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Staple line reinforcement (SLR) is commonly used in bariatric surgeries to reduce leaks and bleeds. With the evolution of staplers, the need for buttressing with the latest surgical stapling technology is in question. The efficacy of GORE® SEAMGUARD® (G-SLR) to improve staple line strength based on an established measure of burst pressure was evaluated. A benchtop test on synthetic tissue evaluated the pressure required for staple line leak across surgical staplers with and without G-SLR.Staple lines on a consistent thickness synthetic bowel were pressurized to the point of failure (burst pressure) among Ethicon®, Intuitive®, and Medtronic® surgical staplers with and without G-SLR. Burst pressure and leak location (through the staple line [TTSL] or through the staple [TTS], on the anvil or cartridge side) were recorded. Visual confirmation of a leak concluded each test.The pooled mean burst pressure for G-SLR was greater (p 0.05) by 0.494 pounds/square inch compared with no reinforcement with no meaningful differences among staplers. Leak failures were primarily TTS (91.7%) and equally distributed between reinforcement groups with more leak failures on the cartridge side with G-SLR and on the anvil side for non-SLR group. Leaks occurred across the length of staple lines with no discernable pattern.Employing a buttressing material strengthens the staple line, as measured by burst pressure, and may reduce the risk for staple line failure. This benchtop study of G-SLR with three commonly used surgical staplers demonstrated a significant increase in burst pressures among the studied stapling devices.

Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.

Introduction This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures. Methods We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion. Results 117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both laparoscopic gastric bypass (IRR 1.08; 95% CI: [1.02, 1.15]) and Nissen fundoplication (IRR 1.17; 95% CI [1.09, 1.26]) increased in Medicaid patients treated in expansion states than in those treated in non-expansion states. Simultaneously, the costs reported for self-pay patients increased in expansion states more than in non-expansion states (+$1669; 95% CI [$655, $2682]). Conclusions Medicaid expansion was associated with increased rates of utilization of MIS approaches to several surgical procedures and a shifting of costs toward patients who were self-insured.

Endoscopy highlights the intersection of technological advancements and medical application. Innovation in optics, illumination, imaging, and manufacturing has allowed for the development of a complex array of instruments for use by endoscopists. Flexible gastrointestinal (GI) endoscopy has emerged to become a well-established minimally invasive aspect of prevention, diagnosis, and treatment of GI disease.Flexible endoscopes and their associated instruments and platforms are described, acknowledging that such lists are dynamic. The procedure environment is also described in terms of location, equipment, ergonomics, personnel involved, and recovery considerations.Recommendations from GI and anesthesiology associations are outlined to summarize current practices in the administration of sedative drugs to reduce patient discomfort, allow for a technically successful procedure, and reduce patient memory of the procedure.The training process for GI endoscopy is described for general surgery residents and GI fellows. Training involves didactic and technical curriculum along with mentor-supervised endoscopic procedures. After the completion of training, residents and fellows proceed through a credentialing process, which culminates in granting privileges to an individual to perform GI endoscopic procedures. Once in practice, providers must stay up to date on the ever-changing world of medical documentation, coding, and billing to ensure appropriate reimbursement.

Gastroesophageal reflux disease (GERD), a prevalent problem among obese individuals, is strongly associated with obesity and weight loss. Hence, bariatric surgery effectively improves GERD for many patients. Depending on the type of bariatric procedure, however, surgery can also worsen or even cause a new onset of GERD. As a consequence, GERD remains a relevant problem for many bariatric patients, and especially those who have undergone sleeve gastrectomy (SG). Affected patients report not only a decrease in physical functioning but also suffer from mental and emotional problems, resulting in poorer social functioning. The pathomechanism of GERD after SG is most likely multifactorial and triggered by the interaction of anatomical, physiological, and physical factors. Contributing factors include the shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia. In order to successfully treat post-sleeve gastrectomy GERD, the cause of the problem must first be identified. Therapeutic approaches include lifestyle changes, medication, interventional treatment, and/or revisional surgery.

