. The aim of this study is to evaluate the safety profile and long-term outcomes of using GORE BIO-A (BIO-A) as an adjunct to abdominal wall reconstruction in all wound classes. Methods: A retrospective review identified patients undergoing abdominal hernia repair using BIO-A from October 2008 to June 2018. The primary outcome was hernia recurrence rate. Only patients with at least 6-month follow-up were included when looking at recurrence rates. Secondary outcomes included 30-day morbidity categorized according to CDC Surgical Site Infection Criteria, return to operating/procedure room (RTOR), 30-day readmission, length of stay (LOS), and mortality. Results: A total of 207 patients were identified, CDC Wound Classification breakdown was 127 (61.4%), 41 (19.8%), 14 (6.8%), and 25 (12.1%) for wound classes I, II, III, and IV, respectively. Median follow-up was 55.4 months (range 0.2–162.4). Overall recurrence rate was 17.4%. Contaminated cases experienced higher recurrence rates (28.8% versus 10.4%, p = 0.002) at a mean follow up of 46.9 and 60.8 months for contaminated and clean patients, respectively. Recurrent patients had higher BMI (32.4 versus 28.4 kg/m2, p = 0.0011), larger hernias (162.2 versus 106.7 cm2, p = 0.10), higher LOS (11.1 versus 5.6 days, p = 0.0051), and higher RTOR rates (16.7% versus 5.6%, p = 0.053). 51 (24.5%) patients experienced some morbidity, including 19 (9.2%) surgical site occurences, 7 (3.4%) superficial surgical site infections, 16 (7.7%) deep surgical site infections, and 1 (0.5%) organ space infection. Conclusion: This study affirms the use of biosynthetic mesh as a cost-effective alternative in all wound classifications, yielding good outcomes, limited long-term complications, and low recurrence. rates. [ABSTRACT FROM AUTHOR]

Background: Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis which can resemble gallbladder adenocarcinoma (GAC) on preoperative imaging and present technical challenges in the performance of cholecystectomy. We examined our experience with each pathology to identify distinguishing characteristics that may guide patient counseling and surgical management. Methods: A retrospective review of all pathologically confirmed cases of XGC and GAC following cholecystectomy between 2015 and 2021 at a single institution was performed. Clinical, biochemical, radiographic, and intraoperative features were compared. Results: There were 37 cases of XGC and 20 cases of GAC. Patients with GAC were older (mean 70.3 years vs 58.0, p = 0.01) and exclusively female (100% vs 45.9%, p < 0.0001). There were no significant differences in accompanying symptoms between groups (nausea/vomiting, fevers, or jaundice). The mean maximum white blood cell count was elevated for XGC compared to GAC (16.4 vs 8.6 respectively, p = 0.044); however, there were no differences in the remainder of the biochemical profile, including bilirubin, liver transaminases, CEA, and CA 19–9. The presence of an intraluminal mass (61.1% vs 9.1%, p = 0.0001) and lymphadenopathy (18.8%. vs 0.0%, p = 0.045) were associated with malignancy, whereas gallbladder wall thickening as reported on imaging (87.9% vs 38.9%, p = 0.0008) and gallstones (76.5% vs. 50.0%, p = 0.053) were more often present with XGC. Cases of XGC more often had significant adhesions/inflammation (83.8% vs 55.0%, p = 0.03). Conclusion: Clinical features that may favor benign chronic cholecystitis over gallbladder adenocarcinoma include younger age, male gender, current or prior leukocytosis, and the absence of an intraluminal mass or lymphadenopathy. Laparoscopic cholecystectomy is a safe surgical option for equivocal presentations. Intraoperative frozen section or intentional staging of more extensive procedures based upon final histopathology are valuable surgical strategies. [ABSTRACT FROM AUTHOR]

Background: Multidisciplinary approaches to weight loss have been shown to improve outcomes in bariatric patients. Few studies have been performed assessing the utility and compliance of fitness tracking devices after bariatric surgery. We aim to determine whether use of an activity tracking device assists bariatric patients in improving postoperative weight loss behaviors. Methods: A fitness wearable was offered to patients undergoing bariatric surgery from 2019 to 2022. A telephone survey was conducted to elucidate the impact of the device on the patient's postoperative weight loss efforts 6 to 12 months after surgery. Weight loss outcomes of sleeve gastrectomy (SG) patients receiving the fitness wearable (FW) were compared to those of a group of SG patients who did not receive one (non-FW). Results: Thirty-seven patients were given a fitness wearable, 20 of whom responded to our telephone survey. Five patients reported not using the device and were excluded. 88.2% reported that using the device had a positive impact on their overall lifestyle. Patients felt that using the fitness wearable to keeping track of their progress helped them both to achieve short-term fitness goals and sustain them in the long run. From the patients that utilized the device, 44.4% of those that discontinued felt like it helped them build a routine that they maintained even after they were no longer using it. Demographic data between FW and non-FW groups (age, sex, CCI, initial BMI, and surgery BMI) did not differ significantly. The FW group trended towards greater %EWL at 1 year post-operation (65.2% versus 52.4%, p = 0.066) and had significantly greater %TWL at 1 year post-operation (30.3% versus 22.3%, p = 0.02). Conclusion: The use of an activity tracking device enhances a patient's post-bariatric surgery experience, serving to keep patients informed and motivated, and leading to improved activity that may translate to better weight loss outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Post-operative gastroesophageal reflux disease (GERD) remains a significant morbidity following sleeve gastrectomy (SG). We aim to evaluate the incidence and impact within a single center experience. Materials and methods: A retrospective review of a prospectively maintained database was performed identifying laparoscopic or robotic SG patients. Primary outcomes included weight loss, rates of post-operative GERD (de-novo or aggravated), and re-intervention. Subgroup analysis was performed between patients with (Group 1) and without (Group 2) post-operative GERD. De-novo GERD and aggravated was defined as persistent GERD complaints or new/increased PPI usage in GERD naive or prior GERD patients, respectively. Results: 392 patients were identified between 2014 and 2019. Average demographics: age 42.3 (18–84) years, Charlson Comorbidity Index (CCI) 1.12 (0–10), and body mass index (BMI) 47.7 (28–100). 98% were performed laparoscopically. Average excess weight loss (EWL) was 51.0% and 46.4% at 1 and 2 years post-operatively. Average follow up was 516 (6–2694) days. 69 (17%) patients developed post operative de-novo or aggravated GERD. Group 1 had significantly higher EWL at 9 months (57% vs 47%, p 0.003). 13 (3%) patients required operative re-intervention for GERD and other morbidities: 4 RYGB conversions, 4 diagnostic laparoscopies, 3 HHR, 1 MSA placement. Group 1 had higher rates of post-operative intervention (14% vs 1%, p 0.0001). Subanalysis demonstrated that Group 1 had elevated preoperative DeMeester scores on pH testing (34.8 vs 18.9, p 0.03). De-novo GERD had an elevated post-operative total acid exposure when compared to aggravated GERD (12.7% vs 7.0% p 0.03). No significant differences were found between preoperative endoscopy findings, pre and postoperative total acid exposure, post-operative DeMeester scores, and high-resolution manometry values regarding de-novo/aggravated GERD development. Conclusion: Preoperative DeMeester scores may serve as risk indicators regarding post-operative GERD. Outcomes such as reintervention remain elevated in post-operative GERD patients. [ABSTRACT FROM AUTHOR]

