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With an obesity rate of over 30% in the United States, obesity continues to be a serious epidemic. In addition to excessive weight, obesity involves a myriad of comorbidities that contribute to severe morbidity and mortality. Bariatric surgery has been shown to lead to significant weight loss, resolution of obesity-related comorbidities, and overall improved quality of life. After several decades, laparoscopic sleeve gastrectomy has emerged as a leading bariatric procedure, and emergent surgical robotic technology has led to the advent of the robotic sleeve gastrectomy. This procedure has been shown to have outcomes on par with laparoscopic sleeve gastrectomy along with similar and sometimes lower risks and complications. Additionally, surgeons have become more comfortable and proficient in using robotic surgery overall. While currently an expensive procedure, robotic sleeve gastrectomy has the potential to emerge as the preferred procedure as technology continues to improve, as the surgical robot becomes cheaper and more widely available, and as physicians continue to learn to perform robotic procedures early on in their training.

Gastroesophageal reflux disease (GERD) is a very prevalent disorder that can often be managed pharmacologically, but may require surgery in patients with certain symptoms or complications. Nissen fundoplication is the cornerstone of surgical management of GERD, especially when associated with a hiatal hernia. In order to identify surgical candidates, an objective diagnosis of GERD must be made using upper endoscopy, ambulatory pH monitoring, barium esophagram, and manometry.

Introduction: The incidence and significance of hyperparathyroidism in patients after bariatric surgery have been established to some degree; however, the impact it has on the national healthcare system has not. We sought to assess the risk of readmission and related comorbidities in this patient population. Methods: The Healthcare Cost and Utilization Project Nationwide Readmission Database was queried for all patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Multivariate logistic regression analysis was conducted to identify factors associated with readmission for hyperparathyroidism. Results: A total of 915,792 patients between 2010 and 2015 were queried; 43.2% had undergone SG and 56.8% had RYGB. A total of 589 patients were readmitted for hyperparathyroidism; 80.8% were female and 68% had a Charlson comorbidity index ≥ 2. Factors associated with readmission were as follows: age 45-64 years (odds ratio [OR] 1.42, p=0.001), Medicare (OR 3.01, p

Laparoscopic sleeve gastrectomy (SG) has rapidly become the most commonly performed bariatric procedure in the United States as well as other countries, with approximately 120,000 procedures being performed annually in the United States. Reoperative interventions after SG have become more prevalent in the past few years since the initial development of SG as a primary operation. Given the expected rapid growth of these reinterventions, an expert consensus conference was held with some of the most experienced bariatric surgeons in the world to better understand, discuss, and provide consensus on the reasons, indications, contraindications, and surgical options for nonresponders and complicated SG operations.Provide consensus-based best practice guidelines regarding the performance of reinterventions after failed or complicated SG in patients with obesity, using expert opinion by organizing a consensus meeting of experts and evaluating the current literature.The meeting was held in Boca Raton, Florida on February 18, 2017.The panel of 32 expert bariatric surgeons representing 12 countries and major regions of the world and all 6 populated continents identified 54 questions for consensus. Questions encompassed patient selection, indications, contraindications, surgical technique, prevention and management of weight regain, and short- and long-term complications after SG. Responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (70% agreement). The current available literature was extensively reviewed for each topic in question and proposed to the panel.Full consensus was obtained for the essential aspects of indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 35 of 54 key questions. Highlights include consensus recommendations regarding technique in reoperation, management of GERD and Barrett's esophagus after SG, and surgical options for poor initial weight loss. No consensus was reached on topics, such as management of chronic proximal fistula after SG.This first international expert meeting provides 35 statements and recommendations for a clinical consensus guideline regarding standardization of indications, contraindications, surgical options, and surgical techniques when reoperating on patients who underwent a failed or complicated SG. To our knowledge, the present consensus report represents the first document that defines best practice guidelines for the performance of reinterventions after failed or complicated SG.

Accurate localization of parathyroid adenomas allows for minimally invasive parathyroidectomy. This results in a shorter length of stay and increased patient satisfaction. Preoperative Technetium (99mTc) sestamibi scans accurately localize parathyroid adenomas in 70 to 85 per cent of cases. If a patient has a negative scan, it is logical to believe that with a preoperative sestamibi injection, the gamma probe may fail to help find an adenoma. We hypothesized that the gamma probe would not be useful intraoperatively for patients with primary hyperparathyroidism (PHPTH) and a negative sestamibi scan. We retrospectively reviewed the cases of parathyroidectomy at our institution from 2010 to 2016. We selected patients with PHPTH and negative sestamibi scan. In all cases, an attempt was made to find adenomas intraoperatively with the gamma probe. A frozen section was obtained as well as intraoperative parathyroid hormone levels to confirm removal of hyperfunctioning parathyroid tissue. There were 132 parathyroidectomies of which 22 had PHPTH and a negative sestamibi scan. One case was excluded because of insufficient documentation of the intraoperative use of the gamma probe. In 19 of the 21 patients analyzed, the gamma probe successfully identified the adenoma in the operating room (sensitivity, 90.5%). In two patients, the gamma probe did not aid in localization. There were no false positives. In all cases, the parathyroid resected was confirmed by frozen section. The intraoperative parathyroid hormone levels dropped >50 per cent in all but three cases, two of which corresponded to those cases where the gamma probe did not help. Even in patients with negative sestamibi scans, intraoperative use of the gamma probe after preoperative sestamibi injection is effective in localizing parathyroid adenomas.

