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Background: The primary obesity surgery endoluminal (POSE) procedure is an innovative incision-less endoscopic bariatric procedure that is increasingly used. However, variable weight loss response and recurrence post-endoscopic bariatric procedures have at times necessitated laparoscopic bariatric conversion. The safety and approach of conversion to laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB), however, have been an active point of discussion within revisional bariatric surgery., Methods: This retrospective review of four consecutive patients is the largest description of medium-term postoperative outcomes and technical highlights of a laparoscopic conversion of POSE to RYGB. Chart review was completed to evaluate patients' post-POSE clinical course and perioperative outcomes after surgical conversion., Results: Early data suggests varied weight loss trajectory with POSE and marked improvement in weight response after surgical conversion. Qualitative review reveals successful single-staged conversions contrary to previous smaller case series describing staged conversions involving endoscopic removal of plications followed by RYGB. Review additionally reveals key perioperative considerations for successful conversions to include intraoperative endoscopy, upper gastrointestinal fluoroscopic studies, and at times computed tomography. The latter study and laparoscopic view of the post-POSE stomach challenge the prior notion that distal POSE allows for easy revision to LSG., Conclusions: Our case series underscores the complex multifactorial nature of metabolic disease and the increasing importance of a conscientious approach to conversion bariatric surgery as the adoption of POSE and the bariatric patient population continues to grow., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Recent data describing gastrointestinal (GI) symptoms experienced by patients after bariatric surgery is lacking, and previous studies in sleeve gastrectomy patients have been limited in scope of follow-up time or extent of GI symptoms examined. We sought to characterize the prevalence and time course of patient-reported eating-related symptoms in sleeve gastrectomy patients., Methods: From July 2020 to July 2021, sleeve gastrectomy patients seen at three Boston area hospitals received electronic surveys and prospectively reported GI symptoms using the BODY-Q eating-related symptoms scale. Descriptive analyses were performed for patient demographics and symptom prevalence. Chi-square tests were used to compare prevalence of eating-related symptoms between follow-up time intervals., Results: 491 sleeve gastrectomy patients completed postoperative surveys with mean follow-up time of 1.9 years. Mean age was 46.6 years, and 81.3% were female. The most reported GI symptoms overall included constipation (56.6%), bloating (54.0%), heartburn when standing (41.5%), and heartburn when lying down (39.9%) while the least commonly reported symptoms were palpitations (16.3%), low blood sugar (15.7%), and emesis (15.1%). At greater than 12 months, the most reported symptoms similarly included bloating (60.3%), constipation (53.2%), and heartburn while standing (46.0%). When comparing prevalence of eating-related symptoms across follow-up time intervals from < 1 to > 12 months, patients reported a significant decrease in constipation, abdominal pain, and nausea over time (p = 0.012, p < .0001, p = 0.03, respectively)., Conclusion: Patients experience both upper and lower GI symptoms following sleeve gastrectomy, and symptoms, including bloating, constipation, and heartburn may persist through long-term follow-up. These patient-centered measures add value by guiding preoperative counseling, informing postoperative expectations, and providing real-time clinical feedback for bariatric surgery patients., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure. Little is known about how surgeon training background influences the learning curve of this procedure. We examined operating times (OT), weight loss outcomes, and 30-day complications between surgeons with and without fellowship training in LSG. We hypothesize that post-residency training specific to LSG influences learning curves., Methods: Surgeons from a single institution were split into two groups: those who had not completed fellowship training in LSG (NF, n = 3), and those who had completed LSG specific training in fellowship (SGF, n = 3). OTs, BMI changes at 1 year, and 30-day readmissions, reoperations, and complications were extracted for the first 100 LSG cases of each surgeon. Data were analyzed in bins of 20 cases. Comparisons were made between cohorts within a bin and between adjacent bins of the same surgeon cohort. Logistic regression analyses were performed of OT and weight loss outcomes., Results: SGF surgeons showed no difference in OTs over their first 100 cases. NF surgeons had statistically significant increased OTs compared to SGF surgeons during their first 60 cases and progressively shortened OTs during that interval (109 min to 78 min, p < 0.001 for NF surgeons vs. 73 min to 69 min, SGF surgeons). NF surgeons had a significantly steeper slope for improvement in OT over case number. There was no correlation between case number and weight loss outcomes in either group, and no differences in 30-day outcomes between groups., Conclusion: Surgeons who trained to perform LSG in fellowship demonstrate faster and consistent OR times on their initial independent LSG cases compared to surgeons who did not, with no correlation between case number and weight loss outcomes or safety profiles