Enteral access is a common procedure in managing patients in need of enteral nutrition and decompression. Enhancements of technology and improvements in operator skills have resulted in the development of several techniques of enteral access including endoscopic-guided, imaging-guided, laparoscopic-assisted, or combined techniques. Endoscopic enteral access techniques are the most commonly used and preferred method. These include endoscopy-guided nasoenteric tube placement and percutaneous endoscopic enterostomy. These techniques can be safely performed even in challenging conditions such as prior operative intervention, ascites, and head and neck obstructions. However, each type of procedure has its unique set of indication as well as complications. The decision to use endoscopic enteral access should be carefully considered and individualized based on the patient's specific anatomical limitations, preference, overall health status, and disease. In this article, we review current knowledge focusing on endoscopic enteral feeding access including indications, contraindications, preprocedural preparation, procedure technique, enteral access in specific conditions, postprocedural care, and prevention and management of associated complications.

A preoperative very low-calorie diet (VLCD) is a common method to reduce weight before bariatric surgery. However, patient compliance and acceptability are not always known. The aim of this study is to evaluate the effectiveness, compliance, and acceptability of our regimen in a metropolitan academic quaternary care center. Patients with a BMI

Bariatric surgery has revolutionized obesity treatment. There remains, however, a large demand for less invasive and potentially cheaper or even reversible procedures that impart a similar effect on obesity and its related comorbidities. Endoluminal Bariatric Therapies, such as endoluminal sleeves or barriers, duodenal mucosal resurfacing technology, and magnetic anastomoses may emerge to fill this gap. To date, their safety profiles and the reported success with regard to both weight loss and diabetes control have proven favorable, yet need to be further studied before widespread adoption. The following review will discuss in detail these procedures and the literature supporting their continued development and potential clinical applications.

Background Pancreaticoduodenectomy remains the mainstay of surgical treatment of malignant periampullary disorders. Postoperative morbidity rates are driven by postoperative pancreatic fistula. Although most can be managed conservatively or with percutaneous techniques, complex fistulas including gastroenteric leakage frequently require operative reexploration. Endoscopic therapies in this setting offer an opportunity to avoid invasive reoperation. Case report We present the case of a 67-year-old male individual who developed a complex intra-abdominal abscess after pancreaticoduodenectomy with confirmed pancreaticojejunal disruption, gastric staple line dehiscence, and enterocutaneous fistula. Five endoscopic sessions utilizing advanced techniques over a period of 60 days led to complete healing of the patient's external fistula, resolution of complex abdominal abscess, creation of functional communication between the gastric staple line disruption and the afferent jejunum, and return of normal gastrointestinal function. Baseline functional and dietary status was restored without gastrointestinal symptoms or necessity for supplemental tube feedings.

Bariatric and metabolic surgery has demonstrated safety and efficacy with an acceptable risk profile leading to significant growth in recent decades. Bariatric interventions alter gastrointestinal anatomy that can lead to unique late complications requiring specialized referral and management. Following available dietary, behavioral, and medical treatment options, patients with refractory complications may require endoscopic or surgical revision or conversion to other surgical procedures. Such chronic complications requiring revision are discussed following primary laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.

This chapter details the benefits, outcomes, and practical applications of the direct percutaneous endoscopic jejunostomy (DPEJ) technique for enteral access. The reader will understand the indications and patient scenarios for when one should consider DPEJ, conditions and situations that preclude its use, and the technique by which the DPEJ is inserted and secured. Complications associated with DPEJ are described along with their incidence and measures to manage and prevent the same.

Background Intraoperative leak test (IOLT) is commonly performed to evaluate the integrity of an anastomosis or staple line during bariatric surgery. However, the utility of IOLT is controversial. Objective To evaluate the effect of IOLT on postoperative leak-related outcomes after primary bariatric surgery. Setting Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited centers. Methods The 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement databases were analyzed for sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPDDS) to determine the postoperative anastomotic/staple line leak (A/SL) and leak-related outcomes. Results Data for a total of 265,309 patients who underwent SG (69.6%), RYGB (29.7%), or BPDDS (.8%) were analyzed. IOLT was performed in 81.9% of all patients. Overall A/SL, mortality rate in patients with leakage, and 30-day leak-related mortality were .28%, .1%, and .003%, respectively. There were no significant differences between the IOLT and non-IOLT groups in terms of A/SL, 30-day mortality in patients with leakage, 30-day leak-related mortality, readmission, reoperation, intervention, or organ/space surgical site infection. However, the rate of 30-day leak-related intervention in BPDDS was significantly lower in the IOLT group compared to the non-IOLT group (.18% versus 1.15%, P = .01). Whether IOLT was performed endoscopically or nonendoscopically had no effect on the rate of postoperative leaks. Overall mean operative time increased by 19.1 minutes (9.5, 11.9, and 21.2 min for SG, RYGB, and BPDDS, respectively) when IOLT was performed. Conclusion The overall rate of postoperative A/SL and leak-related morbidity was low. This study provided no evidence of either benefit or harm from IOLT in patients who underwent SG, RYGB, or BPDDS.

