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Background: Obesity is an epidemic in the USA that continues to grow, becoming a leading cause of premature avoidable death. Bariatric surgery has become an effective solution for obesity and its comorbidities, and one of the most commonly utilized procedures, the sleeve gastrectomy, can lead to an increase in gastroesophageal reflux following the operation. While these data are controversial, sometimes operative intervention can be necessary to provide durable relief for this problem.Methods: We performed an extensive literature review examining the different methods of anti-reflux procedures that are available both before and after a sleeve gastrectomy.Results: We reviewed several different types of anti-reflux procedures, including those that supplement the lower esophageal sphincter anatomy, such as magnetic sphincter augmentation and radiofrequency ablation procedures. Re-operation was also discussed as a possible treatment of reflux in sleeve gastrectomy, especially if the original sleeve becomes dilated or if a conversion to a Roux-en-Y gastric bypass or biliopancreatic diversion is deemed necessary. Sleeve gastrectomy with concomitant anti-reflux procedure was also reviewed, including the anti-reflux gastroplasty, hiatal hernia repair, and limited fundoplication.Conclusion: A number of techniques can be used to mitigate the severity of reflux, either by maintaining the normal anatomic structures that limit reflux or by supplementing these structures with a plication or gastroplasty. Individuals with existing severe reflux should not be considered for a sleeve gastrectomy. New techniques that incorporate plication at the time of the index sleeve gastrectomy show some improvement, but these are in small series that will need to be further evaluated. The only proven method of treating intractable reflux after sleeve gastrectomy is conversion to a Roux-en-Y gastric bypass. [ABSTRACT FROM AUTHOR]

Background: Surgical procedures have a learning curve regarding the number of cases required for proficiency. Consequently, involvement of less experienced resident surgeons may impact patients and the healthcare system. This study examines basic and advanced laparoscopic procedures performed between 2010 and 2011 and evaluates the resident surgeon participation effect.Methods: Basic laparoscopic procedures (BL), appendectomy (LA), cholecystectomy (LC), and advanced Nissen fundoplication (LN) were queried from the American College of Surgeons National Surgical Quality Improvement Program database. Cases were identified using Current Procedural Terminology codes. Analyses were performed using IBM SPSS Statistics v.22, α-level = 0.05. Multiple logistic regression was used, accounting for age, race, gender, admission status, wound classification, and ASA classification.Results: In total, 71,819 surgeries were reviewed, 66,327 BL (37,636 LC and 28,691 LA) and 5492 LN. Median age was 48 years for LC and 37 years for LA. In sum, 72.2 % of LC and 49.5 % of LA patients were female. LN median age was 59 years, and 67.7 % of patients were female. For BL, resident involvement was not significantly associated with mortality, morbidity, and return to the OR. Readmission was not related to resident involvement in LC. In LA, resident-involved surgeries had increased readmission and longer OR time, but decreased LOS. In LC, resident involvement was associated with longer LOS and OR time. Resident involvement was not a significant factor in the odds of mortality, morbidity, return to OR, or readmission in LN. Surgeries involving residents had increased odds of having longer LOS, and of lengthier surgery time.Conclusions: We demonstrate resident involvement is safe and does not result in poorer patient outcomes. Readmissions and LOS were higher in BL, and operative times were longer in all surgeries. Resident operations do appear to have real consequences for patients and may impact the healthcare system financially. [ABSTRACT FROM AUTHOR]

Introduction: Paraesophageal hernia (PEH) repair has a high radiologic recurrence rate, even with the use of biologic mesh as a prosthetic buttress to reinforce the primary crural repair. This review was done to evaluate outcomes after PEH repair with mesh. Methods: A retrospective analysis was done of all patients who underwent PEH repair with mesh at our institution between December 2004 and March 2013. Patients were reviewed for evidence of recurrence on upper gastrointestinal studies (UGI). Time-specific, mesh-specific, and size-specific recurrence was analyzed as well as pre- and postoperative symptom scores. Results: A total of 209 patients underwent PEH repair with mesh. Mean follow-up was 25 months (range 0-101). In all cases, an absorbable mesh was used (159 Alloderm, 35 BioA, 15 Strattice). One hundred and fifty-six (75 %) were 5 cm or larger. Of the patients, 166 (79 %) had UGIs available to review for radiologic recurrence. Total recurrence was 21 % ( n = 35). No mesh erosions were seen. Recurrence rates increased over time from 16 % ( n = 23) at 1 year up to 39 % after 5-year follow-up ( n = 11). Recurrence rates were higher for large hernias (23 vs. 16 %). The median size of the recurrence was 4 cm (range 2-7 cm). Overall, patients showed significant improvement in their symptom scores. At long-term follow-up, heartburn had 70.6 % reduction ( p < 0.05) and regurgitation had 76.5 % reduction ( p < 0.05). There was no significant difference in postoperative symptom scores between patients with or without radiologic recurrence. Conclusions: In this study, PEH repair with mesh was safe and effective at controlling symptoms over the long term. Radiologic recurrence rate increased over time and was highest in patients with hernias >5 cm. Therefore, in our experience, PEH repair with mesh is a safe therapy and though radiologic recurrence does increase with time, symptom resolution is maintained. [ABSTRACT FROM AUTHOR]