for either group. This suggests that learning curves for LSG are achieved during formal case-specific fellowship training., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Objective: To characterize longitudinal changes in blood biomarkers, leukocyte composition, and gene expression following laparoscopic sleeve gastrectomy (LSG)., Background: LSG is an effective treatment for obesity, leading to sustainable weight loss and improvements in obesity-related comorbidities and inflammatory profiles. However, the effects of LSG on immune function and metabolism remain uncertain., Methods: Prospective data were collected from 23 enrolled human subjects from a single institution. Parameters of weight, comorbidities, and trends in blood biomarkers and leukocyte subsets were observed from preoperative baseline to 1 year postsurgery in 3-month follow-up intervals. RNA sequencing was performed on pairs of whole blood samples from the first 6 subjects of the study (baseline and 3 months postsurgery) to identify genome-wide gene expression changes associated with undergoing LSG., Results: LSG led to a significant decrease in mean total body weight loss (18.1%) at 3 months and among diabetic subjects a reduction in hemoglobin A1c. Improvements in clinical inflammatory and hormonal biomarkers were demonstrated as early as 3 months after LSG. A reduction in neutrophil-lymphocyte ratio was observed, driven by a reduction in absolute neutrophil counts. Gene set enrichment analyses of differential whole blood gene expression demonstrated that after 3 months LSG induced transcriptomic changes not only in inflammatory cytokine pathways but also in several key metabolic pathways related to energy metabolism., Conclusions: LSG induces significant changes in the composition and metabolism of immune cells as early as 3 months postoperatively. Further evaluation is required of bariatric surgery's effects on immunometabolism and the consequences for host defense and metabolic disease., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Patients are increasingly referred for conversion of laparoscopic adjustable gastric band (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG). The safety of a 1- versus 2-stage approach to this revision is debated., Objectives: We examined the safety and efficacy of 1-stage conversion of LAGB to SG at our institution., Setting: University hospital., Methods: An institutional database was used to retrospectively identify patients who underwent single-stage LAGB-to-SG conversion between 2010 and 2018. Patients were matched 1:1 for age, sex, and body mass index with primary SG patients during this same period. Primary endpoints were operative time, complication rate, length of hospital say, and weight loss 12 months from surgery., Results: Two-hundred and twenty-nine patients undergoing conversion of LAGB to SG were identified. Median postoperative length of hospital stay was 2 days. Two patients (.8%) developed surgical site infection. One patient (.4%) developed a postoperative myocardial infarction. There were 4 total readmissions (1.7%) and 1 reoperation within 30 days (.4%). There were no statistically significant differences in 30-day complication rates between groups. Weight loss at 12 months was significantly different: Median body mass index loss for conversion patients was 5.1 kg/m 2 compared with 8.85 kg/m 2 for patients in the primary SG group (P < .0001)., Conclusion: Single-stage conversion of LAGB to SG is safe and effective. Patients may not experience the same extent of weight loss as those with primary SG. Our findings represent the largest single-institutional experience to date and support a 1-stage approach whenever feasible., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Post-operative changes in eating behavior, eating-related distress and eating-related symptoms play an important role in the lives of bariatric surgery patients. However, there are no studies that assess these outcomes using a specifically designed patient-reported outcome measure (PROM) for patients undergoing bariatric surgery. We use our newly developed and validated scales as part of the well-established BODY-Q PROMs to compare laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass patients (LRYGB)., Methods: We analyzed data from an international multi-center prospective cohort study of patients over 18 who underwent bariatric surgery. We used multivariable linear regression models to assess the difference between LRYGB and LSG for the new BODY-Q scales, which include eating behavior, eating-related distress and eating-related symptoms. All analyses were corrected for significant confounding variables., Results: Out of 1420 patients, 920 underwent LRYGB and 500 underwent LSG. The LRYGB group had a higher percentage total weight loss (p < 0.001). There was no significant difference in eating behavior (e.g., stop eating before feeling full, avoiding unhealthy snacks, etc.) or eating-related distress (e.g., feeling ashamed or out of control after eating). Patients who underwent LSG scored significantly better on the post-prandial eating-related symptoms scale (e.g., vomiting, reflux; p < 0.001). Symptoms more prevalent in the LRYGB patients were related to dumping syndrome whereas symptoms more prevalent in LSG patients were related to reflux., Conclusion: Patients who underwent LRYGB had a significantly better weight loss after surgery, but they scored worse on post-prandial symptoms in comparison to LSG patients. This information may be relevant for patients in the pre-operative counseling setting, as it may influence their decision for surgical procedure selection.