Thoracic and foregut operations can cause vagal nerve injury resulting in delayed gastric emptying or gastroparesis. However, the cause of gastroparesis in these patients is not always from a vagal injury. We hypothesize that vagal nerve integrity (VNI) testing may better define who has vagal nerve dysfunction. This information may change subsequent operations. The aim of this study was to evaluate the impact of VNI testing in patients with prior thoracic or gastric surgery. From January 2014 to December 2017, patients who had previous operations with the potential risk of vagal injury and had VNI testing were reviewed. Excluded patients were those with no plan for a second operation or the second operation was only for gastroparesis. The main outcome was the percentage of operations altered due to the results of VNI testing. Twelve patients (eight females) were included. Ages ranged from 37 to 77 years. VNI results were compatible with vagal injury in eight patients (67%). VNI test results altered subsequent operative plans in 41.7% (5/12). Pyloroplasty was done in addition to fundoplication in two patients. Plans for hiatal hernia repair with or without redo-fundoplication in three patients were changed by an additional pyloroplasty in one patient and partial gastrectomy with Roux-en-Y reconstruction in two patients. All patients who had secondary surgery had resolution of symptoms and improvement in objective testing. The addition of VNI testing in patients with a previous potential risk of vagal nerve injury may help the surgeon select the appropriate secondary operation.

With obesity continuing as a global epidemic and therapeutic technologies advancing, several novel endoscopic and minimally invasive interventions will likely become available as treatment options. With improved technologies and different treatment strategies, as well as different patient populations being targeted, there will be greater application in the treatment armamentarium of specialists dedicated to treating obesity. We sought to review the existing technology and provide a review. Literature review was carried out for endoscopic and minimally invasive devices. Some of these products are not FDA approved, so limited data are available in their review. A summary of the device and data currently available on weight loss and safety profile is provided. Several products are in clinical trials or will be soon. Some of the technology has limited data and companies will be submitting their results for FDA evaluation. The obesity epidemic and associated weight-related diseases represent a tremendous burden to health care practitioners. As such, a multi-modal and progressive approach, with data and outcomes examined, is likely the best and most comprehensive method to care for these patients. SAGES endorses the benefits of minimally invasive and endoscopic approaches in the treatment of obesity and its related co-morbidities.

Bariatric surgery is an extremely effective and well-proven strategy to achieve substantial weight loss for patients with morbid obesity. However, as with any intervention, bariatric surgery is associated with short- and long-term complications. Significant weight regain can be regarded as a very important and often forgotten barrier to sustained life-long success, both physically and psychologically. The definition, prevalence, etiology, and possible treatment modalities available to address weight regain after both Roux-en-Y gastric bypass and vertical sleeve gastrectomy will be discussed in the following chapter.

Endolumenal bariatric therapies continue to evolve and have become increasingly acceptable in the treatment of obesity and metabolic diseases. Each technique and therapy has its own degree and type of efficacy as well as its own spectrum of side effects and complications. It is vital that each EBT be closely evaluated and scrutinized prior to widespread adoption. Yet at the same time, it is imperative that more treatment options become available to patients and physicians as the obesity epidemic continues to prevail despite decades of recognizing the disease and its ravaging effects. The two preceding chapters dove into various endoluminal therapies and focused on results. This chapter will review side effects and complications of these modalities. As one reads through the chapter, it is important to keep into consideration that many of the devices and techniques are still in evolution and may continue to become more refined prior to commercialization and adoption. As such occurs, many of the adverse side effects and morbidity may decrease.