Background: Conventional laparoscopic fundoplications (CLF) have been the gold standard for Nissen fundoplications (NFs) for two decades. The advent of a robotic approach for fundoplication procedures creates a potential alternative. Thus, we used a national database to examine perioperative outcomes with respect to open, laparoscopic, and robotic approaches. Methods: The University Health System Consortium is an alliance of medical centers, numbering over 115 academic institutions and their 271 affiliated hospitals. We used International Classification of Diseases codes to elicit patients over the age of 18 years who received NF procedures. Results: A total of 12,079 patients of similar demographic background received fundoplication procedures from October 2008 to June 2012. Of those, 2,168 were open fundoplications (OF), 9,572 were CLF, and 339 were robot-assisted laparoscopic fundoplications (RLF). CLF and RLF displayed no significance in mortality (0.1 vs. 0 %; p = 0.5489), morbidity (4.0 vs. 5.6 %; p = 0.1744), length of stay (2.8 ± 3.6 vs. 3.0 ± 3.5; p = 0.3242), and intensive care unit (ICU) cases (8.4 vs. 11.5 %; p = 0.051). However, CLF remained superior, with a lower 30-day re-admission rate (1.8 vs. 3.6 %; p < 0.05) and cost (US$7,968 ± 6,969 vs. US$10,644 ± 6,041; p < 0.05). When RLF was compared with OF, RLF had significantly improved morbidity (5.6 vs. 11 %; p < 0.05), length of stay (6.1 ± 7.2 vs. 3.0 ± 3.5 days; p < 0.05), less ICU admission (11.5 vs. 23.1 %; p <0.05) and less cost (US$10,644 ± 6,041 vs. US$12,766 ± 13,982; p < 0.05). Conclusions: Current data suggests that robot-assisted NF procedures have similar patient outcomes to conventional laparoscopic NF, with the exception of added cost and higher re-admission rate. While the higher costs are expected given the new technology, increasing re-admission rates are concerning and may represent the level of experience of the surgeon as well as the robotic learning curve. [ABSTRACT FROM AUTHOR]

Background: A significant proportion of patients, especially the elderly undergoing colon resections, are likely to be discharged to a skilled care facility. This study aims to examine whether the technique of colectomy, open versus laparoscopic, contributed to their discharge to a skilled care facility. Methods: This was a retrospective analysis using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Adult patients who underwent colectomy in 2009 were evaluated. SAS and SUDAAN software were used to provide weighted estimates and to account for the complex sampling design of the NIS. We compared routine discharge to nonroutine discharge, defined as transfer to short-term hospital, skilled nursing facility, intermediate care, home health, or another type of facility. Results: A weighted total of 221,294 adult patients underwent colectomy in 2009 and had the primary outcome of discharge available. Of these colon resections, 70,361 (32 %) were performed laparoscopically and 150,933 (68 %) by open technique. A total of 139,047 (62.8 %) patients had routine discharge and 73,572 (33.3 %) nonroutine. A total of 8,445 (3.8 %) patients died while in the hospital, and 229 (0.1 %) left against medical advice and were excluded from further analysis. On univariate analysis, age ≥65 years, female gender, Black/Hispanic race, open technique (compared to laparoscopic), Medicare/Medicaid insurance status, comorbidity index of ≥1, and malignant primary diagnosis predicted nonroutine discharge. A multivariate logistic model was then used to predict nonroutine discharge in these patients using variables significant in the univariate analysis at the α = 0.05 significance level. In the multivariate analysis, open compared to laparoscopic technique was independently associated with increased likelihood of discharge to skilled care facilities (odds ratio 2.85, 95 % confidence interval 2.59-3.14). Conclusions: In addition to the expected factors like advancing age, female gender, and increasing comorbidity index, open compared to laparoscopic technique for colectomy is associated with an increased likelihood of discharge to skilled care facilities. When feasible, the laparoscopic technique should be considered as an option, especially in the elderly patients who require colon resection, because it may reduce their likelihood of discharge to a skilled care facility. [ABSTRACT FROM AUTHOR]