Background: The legalization of cannabis in several states has led to increased documented use in the population. Bariatric surgery patients are no exception with estimates of anywhere from 6 to 8%. Cannabis is known to be associated with increased appetite, mood disorders, hyperphagia, and rarely, hyperemesis, which can potentially affect post-surgical weight loss. We aim to study the differences in bariatric surgery outcomes between cannabis users and non-users. Methods: A retrospective review identified patients undergoing bariatric surgery. Patients were divided into two groups, cannabis users (CU) and non-cannabis users (non-CU). Cannabis users (defined as using at least once weekly) and a group of non-users were called to obtain additional information. Primary outcome was weight loss. Secondary outcomes included incidence of post-operative nausea and vomiting (PONV), length of stay (LOS), readmission, and need for additional intervention. Results: A cohort of 364 sleeve gastrectomy patients met inclusion criteria, 31 (8.5%) CU and 333 (91.5%) non-CU. There was no difference in EWL between CU and non-CU at 1 week, 1 month, 3 months, 6 months, 9 months, 1 year, and 2 years. However, the CU group trended towards greater EWL at 3 years (52.9% vs. 38.1%, p = 0.094) and at 5 years (49.8% vs. 32.7%, p = 0.068). There were no significant differences between CU and non-CU with respect to either incidence or severity of PONV at one year after surgery or longer follow-up. Conclusion: Cannabis users did not experience inferior weight loss after bariatric surgery despite common assumptions that appetite stimulation can lead to suboptimal weight loss outcomes. Our findings add to other work challenging this dogma. Larger, long-term, multicenter studies are warranted. [ABSTRACT FROM AUTHOR]

Background: The coronavirus pandemic has caused a worldwide health crisis. Bariatric patients require extensive pre- and post-operative follow-up, which may be less feasible during public health social distancing mandates. We assessed the impact of the pandemic on the behaviors and weight loss outcomes of our pre- and post-operative bariatric patients. Methods: A retrospective review of a prospectively maintained database identified patients who underwent either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at a single institution between March 2018 and May 2020. A cohort undergoing surgery within 12 months before the pandemic as well as a cohort undergoing a medically supervised diet prior to surgery was surveyed regarding pre- and post-COVID-19 lifestyle habits. Excess weight loss (EWL) outcomes from a group of pre-COVID surgical patients were compared to that of a group of post-COVID surgical patients. Primary outcome was whether the lockdown changed 1-year weight loss outcomes. Secondary outcome was whether patient lifestyle behaviors were changed during the pandemic. Results: There was no difference in 1-year EWL between pre- and post-COVID SG patients (51.7% versus 55.9%, p = 0.35), or between pre- and post-COVID RYGB patients (88.9% versus 80.4%, p = 0.42). Pre-stay-at-home order, 91.8% endorsed physical activity compared to 80.3% post-stay-at-home order (p = 0.0025). Mean physical activity decreased from 4.2 h/week to 2.7 h/week after the stay-at-home order (p < 0.0001). Additionally, 41.3% reported worsened dietary habits post-stay-at-home order. Conclusion: The COVID-19 pandemic has greatly impacted the behaviors of bariatric surgery patients. Despite deterioration of lifestyle habits, 1-year weight loss outcomes after bariatric surgery remained the same before and after the instatement of social distancing measures. In the short term, the biological effect of metabolic procedures may mask the effects of suboptimal diet and physical activity, but more studies are necessary to better assess the impact of COVID-19 on outcomes after bariatric surgery. [ABSTRACT FROM AUTHOR]

