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Gastrointestinal stromal tumors (GIST) are the most frequently occurring form of mesenchymal tumors in the gastrointestinal tract. Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric operation in which a portion of the gastric body and fundus is removed and sent for pathological examination. Increasingly, bariatric surgeons have incidentally identified neoplasms in the excised portion of the stomach. The aim of this study is to explore the incidence of GIST in obese patients undergoing LSG. This is a single-center, single-surgeon retrospective case series which included 305 obese patients who underwent LSG. All excised stomach specimens were sent for pathologic analysis.. In the case of pathologically verified GIST (n = 6; 1.97%), detailed analysis was performed. In 305 LSG procedures, six cases of GIST (1.97%) were identified. The tumors were measured between 1 and 7 mm and were all low grade with negative resection margins. The mean BMI was 46.38 ± 3.94 kg/m2 (range: 41.61–51.77). The mean age at time of surgery was 55.33 ± 12.9 years (range: 37–73 years). All cases were asymptomatic and showed no evidence of metastatic disease. The incidental rate of GIST in the excised portion of the stomach in our 305 obese patients who underwent LSG is 6/305 (1.97%). This adds relevant data to the overall goal of determining whether obesity is a risk factor for GIST. Radical surgical resection of these tumors with adequate disease-free margins performed on a low-grade malignancy serves as a definitive oncological treatment, especially when there is an intact pseudocapsule.

Many centers have reported excellent short-term efficacy of per-oral endoscopic myotomy (POEM) for the treatment of achalasia. However, long-term data are limited and there are few studies comparing the efficacy of POEM versus Heller Myotomy (HM). To compare the long-term clinical efficacy of POEM versus HM. Using a retrospective, parallel cohort design, all cases of POEM or HM for achalasia between 2010 and 2015 were assessed. Clinical failure was defined as (a) Eckardt Score > 3 for at least 4 weeks, (b) achalasia-related hospitalization, or (c) repeat intervention. All index manometries were classified via Chicago Classification v3. Pre-procedural clinical, manometric, radiographic data, and procedural data were reviewed. 98 patients were identified (55 POEM, 43 Heller) with mean follow-up of 3.94 years, and 5.44 years, respectively. 83.7% of HM patients underwent associated anti-reflux wrap (Toupet or Dor). Baseline clinical, demographic, radiographic, and manometric data were similar between the groups. There was no statistical difference in overall long-term success (POEM 72.7%, HM 65.1% p = 0.417, although higher rates of success were seen in Type III Achalasia in POEM vs Heller (53.3% vs 44.4%, p

Highlights • 5-Year-old Intra-gastric Balloon. • Gastric perforation. • Acute abdomen. • Bariatric surgery., Introduction Insertion of an Intra gastric Balloon (IGB) has widely been used as a minimally invasive procedure for the treatment of obesity. Gastric balloons are usually inserted for a period of six months only. They have a high safety profile and one of their rare, reported, serious complications include gastric or esophageal perforation, which are usually early and require immediate operative management. Presentation of case We report a 26-year-old lady who presented to the ED with signs and symptoms of acute abdomen and five-year history of endoscopic placement of Intra-gastric Balloon. Emergent endoscopic removal of the balloon revealed a large pressure ulcer at gastric incisura with central necrosis. Laparoscopy confirmed gastric perforation along lesser curvature with extensive soilage of peritoneal cavity. Extensive irrigation and drainage and Graham omental patch repair were carried out laparoscopically, and the perforation sealed satisfactorily. She recovered well from surgery and within days she was tolerating a diet. Broad spectrum IV antibiotics were given for 10 days. Discussion Gastric perforation is a rare complication reported in 0.1% of patients undergoing IGB insertion. It can ensue as early as days after placement or late at weeks to months. In our review of literature, we found the maximum time frame in which a patient presented with an IGB induced gastric perforation was at 22 months. This makes our case unique as the patient was able to tolerate it for 5 years (60 months) before presenting to the emergency with this sinister complication. Conclusion Very late Gastric perforations in patients with IGB placement are rare. An upper gastrointestinal endoscopy should be arranged as soon as possible to remove the balloon and assess the stomach visualize the perforation followed by a laparoscopic approach to repair the defect if expertise is available.

BACKGROUND Similar to understanding how blood pressure is measured by a sphygmomanometer, physicians will soon have to understand how an artificial intelligence–based application has come to the conclusion that a patient has hypertension, diabetes, or cancer. Although there are an increasing number of use cases where artificial intelligence is or can be applied to improve medical outcomes, the extent to which medical doctors and students are ready to work and leverage this paradigm is unclear. OBJECTIVE This research aims to capture medical students’ and doctors’ level of familiarity toward artificial intelligence in medicine as well as their challenges, barriers, and potential risks linked to the democratization of this new paradigm. METHODS A web-based questionnaire comprising five dimensions—demographics, concepts and definitions, training and education, implementation, and risks—was systematically designed from a literature search. It was completed by 207 participants in total, of which 105 (50.7%) medical doctors and 102 (49.3%) medical students trained in all continents, with most of them in Europe, the Middle East, Asia, and North America. RESULTS The results revealed no significant difference in the familiarity of artificial intelligence between medical doctors and students (P=.91), except that medical students perceived artificial intelligence in medicine to lead to higher risks for patients and the field of medicine in general (PP=.03). CONCLUSIONS The question is not whether artificial intelligence will be used in medicine, but when it will become a standard practice for optimizing health care. The low level of familiarity with artificial intelligence identified in this study calls for the implementation of specific education and training in medical schools and hospitals to ensure that medical professionals can leverage this new paradigm and improve health outcomes.