Background: The benefits of laparoscopic splenectomy (LS) over open splenectomy (OS) for normal-sized spleens have been well documented. However, the role of laparoscopy for moderate and massive splenomegaly is debated., Methods: A retrospective review of patients undergoing elective splenectomy at one institution from 1997 to 2017 was conducted. Moderate and massive splenomegaly was defined as splenic weight of 500-1000 g and greater than 1000 g, respectively. We performed a 1:2 matching of laparoscopic to open splenectomy to control for differences in splenic weight. Differences in perioperative morbidity (infection, thromboembolism, reoperation, readmission), intraoperative factors (blood loss, operative time), length of stay, and mortality were examined., Results: A total of 491 elective splenectomies were identified. 268 cases were for splenic weights greater than 500 g. After a 1:2 matching of LS:OS, we identified 22 LS and 44 matched OS for moderate splenomegaly. The LS group had longer mean operative times (178 vs. 107 min, p < 0.01), with similar length of stay and blood loss. For massive splenomegaly, 26 LS were identified and matched to 52 OS. LS had longer mean operative times (171 vs. 112 min, p < 0.01) and higher readmission rates (27% vs. 6%, p < 0.05). Other factors and outcomes did not differ between LS and OS for moderate or massive splenomegaly. The conversion rate for LS was higher for massive versus moderate splenomegaly, but was not statistically significant (35% vs. 14%, p = 0.09)., Conclusions: LS for moderate and massive splenomegaly is associated with longer operative times. Other perioperative outcomes were comparable to OS, with no demonstrated benefits for LS. Although LS may be a feasible approach to moderate and massive splenomegaly, its benefits require further clarification in this patient population.

Objective: To design and validate a novel mixed reality head-mounted display for intraoperative surgical navigation., Design: A mixed reality navigation for laparoscopic surgery (MRNLS) system using a head mounted display (HMD) was developed to integrate the displays from a laparoscope, navigation system, and diagnostic imaging to provide context-specific information to the surgeon. Further, an immersive auditory feedback was also provided to the user. Sixteen surgeons were recruited to quantify the differential improvement in performance based on the mode of guidance provided to the user (laparoscopic navigation with CT guidance (LN-CT) versus mixed reality navigation for laparoscopic surgery (MRNLS)). The users performed three tasks: (1) standard peg transfer, (2) radiolabeled peg identification and transfer, and (3) radiolabeled peg identification and transfer through sensitive wire structures., Results: For the more complex task of peg identification and transfer, significant improvements were observed in time to completion, kinematics such as mean velocity, and task load index subscales of mental demand and effort when using the MRNLS (p < 0.05) compared to the current standard of LN-CT. For the final task of peg identification and transfer through sensitive structures, time taken to complete the task and frustration were significantly lower for MRNLS compared to the LN-CT approach., Conclusions: A novel mixed reality navigation for laparoscopic surgery (MRNLS) has been designed and validated. The ergonomics of laparoscopic procedures could be improved while minimizing the necessity of additional monitors in the operating room.