Background: Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair.Methods: A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention.Results: Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective.Conclusion: Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the "critical view of safety" with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes. Methods: A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion. Results: A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15–94), average BMI 29.4 kg/m2 (13.3–55.6). 989 patients (71.2%) underwent LC without fluorescence and 400 (28.8%) underwent FC with ICG. 30-day mortality detected 2 cases in the non-ICG group and zero with ICG. ICG reduced operative time by 26.47 min per case (p < 0.0001). For patients with BMI ≥ 30 kg/m2, operative duration for ICG vs non-ICG groups was 75.57 vs 104.9 min respectively (p < 0.0001). ICG required conversion to open at a rate of 1.5%, while non-ICG converted at a rate of 8.5% (p < 0.0001). Conversion rate remained significant with multivariable analysis (OR 0.212, p = 0.001). A total of 19 cases were aborted (1.35%), 8 in the ICG group (1.96%) and 11 in the non-ICG group (1.10%), these cases were not included in LC totals. Average LOS was 0.69 vs 1.54 days in the ICG compared to non-ICG LCs (p < 0.0001), respectively. Injuries were more common in the non-ICG group, with 9 patients sustaining Strasberg class A injuries in the non-ICG group and 2 in the ICG group. 1 CBDI occurred in the non-ICG group. There was no significant difference in 30-day complication rates between groups. Conclusion: ICG cholangiography is a non-invasive adjunct to laparoscopic cholecystectomy, leading to improved patient outcomes with respect to operative times, decreased conversion to open procedures, and shorter length of hospitalization. Fluorescence cholangiography improves visualization of biliary anatomy, thereby decreasing rate of CBDI, Strasberg A injuries, and mortality. These findings support ICG as standard of care during laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Introduction: Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA. Materials and methods: A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients. Results: Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m2. 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was significantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12–14 beads) versus a larger MSA implant (15–17 beads) had a significantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026). Conclusion: Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement. [ABSTRACT FROM AUTHOR]

Introduction: Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4–8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed > 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or > 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE). Materials and methods: Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival. Results: 97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36–85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy < 90 days after CRT (n = 62) to > 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04). Conclusion: Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients. [ABSTRACT FROM AUTHOR]

Background: Opioid use in the U.S. has increased dramatically over the last 15 years, recently being declared a public health emergency. Opioid use is associated with esophageal dysmotility lending to a confusing clinical picture compared to true achalasia. Patients exhibit symptoms and elicit diagnostic results consistent with esophageal motility disorders, in particular type III achalasia. Modified therapeutic strategies and outcomes become challenging. Differentiating true achalasia from opioid-induced achalasia is critical. Conventional surgical interventions, i.e., myotomy, are ineffective in the absence of true achalasia. We assess the utility of esophageal muscle layer mapping with endoscopic ultrasound (EUS) in distinguishing primary from opioid-induced achalasia. Methods: From 2016 to 2019, patients with abnormal manometry and suspected achalasia underwent esophagogastroduodenoscopy and EUS mapping of esophageal round muscle layer thickness. Maximum round layer thickness and length of round muscle layer thickness > 1.8 mm were collected and compared between opioid users and non-opioid users using Wilcoxon Rank sum test. Results: 45 patients were included: 12 opioid users, 33 non-opioid users. Mean age 56.8 years (range 24–93), 53.3% male patients. Mean BMI in the opioid-induced achalasia group was 30.2 kg/m2, mean BMI in the primary achalasia group 26.8 kg/m2 (p = 0.11). In comparing endoscopic maximum round layer thickness between groups, non-opioid patients had a thicker round muscle layer (2.7 mm vs 1.8 mm, p = 0.05). Length of abnormally thickened esophageal muscle (greater than 1.8 mm) also differed between the two groups; patients on opioids had a shorter length of thickening (4.0 cm vs 0.0 cm, p = 0.04). Intervention rate was higher in the non-opioid group (p = 0.79). Of the patients that underwent therapeutic intervention, symptom resolution was higher in the non-opioid group (p = 0.002), while re-intervention post-procedure for persistent symptomatology was elevated in the opioid subset (p = 0.06). Patients in the opioid group were less likely to undergo invasive treatment (Heller). As of 2017 all interventions in the opioid group have been endoscopic. Conclusion: Endoscopic ultrasound is an essential tool that has improved our treatment algorithm for suspected achalasia in patients with chronic opioid usage. Incorporation of EUS findings into treatment approach may prevent unnecessary surgery in opioid users. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are commonly performed bariatric procedures in obesity management. Gastroesophageal reflux disease (GERD) in this population has reported rates of 23-100%. GERD after LSG has been noted with recent studies demonstrating de novo reflux or symptom exacerbation despite weight loss. Fundoplication is not an option, and medically refractory GERD after LSG is usually treated with conversion to RYGB. GERD post-RYGB is a unique entity, and management poses a clinical and technical challenge. We evaluate safety and effectiveness of magnetic sphincter augmentation after bariatric surgery.Materials and Methods: A retrospective review of a prospectively maintained database was performed identifying patients that underwent LINX placement for refractory GERD after LSG, LRYGB, or duodenal switch across three institutions. Outcomes included complications, length of stay, PPI use, GERD-HRQL scores, and patient overall satisfaction.Results: From March 2014 through June 2018, 13 identified patients underwent LINX placement after bariatric surgery: 8 LSG, 4 LRYGB, and 1 duodenal switch. The patients were 77% female, with mean age 43 and average BMI 30.1. Average pre-operative DeMeester score was 24.8. Pre-operatively, 5 patients were on daily PPI, 6 on BID PPI, and 1 on PPI + H2 blocker. We noted decreased medication usage post-operatively, with 4 patients taking daily PPI, and 9 off medication completely. A GERD-HRQL score was obtained pre- and post-operatively in 6 patients with average reduction from 25 to 8.5 (p value 0.002). Two patients experienced complications requiring endoscopic dilation after LINX placement. 100% of patients reported overall satisfaction post procedure.Conclusion: LINX placement is a safe, effective treatment option for surgical management of refractory GERD after bariatric surgery. It can relieve symptoms and obviate the requirement of high-dose medical management. Magnetic lower esophageal sphincter augmentation should be another tool in the surgeon's toolbox for managing reflux after bariatric surgery in select patients. [ABSTRACT FROM AUTHOR]