Background Pulmonary depression remains a major concern when performing upper endoscopy in the morbidly obese patient. The aim of this prospective study is to determine the effects of sedation and role of capnography during preoperative upper endoscopy in obese patients. Methods Eighty-two consecutive diagnostic upper gastrointestinal endoscopies were performed in morbidly obese patients in an outpatient setting. Data on amount of drug administration and cardiorespiratory change were recorded. Results Mean body mass index and duration of procedure was 46.4±8.2 kg/m 2 and 9.4 ± 2.5 minutes, respectively. The mean dose of propofol was 139.5±45.1 mg. No clinically significant cardiorespiratory complications occurred. Respiratory depression (RD) was seen in 33/82 (40.2%) patients and included a mean absolute change in end-tidal carbon dioxide (EtCO 2 ) of 7.1±8.5 mm Hg from baseline ( P = .001). 54/82 (65.9%) patients had subclinical RD with 27/54 (50%) having RD. Abnormal EtCO 2 detected all episodes of RD. The sensitivity and negative predictive value in determining RD by a change in EtCO 2 >10 mm Hg or an absent EtCO 2 waveform during any point of the procedure was 81% and 78%, respectively. The relative risk was 2.3. Conclusion Capnography provided a real time assessment of changes in ventilation and can detect early phases of respiratory depression. Utilization of propofol as a means for sedation, with extended advanced monitoring technique, can allow for reduced adverse outcomes in morbidly obese patients undergoing upper endoscopy.

/10.10 14 A ence: E, L e. M orpor Congenital anomalies of the midgut are rare and occur in about 1 in 6,000 live births [1], .2% of a published series of barium enemas and .5–1% of autopsies [2], and frequently cause symptoms early in life. More than 90% of patients are diagnosed within the first year of birth. The etiology is an abnormal rotation of the primitive midgut loop around the superior mesenteric artery (SMA) during embryonic development. In adults, these abnormalities are generally asymptomatic and often incidental findings. The reported incidence of midgut malrotation in adults is approximately .00001% to .19% [3,4]. The true incidence is very difficult to estimate because most patients remain asymptomatic. When asymptomatic, midgut malrotation is often found incidentally during diagnostic abdominal imaging similar to our patient. We present a case of midgut nonrotation that underwent successful laparoscopic Roux-en-Y gastric bypass (LRYGB). We review the preoperative abdominal computed tomography (CT) scan and operative strategy while taking into consideration the anatomic variance and required surgical modifications.

Being able to maintain appropriate nutrition in ill patients is a fundamental part of caring for both surgical and medical patients. It is well known that malnutrition is associated with adverse clinical outcomes, particularly in wound healing. Therefore, every effort should be made to support nutritional status when a patient is acutely or chronically ill. In patients who have an accessible and functional gastrointestinal system, enteral nutrition is the preferred method of nutrition. For patients who need permanent or long-term (greater than four weeks) access to nutrition, enteral nutrition through an enterostomy tube is a good option that can be performed by endoscopy, radiologically or surgically. Endoscopic enteral access is a safe and practical procedure for patients who need nutritional support. This article review will examine the indications, contraindications, pre- and post-procedure care, and procedure techniques for endoscopic enteral access.

A review of benefits, indications, techniques, and special populations when considering enteral access. The purpose of this article is not to provide an exhaustive in-depth review but to highlight major considerations when deciding which patient would benefit and what tools should be considered before procedure. The focus is limited to endoscopic enteral access and does not cover additional methods (radiologic or surgical).