Background: We conducted the following study to evaluate the safety and efficacy of single-stage conversion of failed laparoscopic adjustable gastric band (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) as compared to a cohort of primary LRYGB patients., Methods: A single-institution, prospectively maintained bariatric database was used to retrospectively identify consecutive patients who underwent single-stage removal of LAGB with concomitant conversion to LRYGB between the years of 2007 and 2013. The study cohort was matched 1:1 for age, gender, body mass index (BMI), and approximate date of operation to patients who underwent primary LRYGB. Primary endpoints were operative time, complication rate, length of hospital stay (LOS), and percent excess BMI lost (%EBMIL) at 24-month follow-up., Results: Ninety-four conversion patients met inclusion criteria. There were no statistically significant differences in the mean LOS (3.1 vs. 3.0 days, p = 0.97) or the major complication rate (3.2 vs. 1.1 %, p = 0.62) at 30 days postoperatively. Likewise, 30-day minor complication rates, including readmission, were similar between groups (7.5 vs. 6.4 %, p = 0.77). The average operative time was significantly longer for conversion compared to primary LRYGB (193.5 vs. 132 min; p < 0.01). At most recent follow-up after conversion or primary LRYGB, median %EBMIL was 61.3 and 77.3 % (p < 0.01), percent total weight loss was 23.6 and 30.5 % (p < 0.01), and percent change in BMI was 23.4 and 30.5 % (p < 0.01), respectively. Median follow-up time was 17 and 18.6 months after conversion and primary LRYGB, respectively., Conclusion: Single-stage conversion of LAGB to LRYGB is safe with an acceptable complication rate and similar LOS compared to primary LRYGB.

Background: The latest studies on surgical and cost-analysis outcomes after laparoscopic distal pancreatectomy (LDP) highlight mixed and insufficient results. Whereas several investigators have compared surgical outcomes of LDP vs. open distal pancreatectomy (ODP) for adenocarcinomas, few similar studies have focused on pancreatic neuroendocrine tumors (PNETs)., Methods: We reviewed the medical records of PNET patients undergoing distal pancreatectomy between 2004 and 2014. Patients were divided into LDP vs. ODP groups. Demographics, relevant comorbidities, oncologic variables, and cost-analysis data were assessed. Survival and Cox proportional hazards analyses were used to evaluate outcomes., Results: Of the 171 distal pancreatectomies for PNETs, 73 were laparoscopic, whereas 98 were open. Patients undergoing LDP demonstrated significantly lower rates of postoperative complications (P=0.028) and had significantly shorter hospital stays (P=0.008). On multivariable analysis, positive resection margins (P=0.046), G3 grade (P=0.036), advanced WHO classification (P=0.016), TNM stage (P=0.018), and readmission (P=0.019) were significantly associated with poor survival; however, method of resection (LDP vs. ODP) was not (P=0.254). The median total direct costs of LDP vs. ODP did not differ significantly., Conclusions: In response to the recent considerable controversy surrounding the costs and surgical outcomes of LDP vs. ODP, our results show that LDP for PNETs is cost-neutral and significantly reduces postoperative morbidity without compromising oncologic outcomes and survival.

Background: Hiatal hernia (HH) is a risk factor for complications after laparoscopic adjustable gastric banding (LAGB), with recommendation to repair these at the time of LAGB placement. We reviewed the characteristics and outcomes of bariatric patients undergoing HH repair during LAGB. The aim of this study was to determine the prevalence of HH repair in LAGB patients and its potential effect on outcomes., Methods: Using the Bariatric Outcomes Longitudinal Database, we identified patients who had hiatal hernia repair at the time of their LAGB (HHR group) and compared them to other LAGB patients without a HH repair (NonHHR group)., Results: Of 41,611 patients who underwent LAGB during 2007-2010, 8120 (19.5%) had HH repair (HHR), adding only 4 minutes to the operating time, without an increase in blood transfusion, length of stay, or band-related complications. Preoperatively, the HHR cohort had a higher incidence of gastroesophageal reflux disease (GERD) compared with nonHHR (49% versus 40%, respectively; P<.001) with a higher GERD score (1.13 versus .88, respectively; P<.001). Of those with GERD, similar percentage of patients in the HHR and nonHHR groups experienced improvement 1-year after surgery (53% versus 52%, respectively, P = .4), with similar GERD scores at this time point., Conclusion: HH are repaired in one fifth of LAGB patients, with a surprisingly minimal