Introduction: Chronic anemia is a common, coinciding or presenting diagnosis in patients with paraesophageal hernia (PEH). Presence of endoscopically identified ulcerations frequently prompts surgical consultation in the otherwise asymptomatic patient with anemia. Rates of anemia resolution following paraesophageal hernia repair (PEHR) often exceed the prevalence of such lesions in the study population. A defined algorithm remains elusive. This study aims to characterize resolution of anemia after PEHR with respect to endoscopic diagnosis.Materials and Methods: Retrospective review of a prospectively maintained database of patients with PEH and anemia undergoing PEHR from 2007 to 2018 was performed. Anemia was determined by preoperative labs: Hgb < 12 mg/dl in females, Hgb < 13 mg/dl in males, or patients with ongoing iron supplementation. Improvement of post-operative anemia was assessed by post-operative hemoglobin values and continued necessity of iron supplementation.Results: Among 56 identified patients, 45 were female (80.4%). Forty patients (71.4%) were anemic by hemoglobin value, 16 patients (28.6%) required iron supplementation. Mean age was 65.1 years, with mean BMI of 27.7 kg/m2. One case was a Type IV PEH and the rest Type III. 32 (64.0%) had potential source of anemia: 16 (32.0%) Cameron lesions, 6 (12.0%) gastric ulcers, 12 (24.0%) gastritis. 10 (20.0%) had esophagitis and 4 (8%) Barrett's esophagus. 18 (36%) PEH patients had normal preoperative EGD. Median follow-up was 160 days. Anemia resolution occurred in 46.4% of patients. Of the 16 patients with pre-procedure Cameron lesions, 10 (63%) had resolution of anemia. Patients with esophagitis did not achieve resolution. 72.2% (13/18) of patients with no lesions on EGD had anemia resolution (p = 0.03).Conclusion: Patients with PEH and identifiable ulcerations showed 50% resolution of anemia after hernia repair. Patients without identifiable lesions on endoscopy demonstrated statistically significant resolution of anemia in 72.2% of cases. Anemia associated with PEH adds an indication for surgical repair with curative intent. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic sleeve gastrectomy is the most commonly performed bariatric surgery in the world. Enhanced recovery after surgery (ERAS) protocols have been shown to reduce complications and decrease length of stay for various types of surgeries. In this study, we propose an ERAS protocol for laparoscopic sleeve gastrectomy and compare the clinical outcomes with patients who received standard care.Methods: We performed a single-institution retrospective analysis in patients who underwent laparoscopic sleeve gastrectomy from February 2015 to December 2017. Patients were stratified into standard care and ERAS protocol groups. The ERAS protocol consisted of goal-directed patient education, specific pre- and post-op multi-modal medication regimen, early ambulation, and early oral intake. Patients were discharged on their first post-operative day if they met appropriate post-surgical milestones. The primary outcomes were length of stay, 7- and 30-day readmission rates, and complication rates. Secondary outcomes included anti-emetic and pain medication utilization, post-operative emesis episodes per day, post-operative pain scores, and mortality.Results: We included 214 consecutive patients who underwent sleeve gastrectomy, 130 were in the ERAS group and 84 were in the standard care group. Median hospital stay was significantly shorter in the ERAS group compared to the standard care group (1 vs. 2 days; p < 0.001). There were no differences in 7- or 30-day readmission rates (1.5 vs. 1.2%; p = 0.838, 2.3 vs. 2.4%; p = 0.966) or post-operative complications (6.2 vs. 3.6%; p = 0.410). The ERAS group also had decreased median intra-operative opioid consumption and self-reported pain scores on post-operative day 1 (27.5 MME vs. 27.4 MME; p = 0.044, 3.3 vs. 3.9; p = 0.046). Mortality rate was 0% overall.Conclusion: A cost-effective ERAS protocol for laparoscopic sleeve gastrectomy results in shorter length of stay, without increase in peri-operative morbidity or readmission rates. [ABSTRACT FROM AUTHOR]

Background: Only a small percentage of candidates for bariatric surgery ever undergo a procedure for weight loss. Devices duplicating key effects of bariatric surgeries with removable, fully trans-oral implants could extend their benefits to patients unwilling to undergo anatomy-altering abdominal surgeries.Methods: Thirty-two obese subjects (mean BMI: 42.3) were enrolled in a prospective, multicenter, single-arm, feasibility trial of the first fully trans-oral endoscopic gastrointestinal bypass device. The device is a cuff attached to the distal esophagus by transmural anchors and connected to a 120-cm sleeve diverting undigested nutrients to the jejunum. Bodyweight, vital signs, adverse events, medications, HbA1c, fasting glucose, and lipids were collected at baseline and follow-up visits. Device status was endoscopically assessed every 6 months.Results: The fully trans-oral procedure was successful in all subjects without intraoperative adverse events or postoperative infections. Twenty-eight of 32 subjects (88%) remained implanted with continuing follow-up beyond their 12-month visit. At 12 months, the 32 subjects had lost an average of 44.8% of excess body weight, 17.6% of total body weight, 20.8 kg, and 7.5 BMI points. Weight loss depended on capture of ingesta by the esophageal cuff, with 18 of 32 subjects without visible gaps around their cuffs at the 6 month endoscopy having significantly greater EWL (53.6 vs. 33.4% in the remaining subjects, p < 0.002). Mean HbA1c and fasting glucose declined by 1.1% points and 29 mg/dL in type 2 diabetic subjects, 80% of whom had remission of their diabetes at 12 months.Conclusion: This study demonstrates the feasibility, safety, and efficacy of a fully trans-oral gastrointestinal bypass implant. This purely endoscopic device may provide a valuable addition to the armamentarium of treatment available for the management of morbid obesity. [ABSTRACT FROM AUTHOR]