Evaluate the long-term effects of bariatric surgery on type 2 diabetes (T2DM) remission and metabolic risk factors.Although the impressive antidiabetic effects of bariatric surgery have been shown in short- and medium-term studies, the durability of these effects is uncertain. Specifically, long-term remission rates following bariatric surgery are largely unknown.Clinical outcomes of 217 patients with T2DM who underwent bariatric surgery between 2004 and 2007 and had at least 5-year follow-up were assessed. Complete remission was defined as glycated hemoglobin (A1C) less than 6% and fasting blood glucose (FBG) less than 100 mg/dL off diabetic medications. Changes in other metabolic comorbidities, including hypertension, dyslipidemia, and diabetic nephropathy, were assessed.At a median follow-up of 6 years (range: 5-9) after surgery (Roux-en-Y gastric bypass, n = 162; gastric banding, n = 32; sleeve gastrectomy, n = 23), a mean excess weight loss (EWL) of 55% was associated with mean reductions in A1C from 7.5% ± 1.5% to 6.5% ± 1.2% (P0.001) and FBG from 155.9 ± 59.5 mg/dL to 114.8 ± 40.2 mg/dL (P0.001). Long-term complete and partial remission rates were 24% and 26%, respectively, whereas 34% improved (1% decrease in A1C without remission) from baseline and 16% remained unchanged. Shorter duration of T2DM (P0.001) and higher long-term EWL (P = 0.006) predicted long-term remission. Recurrence of T2DM after initial remission occurred in 19% and was associated with longer duration of T2DM (P = 0.03), less EWL (P = 0.02), and weight regain (P = 0.015). Long-term control rates of low high-density lipoprotein, high low-density lipoprotein, high triglyceridemia, and hypertension were 73%, 72%, 80%, and 62%, respectively. Diabetic nephropathy regressed (53%) or stabilized (47%).Bariatric surgery can induce a significant and sustainable remission and improvement of T2DM and other metabolic risk factors in severely obese patients. Surgical intervention within 5 years of diagnosis is associated with a high rate of long-term remission.

Background Weight recidivism after Roux-en-Y gastric bypass (RYGB) is a challenging problem for patients and bariatric surgeons alike. Traditional operative strategies to combat weight regain are technically challenging and associated with a high morbidity rate. Endoluminal interventions are thus an attractive alternative that may offer a good combination of results coupled with lower periprocedure risk that might one day provide a solution to this increasingly prevalent problem. The purpose of this article is to systematically review the available literature on endoluminal procedures used to address weight regain after RYGB, with specific attention to the safety profile, efficacy, cost, and current availability. This review focuses only on endoluminal procedures that are performed for weight regain after RYGB, as opposed to primary endoluminal obesity procedures. Methods This study was a retrospective review. Results Several methods of endoluminal intervention for weight regain are reviewed, ranging from injection of inert substances to suturing and clipping devices. The literature review shows the procedures on the whole to be well tolerated with limited efficacy. The majority of the literature is limited to small case series. Most of the reviewed devices are no longer commercially available. Conclusions Endoluminal therapy represents an intriguing strategy for weight regain after RYGB. However, the current and future technologies must be rigorously studied and improved such that they offer durable, repeatable, cost-effective solutions.

Gastric electrical stimulator (GES) implantation is effective in certain patients with gastroparesis; however, laparotomy is often employed for placement. The aim of this study is to review outcomes of patients who underwent laparoscopic GES therapy for diabetic and idiopathic gastroparesis at a large referral center.Patients who underwent GES (Enterra Therapy System; Medtronic, Minneapolis, MN) implantation with subsequent interrogation and programming between March 2001 and November 2011 were analyzed.A total of 113 patients underwent GES placement or revision during the study period. One hundred eleven patients underwent primary GES at our institution, while two patients underwent GES generator revision at our institution. Primary operations were completed laparoscopically in 110 of 111 cases, with one conversion to laparotomy due to severe adhesions. At a mean follow-up of 27 months (1-113), symptom improvement was achieved in 91 patients (80 %) and was similar for both the diabetic and idiopathic subgroups. Need for supplemental nutrition (enteral and/or parental) decreased in both groups.GES placement is feasible using a laparoscopic approach. Medical refractory gastroparesis in the diabetic and idiopathic groups had significant symptom improvement with no difference between the two groups. Need for supplemental nutrition is decreased following GES.