Since the uprise of the obesity pandemic in most industrialized countries, different clinical and surgical approaches have been proposed as a treatment for obesity. Laparoscopic adjustable gastric banding (LAGB) proposed a concept that was described several decades ago using a band to mechanically restrict the gastric reservoir for the purpose of weight loss. Several attempts were made using nonadjustable gastric bands placed with an open surgery, although these attempts were somewhat successful in terms of initial weight loss, the fixed gastric banding with the open technique was rather a morbid procedure with several complications. Later on, the fixed gastric banding was replaced with a less morbid adjustable band and laparoscopic surgery became standard in this restrictive procedure, not only changing the LAGB outcome but also transforming the outlook for bariatric surgery in general. Positive outcomes combined with the fairly simple technique and short length of stay surgery made LAGB the most popular bariatric surgery in the early 2000s. Long-term outcomes have since shadowed the early positive results of this procedure, showing multiple complications, high rates of reoperations, and weight loss failure making LAGB a less desirable procedure and sharply declining its use in just a couple of years. The most significant historic milestones, the fundamental changes in the design and most recent technique, and the potential reasons that determined a quick rise and a progressive fall of LAGB's popularity are reviewed.

General surgery residency training can lead to a rewarding career in general surgery and serve as the foundation for careers in several surgical subspecialties. It offers broad-based training with exposure to the cognitive and technical aspects of several surgical specialties and prepares graduating residents for a wide range of career paths. This career development resource discusses the training aspects of general surgery.

Objectives Development and maintenance of scholarly activity is a challenge for small community-based surgical training programs. The current Accreditation Council for Graduate Medical Education Program Requirements in General Surgery states that, “Residents should participate in scholarly activity,” and “The sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities.” We adopted a program designed to improve the quality of research projects pursued by surgical residents and to increase the number of projects submitted for both presentation and publication. Design We hereby describe a structured step-by-step program to mentor surgical residents through clinical projects from development to publication. Setting Community hospital with academic affiliation, located in the Southeastern United States. Participants The Resident Scholarly Activity Program at our facility includes 2 faculty mentors who work in direct contact with all the surgical residents of our program (2 residents/y, postgraduate years 1-5). The faculty members are MD, MPH professionals who specialize in resident education and scholarly activity. Results Implementation of Resident Scholarly Activity Program instruction and mentoring increased the number of publications in all categories defined. The number of publications and presentations increased from 6 to 28 over a 1-year period. Conclusions A structured scholarly activity program positively affects the number of clinical projects produced by a small community-based surgical training program. Familiarity with project design and biostatistics, plus one-on-one mentoring improves the quality of research produced. A potential additional benefit is the ability to involve private surgical faculty with the residentsʼ projects.

An increasing number of studies have been published since the introduction of robotic technology into general surgery. Gastrointestinal surgery is an area of special interest for the robotic surgeon. Colonic surgery can be challenging depending on the disease and the operative approach. We seek to perform a meta-analysis comparing robotic surgery against laparoscopic surgery in this particular field.We performed a systematic search of MEDLINE database from January 2001 to July 2013 supplemented by manual searches of bibliographies of key relevant articles. Randomized controlled trials and cohort studies were selected for review and for collection of postoperative data (length of stay, time to first flatus and complications).After careful review, nine studies were considered for analysis. Non-pooled data showed a slight trend toward laparoscopy with increased number of events without statistical significance. Pooled data demonstrated a statistical significance for return to bowel function in the right and mixed robotic colectomy arm (WSMD -0.33, 95 % CI -0.5, -0.1; p0.005 and WSMD -0.26, 95 % CI -0.51, 0.0; p = 0.05). Pooled data of length of stay and complications showed no statistical significance between robotic and laparoscopic colonic surgery.Robotic surgery is a comparable option when dealing with colonic disease, either benign or malignant. No difference in complication rate or length of stay was found when comparing the two. Robotic surgery appears to have an advantage over laparoscopy in regards to return of bowel function when dealing with right colectomies.