Background: Long-term resorbable mesh represents a promising technology for complex ventral and incisional hernia repair (VIHR). Preclinical studies indicate that poly-4-hydroxybutyrate (P4HB) resorbable mesh supports strength restoration of the abdominal wall. This study evaluated outcomes of high-risk subjects undergoing VIHR with P4HB mesh.Methods: This was a prospective, multi-institutional study of subjects undergoing retrorectus or onlay VIHR. Inclusion criteria were CDC Class I, defect 10-350 cm2, ≤ 3 prior repairs, and ≥ 1 high-risk criteria (obesity (BMI: 30-40 kg/m2), active smoker, COPD, diabetes, immunosuppression, coronary artery disease, chronic corticosteroid use, hypoalbuminemia, advanced age, and renal insufficiency). Physical exam and/or quality of life surveys were performed at regular intervals through 18 months (to date) with longer-term, 36-month follow-up ongoing.Results: One hundred and twenty-one subjects (46M, 75F) with an age of 54.7 ± 12.0 years and BMI of 32.2 ± 4.5 kg/m2 (mean ± SD), underwent VIHR. Comorbidities included the following: obesity (n = 95, 78.5%), hypertension (n = 72, 59.5%), cardiovascular disease (n = 42, 34.7%), diabetes (n = 40, 33.1%), COPD (n = 34, 28.1%), malignancy (n = 30, 24.8%), active smoker (n = 28, 23.1%), immunosuppression (n = 10, 8.3%), chronic corticosteroid use (n = 6, 5.0%), advanced age (n = 6, 5.0%), hypoalbuminemia (n = 3, 2.5%), and renal insufficiency (n = 1, 0.8%). Hernia types included the following: primary ventral (n = 17, 14%), primary incisional (n = 54, 45%), recurrent ventral (n = 15, 12%), and recurrent incisional hernia (n = 35, 29%). Defect and mesh size were 115.7 ± 80.6 and 580.9 ± 216.1 cm2 (mean ± SD), respectively. Repair types included the following: retrorectus (n = 43, 36%), retrorectus with additional myofascial release (n = 45, 37%), onlay (n = 24, 20%), and onlay with additional myofascial release (n = 8, 7%). 95 (79%) subjects completed 18-month follow-up to date. Postoperative wound infection, seroma requiring intervention, and hernia recurrence occurred in 11 (9%), 7 (6%), and 11 (9%) subjects, respectively.Conclusions: High-risk VIHR with P4HB mesh demonstrated positive outcomes and low incidence of hernia recurrence at 18 months. Longer-term 36-month follow-up is ongoing. [ABSTRACT FROM AUTHOR]

Introduction: Nonalcoholic fatty liver disease (NAFLD) is an epidemic in the obese population. Bariatric surgery is known to reverse multiple metabolic complications of obesity such as diabetes, dyslipidemia, and NAFLD, but the timing of liver changes has not been well described.Materials and Methods: This was an IRB-approved, two-institutional prospective study. Bariatric patients received MRIs at baseline and after a pre-operative liquid diet. Liver biopsies were performed during surgery and if NAFLD positive, the patients received MRIs at 1, 3, and 6 months. Liver volumes and proton-density fat fraction (PDFF) were calculated from offline MRI images. Primary outcomes were changes in weight, body mass index (BMI), percent excess weight loss (EWL%), liver volume, and PDFF. Resolution of steatosis, as defined as PDFF < 6.4% based on previously published cutoffs, was assessed. Secondarily, outcomes were compared between patients who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB).Results: From October 2010 to June 2015, 124 patients were recruited. 49 patients (39.5%) completed all five scans. EWL% at 6 months was 55.6 ± 19.0%. BMI decreased from 45.3 ± 5.9 to 34.4 ± 5.1 kg/m2 and mean liver volume decreased from 2464.6 ± 619.4 to 1874.3 ± 387.8 cm3 with a volume change of 21.4 ± 11.4%. PDFF decreased from 16.6 ± 7.8 to 4.4 ± 3.4%. At 6 months, 83.7% patients had resolution of steatosis. Liver volume plateaued at 1 month, but PDFF and BMI continued to decrease. There were no statistically significant differences in liver volume or PDFF reduction from baseline to 6 months between the LSG versus LRYGB subgroups.Conclusion: Patients with NAFLD undergoing bariatric surgery can expect significant decreases in liver volume and hepatic steatosis at 6 months, with 83.7% of patients achieving resolution of steatosis. Liver volume reduction plateaus 1-month post-bariatric surgery, but PDFF continues to decrease. LSG and LRYGB did not differ in efficacy for inducing regression of hepatosteatosis. [ABSTRACT FROM AUTHOR]

Introduction: The widespread adoption of laparoscopic surgery has put new physical demands on the surgeon leading to increased musculoskeletal disorders and injuries. Shoulder, back, and neck pains are among the most common complaints experienced by laparoscopic surgeons. Here, we evaluate the feasibility and efficacy of a non-intrusive progressive arm support exosuit worn by surgeons under the sterile gown to reduce pain and fatigue during surgery.Methods and Procedures: This is a prospective randomized crossover study approved by the Internal Review Board (IRB). The study involves three phases of testing. In each phase, general surgery residents or attendings were randomized to wearing the surgical exosuit at the beginning or at the crossover point. The first phase tests for surgeon manual dexterity wearing the device using the Minnesota Dexterity test, the Purdue Pegboard test, and the Fundamentals of Laparoscopic Surgery (FLS) modules. The second phase tests the effect of the device on shoulder pain and fatigue while operating the laparoscopic camera. The third phase rates surgeon experience in the operating room between case-matched operating days.Results: Twenty subjects were recruited for this study. Surgeons had the similar dexterity scores and FLS times whether or not they wore the exosuit (p value ranges 0.15-0.84). All exosuit surgeons completed 15 min of holding laparoscopic camera compared to three non-exosuit surgeons (p < 0.02). Exosuit surgeons experienced significantly less fatigue at all time periods and arm pain (3.11 vs 5.88, p = 0.019) at 10 min. Surgeons wearing the exosuit during an operation experienced significant decrease in shoulder pain and 85% of surgeons reported some form of pain reduction at the end of the operative day.Conclusion: The progressive arm support exosuit can be a minimally intrusive device that laparoscopic surgeons wear to reduce pain and fatigue of surgery without significantly interfering with operative skills or manual dexterity. [ABSTRACT FROM AUTHOR]

The article presents the analysis by the technology and value assessment committee of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) on the use of immunofluorescence for biliary visualization and perfusion assessment. Topics discussed include an overview of near-infrared fluorescence angiography (NIRFA), indocyanine green usage for biliary visualization, and comparison between near infrared fluorescent cholangiography (NIFFC) and intraoperative cholangiography (IOC).