This report details laparoscopic remnant cholecystectomy and transcystic common duct exploration after previous single-port cholecystectomy., Background: Recent enthusiasm in the surgical community for less invasive surgical approaches has resulted in widespread application of single-incision techniques. This has been most commonly applied in laparoscopic cholecystectomy in general surgery. Cosmesis appears to be improved, but other advantages remain to be seen. Feasibility has been demonstrated, but there is little description in the current literature regarding complications. Patient and Methods: We report the case of a patient who previously underwent single-incision laparoscopic cholecystectomy for symptomatic gallstone disease. After a brief symptom-free interval, she developed acute pancreatitis. At evaluation, imaging results of ultrasonography and magnetic resonance cholangiopancreatography demonstrated a retained gallbladder with cholelithiasis. The patient was subsequently referred to our hospital, where she underwent further evaluation and surgical intervention. Results: Our patient underwent 4-port laparoscopic remnant cholecystectomy with transcystic common bile duct exploration. Operative exploration demonstrated a large remnant gallbladder and a partially obstructed cystic duct with many stones. Transcystic exploration with balloon extraction resulted in duct clearance. The procedure took 75 minutes, with minimal blood loss. The patient's postoperative course was uneventful. Final pathology results demonstrated a remnant gallbladder with cholelithiasis and cholecystitis. Conclusion: This report is the first in the literature to describe successful laparoscopic remnant cholecystectomy and transcystic common bile duct exploration after previous single-port cholecystectomy. Although inadvertent partial cholecystectomy is not unique to this technique, single-port laparoscopic procedures may result in different and significant complications.

Bariatric surgery is well-recognized for its effects on health, beyond weight-loss. It underwent a revolution recently with the growing performance of laparoscopic procedures, leading to enhanced recovery and a reduction in procedural risk. However, surgical complications, although rare, do develop. It is important to recognize the complications, and ideally prevent them from happening. This article reviews the risks of the four most commonly performed bariatric procedures, with an emphasis on technique and management in the intraoperative and postoperative period. The nutritional aspect of bariatric surgery is of the utmost importance, because catastrophic consequences have been linked to malnutrition and vitamin deficiencies.

Acute abdomen is the primary complaint of morbidly obese patients who visit the emergency room or require readmission following gastric bypass and sleeve gastrectomy. Physician who deals with this specific situation should develop basic anatomic, clinical, and surgical understanding of these common bariatric operations. Most of intra-abdominal complications after bariatric surgery differ from standard descriptions in the non-obese patient. Furthermore, after primary care and resuscitation, a consultation with a bariatric surgeon should be obtained early during the course of the evaluation. An understanding of each bariatric procedure and its potential complications is essential to reveal the corrected diagnosis with achieve management.

Endoscopic therapies have evolved significantly over the past decade and allow for intervention in the management of anastomotic dehiscence in both the upper and lower gastrointestinal tract. Endoscopy allows for recognition and various management techniques in the treatment algorithm and should be considered a first-line approach for selected patients to avoid the morbidity of reoperation.

Changes in the biliary system after gastric bypass are not well defined. Dilation may be normal or due to biliary tract pathology. The purpose of this study is to review patients who underwent imaging of their biliary system both before and after Roux-en-Y gastric bypass in an effort to elucidate the effect this operation has on hepatic duct diameter. Patients with imaging both before and at least 3 months after gastric bypass were analyzed. Hepatic duct was measured at the level of the porta hepatis to determine interval changes. Thirty-three patients had postoperative imaging at least 3 months following gastric bypass. Mean hepatic duct diameter was 5.2 ± 2 and 7.1 ± 2.6 mm preoperatively and postoperatively, respectively (p

Enlargement of the gastric pouch and/or gastrojejunostomy after Roux-en-Y gastric bypass (RYGB) is postulated to be the antecedent to suboptimal weight loss or weight regain. The present study evaluated the gastric pouch and stoma dimensions in RYGB patients and correlated them with the weight loss outcomes.Patients who underwent upper endoscopy for investigation of gastrointestinal symptoms or weight regain after RYGB were identified. The stoma was considered enlarged if2 cm in diameter and the pouch was considered enlarged if6 cm long or5 cm wide. Successful weight loss was defined as excess weight loss50% or a body mass index decrease to ≤ 30 kg/m(2).A total of 380 patients had nondiagnostic upper endoscopy findings at a mean post-RYGB interval of 5.9 ± 4.0 years. Among these were 175 patients (group A; 87% women) who had successful weight loss and 205 patients (group B; 86% women) who were referred for investigation of weight regain. The pouch and stoma size were normal in most of the patients in group A (63.4%) compared with 28.8% of the patients in group B (P.001). The most common abnormality was an enlarged stoma. The pouch length, pouch volume, and stoma diameter correlated inversely with excess weight loss. Multivariate analysis identified that the stoma diameter was independently associated with weight regain after RYGB.The current definition of a "normal" size pouch/stoma is associated with optimal weight loss after RYGB, although this might need to be reviewed. Patients who regain weight are likely to have abnormal anatomy, in particular, stoma enlargement. The surgical RYGB technique and methods of evaluating the gastric anatomy in RYGB patients need to be standardized, intraoperatively and postoperatively.