increase in operative times and no change in length of stay, morbidity, or mortality. In patients with GERD, HH repair had minimal effect on postoperative improvements in reflux symptoms. These findings suggest that many of the repairs may involve small hernias with unclear clinical effect., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The role of adrenalectomy in management of isolated metastatic adrenal tumors is increasingly established. Laparoscopy is becoming the preferred approach for these resections. We evaluated surgical and oncological outcomes of patients who underwent laparoscopic versus open adrenal metastasectomy and assessed the effect of such surgery on postoperative adjuvant therapy and survival., Methods: We reviewed our institutional experience with adult patients who underwent an adrenal metastasectomy from 1997 to 2013. We assessed preoperative tumor size, operating room (OR) time, status of resection margin, and length of stay (LOS), as well as oncological outcomes including the use of adjuvant chemotherapy and radiotherapy within 1 year of surgery and 5-year survival. The χ (2) test, Mann-Whitney U test, and Kaplan-Meier curve were used for statistical analysis., Results: Thirty-eight patients were identified. Lung was the primary site of malignancy (52.6 % of cases). Of the metastasectomies, 55.2 % (n = 21) were performed laparoscopically and 44.7 % (n = 17) were open. In the laparoscopic group, median tumor size was 2.6 cm versus 4.8 cm in the open group (p = 0.09). Median OR time and complication rates were similar between the 2 groups. The laparoscopic group, however, trended toward a shorter LOS (3 days laparoscopic vs. 4 days for open; p = 0.07). At 1 year, 37 % of all patients had not required any adjuvant chemotherapy or adjuvant radiotherapy., Conclusions: This series confirms that adrenal metastasectomy leads to favorable oncological outcomes in select patient groups, with over one-third of patients not requiring adjuvant therapy for at least 1 year after their resection. Laparoscopic approach leads to excellent oncological resection margins without increasing OR time and with a possible reduction in LOS.

Background: Although laparoscopic splenectomy (Lap-Spleen) has become the standard surgical approach for normal-sized spleens, open splenectomy (Open-Spleen) is still recommended by many in the setting of splenomegaly. We set out to compare the impact of spleen size on Lap-Spleen and Open-Spleen outcomes using a national database., Study Design: We reviewed the American College of Surgeons' National Surgical Quality Improvement Program database to identify patients who had undergone non-emergency splenectomy during 2005-2010. To evaluate the impact of spleen size on outcomes, we considered patients with diagnoses of splenomegaly and hypersplenism as those having large spleens (Large-Sp group) and those with diagnoses of primary thrombocytopenia and immune thrombocytopenic purpura as having normal spleens (Normal-Sp group). Patients were also categorized based on surgical approach into Lap-Spleen and Open-Spleen groups., Results: We identified 639 patients in the Large-Sp group and 879 patients in the Normal-Sp group. During 2005-2010 laparoscopy was used in 84.2% of cases in the Normal-Sp group (annual range, 77.8%-90.8%). However, the rate of laparoscopy in the Large-Sp group remained consistently below 50% with an average of 41.8% (annual range, 20%-47%). In the Lap-Spleen group, those with Large-Sp had longer operative time and length of stay and higher blood transfusion and morbidity compared with the Normal-Sp group. However, when looking specifically at the Large-Sp group, patients with Open-Spleen had more transfusion requirements, longer length of stay, and higher morbidity, compared with those with Lap-Spleen., Conclusions: Lap-Spleen leads to significant improvement in outcomes. These advantages were believed to be limited to normal-sized spleens, but this study demonstrates that laparoscopy can still be advantageous in patients with splenomegaly. We hope such data encourages wider utilization of laparoscopy in the setting of splenomegaly, especially among surgeons who are experienced with the technique.

Intestinal intussusception is a rare cause of bowel obstruction in adults and can be associated with a pathologic lead point. We report a case of multiple simultaneous small bowel intussusceptions in a 41-year-old female who presented with a 3-week history of intermittent, crampy epigastric abdominal pain, nausea and diarrhea. Computed tomography imaging demonstrated two areas of intussusception. The patient underwent exploratory laparoscopy, and six separate regions of intussusception were discovered. [ABSTRACT FROM PUBLISHER]