Background: The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in the literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume.Methods: We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (<6), intermediate (6-19), and high (≥20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine whether hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology.Results: A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %), and multivariate analysis revealed that high hospital volume had a protective effect (OR 0.54, 95 % CI 0.45-0.65). On subgroup analyses for low- and intermediate-volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high-volume hospitals (p < 0.05). There was no difference in mortality between low- and medium-volume hospitals and between subgroups.Conclusion: No lower mortality risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is lower in high-volume hospitals. [ABSTRACT FROM AUTHOR]

Background: Approximately 20-30 % of patients who undergo Roux-en-Y gastric bypass (RYGB) will not meet the goals of weight loss surgery. Revisional surgery is associated with higher morbidity compared to initial operative management, and results in terms of weight loss have been inconsistent. Endoscopic plication has been seen as a less invasive option, with encouraging initial results. The objective was to analyze the outcomes after Restorative Obesity Surgery, Endolumenal (ROSE) procedure.Methods: We retrospectively analyzed patients who underwent ROSE between 5/2008 and 11/2013. All patients had failure of weight loss or regain weight after RYGB. Demographics, operative data, and follow-up were recorded.Results: Twenty-seven patients underwent ROSE. One patient was excluded due to lack of follow-up. Twenty-five (96 %) patients were female. Mean time since initial RYGB was 11.9 ± 4.3 years. Mean initial weight and BMI were 236 ± 47 lb and 40.6 ± 8.1 kg/m(2), respectively. Mean OR time was 77 ± 30 min. Preoperative average pouch length and stoma diameter were 6.8 ± 2.3 and 2.1 ± 0.7 cm, respectively. On average, 4 ± 1.6 stitches were placed. Final pouch length and stoma diameter were 3.4 ± 1.6 (50 % reduction) and 0.86 ± 0.4 cm (61 % reduction). A total of 12 (46 %) and seven (28 %) patients underwent EGD at 3 and 12 months postoperatively. The mean pouch length and stoma diameter were 5 ± 1.9 (26.5 % reduction) and 1.2 ± 0.7 cm (42.9 % reduction) at 3 months and 6.14 ± 1.6 (10 % reduction) and 2.2 ± 1.2 cm (4.7 % increase) at 12 months, respectively. The %EWL was 8.9, 9.3, 8, 6.7, -10.7, -13.5, -5.8, -4.5 at 3, 6, 12, 24, 36, 48, 60, and 72 months, respectively.Conclusion: Although endoscopic plication achieved the intended reduction in the pouch and stoma diameter at 3 months, these tend toward the preoperative diameter at 12 months. This anatomical failure and the lack of follow-up may explain why most patients failed to achieve sustainable weight loss. [ABSTRACT FROM AUTHOR]

Background: Single-incision minimally invasive surgery has previously been associated with incisions 2.0-3.0 cm in length. We present a novel single-incision surgical platform compatible for insertion through a standard 15-mm trocar we previously described in six patients with short-term follow-up data. The objective of this phase II study was to evaluate the safety and feasibility of the platform in a larger collective and to evaluate 1-year follow-up data of the phase I trial.Methods: The technology features a multiple-use introducer, accommodating the articulating instruments, and is inserted through a 15-mm laparoscopic trocar. Cholecystectomy is performed through an umbilical incision. A prospective feasibility study was performed at a single center. Inclusion criteria were age of 18-75 years and biliary colic, exclusion criteria were acute cholecystitis, dilation of the biliary tree, severe coagulopathy, BMI > 40 kg/m(2), or choledocholithiasis. Endpoints included complications, length of stay, pain medication, cosmetic results, and the presence of hernia.Results: Twenty-seven patients (23 females; phase I: 6 patients, phase II: 21 patients) with an average age of 41.7 years and BMI 26.6 kg/m(2) were recruited for the study. Umbilical incision length did not exceed 15 mm. There were no intraoperative complications. Average OR time decreased from 91 min for the first six cases to 56 min for the last six cases. Average length of stay was 7.8 h. Pain control was achieved with diclofenac for no more than 7 days. All patients had no adverse events at 5-month follow-up, and all phase I patients had no adverse events nor evidence of umbilical hernia at 1 year.Conclusion: This study demonstrates that single-incision cholecystectomy with the platform is feasible, safe, and reproducible in a larger patient population. Long-term follow-up showed no hernias or other adverse events. Further studies will be needed to evaluate longer-term hernia rates. [ABSTRACT FROM AUTHOR]