There has been recent interest in using robots for general surgical procedures. This shift in technique raises the issue of patient safety with automated instrumentation. Although the safety of robotics has been established for urologic procedures, there are scant data on its use in general surgical procedures. The aim of this study is to analyze the incidence of robotic malfunction and its consequences for general surgical procedures. All robotic general surgical procedures performed at a tertiary center between 2008 and 2011 were reviewed from institutional review board (IRB)-approved prospective databases. A total of 223 cases were done robotically, including 102 endocrine, 83 hepatopancreaticobiliary, 17 upper gastrointestinal, and 21 lower gastrointestinal colorectal procedures. There were 10 cases of robotic malfunction (4.5 %). These failures were related to robotic instruments (n = 4), optical system (n = 3), robotic arms (n = 2), and robotic console (n = 1). None of these failures led to adverse patient consequences or conversion to open. Six (2.7 %) cases were converted to open due to bleeding (n = 3), difficult dissection plane (n = 1), invasion of tumor to surrounding structures (n = 1), and intolerance of pneumoperitoneum due to CO2 retention (n = 1). There was no mortality, and morbidity was 1 % (n = 2). To our knowledge, this is the largest North American report to date on robotic general surgical procedures. Our results show that robotic malfunction occurs in a minority of cases, with no adverse consequences. We believe that awareness of these failures and knowing how to troubleshoot are important to maintain the efficiency of these procedures.

Background Endoscopic balloon dilation is an effective treatment of gastrojejunal (GJ) strictures after Roux-en-Y gastric bypass (RYGB), although its success might depend on the point at which they occur postoperatively. We hypothesized that "late" strictures (≥90 d after RYGB) might be less amenable to balloon dilations than "early" strictures occurring within 90 days postoperatively. Methods A review of a prospectively maintained database at a bariatric center was conducted to identify all patients who underwent upper endoscopy (UE) for investigation of gastrointestinal symptoms after RYGB. Those who were diagnosed with a GJ anastomotic stricture at endoscopy were selected for additional evaluation. The patients were classified into 1 of 3 groups, according to the point at which they presented with stricture symptoms (group 1, 0–90 d after RYGB; group 2, 91–365 d after RYGB; and group 3, >1 yr after RYGB). All strictures were dilated using through-the-scope controlled radial expansion balloons. Results From July 2006 to July 2009, 929 RYGB procedures were performed in our bariatric unit. Our surgical endoscopy team performs approximately 1500 UE investigations annually. Most investigations were for preoperative assessment of bariatric patients; however, a proportion is indicated for the investigation of postoperative weight regain and complications of foregut surgery, as well as endoluminal surgery. In the present study period, 591 gastric bypass patients underwent UE for investigation of gastrointestinal symptoms postoperatively. In total, 72 patients were diagnosed with a symptomatic GJ anastomotic stricture and underwent balloon dilation. Almost two thirds (63.9%) of the dilations were performed within 90 days after RYGB; 98% of these "early" strictures resolved with dilation. In comparison, of the "late" strictures, only 61% (16 of 26 patients) resolved and 38.5% (n = 10) required revisional surgery for additional management. Conclusion Endoscopic balloon dilation is effective in treating early GJ strictures after RYGB. Late strictures are less amenable to endoscopic dilation and often require revisional surgery. Patients presenting with upper gastrointestinal symptoms after RYGB warrant early investigation with UE to investigate for a GJ stricture, which if present, should be promptly dilated.