Background: With increasing childhood obesity, adolescent bariatric surgery has been increasingly performed. We used a national database to analyze current trends in laparoscopic bariatric surgery in the adolescent population and related short-term outcomes. Methods: Discharge data from the University Health System Consortium (UHC) database was accessed using International Classification of Disease codes during a 36 month period. UHC is an alliance of more than 110 academic medical centers and nearly 250 affiliate hospitals. All adolescent patients between 13 and 18 years of age, with the assorted diagnoses of obesity, who underwent laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) were evaluated. The main outcome measures analyzed were morbidity, mortality, length of hospital stay (LOS), overall cost, intensive care unit (ICU) admission rate, and readmission rate. These outcomes were compared to those of adult bariatric surgery. Results: Adolescent laparoscopic bariatric surgery was performed on 329 patients. At the same time, 49,519 adult bariatric surgeries were performed. One hundred thirty-six adolescent patients underwent LAGB, 47 had SG, and 146 patients underwent LRYGB. LAGB has shown a decreasing trend ( n = 68, 34, and 34), while SG has shown an increasing trend ( n = 8, 15, and 24) over the study years. LRYGB remained stable ( n = 44, 60, and 42) throughout the study period. The individual and summative morbidity and mortality rates for these procedures were zero. Compared to adult bariatric surgery, 30 day in-hospital morbidity (0 vs. 2.2 %, p < 0.02), the LOS (1.99 ± 1.37 vs. 2.38 ± 3.19, p < 0.03), and 30 day readmission rate (0.30 vs. 2.02 %, p < 0.05) are significantly better for adolescent bariatric surgery, while the ICU admission rate (9.78 vs. 6.30 %, p < 0.02) is higher and overall cost ($9,375 ± 6,452 vs. $9,600 ± 8,016, p = 0.61) is comparable. Conclusion: Trends in adolescent laparoscopic bariatric surgery reveal the increased use of sleeve gastrectomy and adjustable gastric banding falling out of favor. [ABSTRACT FROM AUTHOR]

Background: As surgical robots begin to occupy a larger place in operating rooms around the world, continued innovation is necessary to improve our outcomes. Methods: A comprehensive review of current surgical robotic user interfaces was performed to describe the modern surgical platforms, identify the benefits, and address the issues of feedback and limitations of visualization. Results: Most robots currently used in surgery employ a master/slave relationship, with the surgeon seated at a work-console, manipulating the master system and visualizing the operation on a video screen. Although enormous strides have been made to advance current technology to the point of clinical use, limitations still exist. A lack of haptic feedback to the surgeon and the inability of the surgeon to be stationed at the operating table are the most notable examples. The future of robotic surgery sees a marked increase in the visualization technologies used in the operating room, as well as in the robots' abilities to convey haptic feedback to the surgeon. This will allow unparalleled sensation for the surgeon and almost eliminate inadvertent tissue contact and injury. Conclusions: A novel design for a user interface will allow the surgeon to have access to the patient bedside, remaining sterile throughout the procedure, employ a head-mounted three-dimensional visualization system, and allow the most intuitive master manipulation of the slave robot to date. [ABSTRACT FROM AUTHOR]

Background: Robotic techniques are routinely used in urological and gynecological procedures; however, their role in general surgical procedures is limited. A robotic technique has been successfully adopted for a minimally invasive Heller myotomy procedure for achalasia. This study aims to compare perioperative outcomes following open, laparoscopic, and robotic Heller myotomy. Methods: This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium (UHC) is an alliance between academic medical centers and affiliate hospitals. The UHC database was accessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes and analyzed. Results: 2,683 patients with achalasia underwent Heller myotomy between October 2007 and June 2011. Myotomy was performed by open surgery (OM) in 418 patients, by laparoscopic approach (LM) in 2,116, and by robotic approach (RM) in 149. Comparison between LM and RM groups demonstrated no significant difference in mortality (0.14 vs. 0.0%; P = 1), morbidity (5.19 vs. 4.02%; P = 0.7), intensive care unit (ICU) admission (6.62 vs. 3.36%; P = 0.12), length of stay (LOS) (2.70 ± 3.87 days vs. 2.42 ± 2.69 days; P = 0.34), or 30-day readmission (1.41 vs. 2.84%; P = 0.27). However, hospital costs were significantly lower for the LM group (US $7,441 ± 7,897 vs. US $9,415 ± 5,515; P = 0.0028). Comparison between OM and RM demonstrated significant lower morbidity (9.08 vs. 4.02%; P = 0.02), ICU admission rate (14.01 vs. 3.36%, P = 0.0002), and LOS (4.42 ± 5.25 days vs. 2.42 ± 2.69 days; P = 0.0001). Conclusions: The perioperative outcomes are superior in LM and RM groups when compared with OM. The outcomes for the LM and RM group are comparable, with the robotic group having slightly improved results, although with increased costs. We conclude that robotic surgery is equivalent in safety and efficacy to laparoscopic Heller myotomy, and feel that the increased cost should come down as surgeons and manufacturers work together on cost reduction strategies. [ABSTRACT FROM AUTHOR]