Introduction: Patients with psychiatric disorder were reported to have a poor outcome in bariatric surgery. Few studies have examined the outcome of laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in patients with psychiatric history. We aimed to compare excess weight loss (%EWL) in patients with and without psychiatric comorbidities who underwent LSG or LAGB.Methods: Patients undergoing LSG or LAGB were identified from our prospective database. A multidisciplinary team evaluated all patients preoperatively, including a psychological evaluation. Patients with the diagnosis of depression, anxiety, bipolar disorder, and schizophrenia were included in the psychiatric comorbidity group (PSY). Others were included in group NON-PSY. All patients were first screened to be psychologically stable to undergo surgery. Initial BMI and %EWL at 3, 6, and 12 months postoperatively were compared.Results: A total of 590 patients (81.4 % women), with a median BMI of 43.8 kg/m(2) (range 30-99) who underwent LSG (n = 222) or LAGB (n = 368) from January 2006 to June 2013, were identified. Psychiatric comorbidities that were well controlled at the time of surgery were found in 188 patients (31.9%). Diagnostic criteria for depression were met in 154 patients (26.1%), 75 patients suffered from anxiety (12.7%), 9 from bipolar disorder, and 4 from schizophrenia (0.7%). Initial BMI was not different between the two groups. No significant difference in %EWL between the groups was found during follow-up (44.13 vs. 43.37%EWL, respectively, at 1 year; p = 0.76). When LSG and LAGB patients were analyzed as subsets, again no difference in %EWL at 1 year was found for PSY vs. NON-PSY (LSG: 51.56 vs. 54.86%EWL; LAGB: 38.48 vs. 38.45%EWL, all p = ns). In multivariate analysis, the differences from unadjusted analysis persisted.Conclusion: These findings demonstrate that a similar %EWL can be achieved in patients undergoing LSG or LAGB despite the presence of well-controlled psychiatric comorbidity. [ABSTRACT FROM AUTHOR]

Introduction: Here, we report the first series of patients with 1-year implantation of a novel, endoluminal, endoscopically delivered and retrieved gastro-duodeno-jejunal bypass sleeve (GJBS) (ValenTx, Inc. Carpinteria, CA, USA). In this report, we present the safety, feasibility of the device, weight loss, and changes in comorbidities.Methods and Procedures: A prospective, single-center, 12-month trial was designed. The patients are morbidly obese individuals who meet the NIH criteria for bariatric surgery. The GJBS is a 120-cm sleeve secured at the esophago-gastric junction with endoscopic and laparoscopic techniques that is designed to create an endoluminal gastro-duodeno-jejunal bypass. The device was implanted and, at the completion of the trial, retrieved with an endoscopic technique. The primary endpoints were safety and incidence of adverse events. The secondary outcomes included the percentage of excess weight loss (EWL) and changes in comorbidities, specifically glucose control, use of antihyperglycemics, and changes in hemoglobin A1C levels.Results: From July 2009 until October 2009, 13 patients were prospectively enrolled for the 1-year trial. The study included five men and eight women with a mean preoperative BMI of 42 kg/m(2). One patient was excluded, at the time of endoscopic evaluation, due to inflammation at the GE junction. Two additional patients required early explantation of the device, within the first 4 weeks, due to patient intolerance. Upon explant of the device, both patients' symptoms improved. In the remaining ten patients, the device was implanted, left in situ for 12 months, and then retrieved endoscopically. Safe delivery of the cuff at the gastro-esophageal junction was seen in all ten patients whom had device implants, without complication. No esophageal leak was seen immediately post-procedure or during follow-up. The sleeve device was well tolerated within the bowel lumen during the 12-month study, specifically, no bowel erosions, ulceration, or pancreatitis was observed. All ten patients reached the 1-year mark. Of the ten, six had fully attached and functional devices throughout the follow-up, verified by endoscopy. The mean percentage EWL, at 1 year, in this group was 54 %. In the remaining four patients, partial cuff detachment was observed at follow-up endoscopy. The percentage EWL was lower in this group. Of the six patients that reached a year with a fully attached device, five were followed at an average of 14-months post-explant (26 months from the time of device implant). These five maintained an average percentage EWL of 30 % at the 14-month post-explant follow-up. Co-morbidites measured included diabetes mellitus, hypertension, hyperlipidemia, and use of antihyperglycemics. Each of the measured comorbidities showed improvement during the 12-month trial.Discussion: The endoluminal, GJBS can be safely placed and retrieved. The short-term data show it is well tolerated with a good safety profile. It achieves excellent weight loss results with over 70 % of all comorbidities resolved or significantly improved. [ABSTRACT FROM AUTHOR]

Objective: Single-incision minimally invasive surgery has previously been associated with incisions 2.0-3.0 cm in length. We present a novel single-incision surgical platform compatible for insertion through a standard 15-mm trocar. The objective of this study is to evaluate the safety and feasibility of the platform.Methods: The technology is currently a Phase I investigational device. It features articulating surgical instruments and is inserted through a multiple-use introducer. The platform's introducer requires a standard 15-mm laparoscopic trocar. Cholecystectomy is performed through a 15-mm umbilical incision utilizing an additional epigastric 2-mm needle-port grasper for gallbladder retraction. A prospective feasibility study was performed at a single-center. Inclusion criteria were age 18-75 years and biliary colic. Patients were excluded if they had acute cholecystitis, dilation of the biliary tree, severe coagulopathy, BMI > 40 kg/m(2), or choledocholithiasis. Endpoints included the success rate of the platform, hospital length of stay, post-operative pain medication usage, cosmetic results, and presence of hernia.Results: Six patients (5 female) with an average age of 41 years and BMI 28 kg/m(2) underwent cholecystectomy with the platform. Average OR time was 91 min and umbilical incision length did not exceed 15 mm. One case was converted to standard laparoscopy due to mechanical failure of the clip applier instrument. There were no intraoperative complications. Post-operatively, two patients developed self-resolving umbilical ecchymoses. Average length of stay was 13 h. Pain control was achieved with diclofenac for less than 7 days. At 1 month follow-up there were no complications and no umbilical hernias.Conclusions: This phase I study demonstrates that single-incision cholecystectomy through a 15-mm trocar with the Fortimedix Surgical B.V. single-incision surgical platform is feasible, safe, and reproducible. Additional benefits include excellent triangulation and range of motion as well as exceptional cosmetic results. Further studies will be needed to evaluate long-term hernia rates. [ABSTRACT FROM AUTHOR]

Background: This report describes the authors' experience with a unique endoluminal, endoscopically delivered and retrieved gastroduodenojejunal bypass sleeve, including short-term weight loss and changes in comorbidities. Methods: A prospective, single-center trial was designed. The patients were morbidly obese individuals who met the National Institutes of Health criteria for bariatric surgery. The device used was a unique gastroduodenojejunal bypass sleeve secured at the esophagogastric junction with endoscopic and laparoscopic techniques and designed to create an endoluminal gastroduodenojejunal bypass. At completion of the trial, the device was explanted with endoscopic retrieval. The primary end points were safety and incidence of adverse events. The secondary outcomes included the percentage of excess weight loss and changes in comorbidities, specifically glucose control, use of antihyperglycemic medications, and changes in hemoglobin A1c levels. Results: From July 2008 to February 2010, 24 patients were enrolled in the trial. The gastroduodenojejunal bypass sleeve was implanted, left in situ, and then retrieved. The 7 men and 17 women in the study had a mean preoperative body mass index of 42 kg/m. The device was successfully delivered in 22 of the 24 patients (92%) and retrieved endoscopically from all 22 patients in whom it was implanted (100%). Two patients were excluded from the study preprocedurally. The one patient was excluded preoperatively due to noncompliance with the preoperative liquid diet. For the other excluded patient, the device was not attempted endoscopically due to significant inflammation at the gastroesophageal junction at the time of laparoscopic evaluation. Of the 22 patients who had the device implanted, 17 maintained it (77%) and completed the full 12-week trial. These patients had 39.7% excess weight loss at completion of the study. The primary reason for early explantation of the device was early postoperative dysphagia. The seven patients with preoperative diabetes mellitus all had normal blood glucose levels throughout the trial, and none required antihyperglycemic medications. All four patients with elevated hemoglobin A1c levels preoperatively showed improvement by the end of the trial. Conclusions: This trial demonstrated that the endoluminal gastroduodenojejunal sleeve can achieve excellent weight loss at 12 weeks. No patient safety issues were encountered. Adverse effects were minimal and resolved at endoscopic device removal. Effective glycemic control was demonstrated through use of the device during the trial. Long-term results are needed. [ABSTRACT FROM AUTHOR]

Background: Natural orifice translumenal endoscopic surgery (NOTES) has the potential to decrease the burden of an operation on a patient. Limitations of the endoscopic platform require innovative solutions to provide retraction and create an operation comparable with the gold standard, laparoscopic cholecystectomy. Methods: Four patients underwent transvaginal cholecystectomy. All procedures were performed under laparoscopic vision to ensure safety. The endoscope and a long articulating RealHand instrument were placed via a 15-mm vaginal trocar. A magnetic retraction system was used to retract the gallbladder safely. Laparoscopic clips were used to ligate the cystic duct and artery. All four gallbladders were successfully removed. No complications occurred. The mean operating time was 102 min. Results: All four procedures were completed without complications. The four patients all were discharged shortly after surgery and reported normal sexual activity without pain. Conclusions: Transvaginal cholecystectomy can be completed safely using current technology. Further studies are needed to determine the safety of the procedure and to determine whether it confers any benefits other than cosmesis. [ABSTRACT FROM AUTHOR]

Background: Transvaginal cholecystectomy has been performed at several institutions using hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques.Methods: A 42-year-old woman with symptomatic cholelithiasis was taken to the operating room for transvaginal cholecystectomy after giving informed consent. A single 5-mm laparoscope was placed at the umbilicus, followed by a 15-mm trocar through the vaginal conduit. The endoscope and a long flexible RealHand surgical instrument (Novare, Cupertino, CA) were placed via the vaginal trocar. The cystic duct and artery were identified and clipped using laparoscopic clips from the umbilical port. The long articulating laparoscopic instrument provided stable retraction. Hook cautery was used to dissect the gallbladder, which was removed via the vaginal trocar. The vaginal incision was closed using a single figure-of-eight absorbable suture under direct vision. The procedure lasted 96 min.Results: The cholecystectomy was successfully performed without spillage of bile. The patient was kept overnight for observation only as a precaution. She reported no pain and did not require a discharge prescription for narcotics.Conclusions: The described technique for NOTES cholecystectomy results in a virtually scarless operation. The single 5-mm umbilical trocar allows for safe clipping of the cystic duct. Further work is needed to determine the efficacy of this approach. [ABSTRACT FROM AUTHOR]

Transvaginal cholecystectomy has been performed at several institutions using hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques. A 42-year-old woman with symptomatic cholelithiasis was taken to the operating room for transvaginal cholecystectomy after giving informed consent. A single 5-mm laparoscope was placed at the umbilicus, followed by a 15-mm trocar through the vaginal conduit. The endoscope and a long flexible RealHand surgical instrument (Novare, Cupertino, CA) were placed via the vaginal trocar. The cystic duct and artery were identified and clipped using laparoscopic clips from the umbilical port. The long articulating laparoscopic instrument provided stable retraction. Hook cautery was used to dissect the gallbladder, which was removed via the vaginal trocar. The vaginal incision was closed using a single figure-of-eight absorbable suture under direct vision. The procedure lasted 96 min. The cholecystectomy was successfully performed without spillage of bile. The patient was kept overnight for observation only as a precaution. She reported no pain and did not require a discharge prescription for narcotics. The described technique for NOTES cholecystectomy results in a virtually scarless operation. The single 5-mm umbilical trocar allows for safe clipping of the cystic duct. Further work is needed to determine the efficacy of this approach. [ABSTRACT FROM AUTHOR]