Research and history have largely shown the covert billion-dollar global market of single-use medical device (SUD) reprocessing and reuse to be a safe endeavor, but awareness and perceptions of the practice both within and outside of healthcare have received limited attention.Responses for patients, physicians, and medical practitioners were attained on both online and article-based surveys, in which attitudes and perceptions of SUD reprocessing and reuse were expressed in an assortment of closed-ended questions and partially closed-ended questions.Of the 214 participants, a collective 77% were unaware that the Food and Drug Administration allows SUD reprocessing and reuse. This included 65% of physicians and 84% of patients, which were significantly different proportions (P = 0.005). A significantly greater proportion of patients than physicians (92 vs. 68%) also felt that hospitals bear the responsibility of informing patients of the practice as part of their care (P 0.001).There is a profound lack of awareness of SUD reprocessing and reuse among all relevant stakeholders. In addition, the overwhelming desire for transparency among patients further forces the debate of whether current, covert methods should be altered, in addition to the question of who bears this responsibility. Despite research and history having shown the practice to be safe, apprehension and misconceptions remain. Survey results suggest that education may be able to subdue such patient concerns.

Magnets have been utilized in many industries outside medicine and especially outside surgery for many years. They are part of our daily lives and of numerous items that we may use at home, including clothing, electronics, toys, fashion, etc. In medicine, we have a few prevalent technologies that use magnetic forces such as magnetic resonance scanners and diverse microelectronics, among others. In surgery, however, very few devices or instrumentation have implemented magnets as the main force or mechanism of action. Throughout this book, multiple examples of highly specialized surgery are described. In this chapter, we review some of the initial implementations of magnets in general surgery.

Background Postbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients. Objectives To provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management. Setting Stanford University Hospital and Clinics. Methods Based on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners. Results A team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia. Conclusions G-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.

Global industries are acknowledging that professions as we know them will not require the same skills as they did in the 20th Century. Therefore how can universities prepare students for challenges that have not been fully identified? This paper will present the Design4Health Bootcamp, an initiative that intends to close the so-called “21st century skills gap”. We present its course curriculum, quantitative and qualitative evaluation and conclude with a set of principles that support the implementation of such initiatives.

Background Stress has been shown to impact adversely on multiple facets critical to optimal performance. Advancements in wearable technology can reduce barriers to observing stress during surgery. This study aimed to investigate the association between acute intraoperative mental stress and technical surgical performance. Methods Continuous electrocardiogram data for a single attending surgeon were captured during surgical procedures to obtain heart rate variability (HRV) measures that were used as a proxy for acute mental stress. Two different measures were used: root mean square of successive differences (RMSSD) and standard deviation of RR intervals (SDNN). Technical surgical performance was assessed on the Operating Room Black Box® platform using the Generic Error Rating Tool (GERT). Both HRV recording and procedure video recording were time-stamped. Surgical procedures were fragmented to non-overlapping intervals of 1, 2 and 5 min, and subjected to data analysis. An event was defined as any deviation that caused injury to the patient or posed a risk of harm. Results Rates of events were significantly higher (47-66 per cent higher) in the higher stress quantiles than in the lower stress quantiles for all measured interval lengths using both proxy measures for acute mental stress. The strongest association was observed using 1-min intervals with RMSSD as the HRV measure (P < 0·001). Conclusion There is an association between measures of acute mental stress and worse technical surgical performance. Further study will help delineate the interdependence of these variables and identify triggers for increased stress levels to improve surgical safety.

Objective To evaluate a new magnetic surgical system during reduced-port laparoscopic cholecystectomy in a prospective, multicenter clinical trial. Background Laparoscopic instrumentation coupled by magnetic fields may enhance surgeon performance by allowing for shaft-less retraction and mobilization. The movements can be performed under direct visualization, generating different angles of traction and reducing the number of trocars to perform the procedure. This may reduce well-known associated complications of trocars, including incisional pain, scarring, infection, bowel, and vascular injuries, among others. Methods A prospective, multicenter, single-arm, open-label study was performed to assess the safety and performance of a magnetic surgical system (Levita Magnetics' Surgical System). The investigational device was used during a 3-port laparoscopic technique. The primary endpoints evaluated were safety and feasibility of the device to adequately mobilize the gallbladder to achieve effective exposure of the targeted surgical site. Patients were followed for 30 days postprocedure. Results Between January 2014 and March 2015, 50 patients presenting with benign gallbladder disease were recruited. Forty-five women and 5 men with an average age of 39 years (18-59), average body mass index of 27 kg/m (20.4-34.1) and an average abdominal wall thickness of 2.6 cm (1.8-4.6). The procedures were successfully performed in all 50 patients. No device-related serious adverse events were reported. Surgeons rated as "excellent" (90%) or "sufficient" (10%) the exposure of the surgical site. Conclusions This clinical trial shows that this new magnetic surgical system is safe and effective in reduced-port laparoscopic cholecystectomy.

Up to 50% of preventable hospital medical errors occur in or after visiting an operating theater in the United States. To address this issue, hospitals use a Surgical Safety Checklist (SSC), which can reduce complications and mortality rates when used systematically. To execute it, surgeons read aloud from a poster hanging on a wall. However, studies report usability issues with posters and often surgeons execute the checklist from memory, which can reduce completion rates at the expense of patient safety. We present a novel approach to increase the SSC's usability in view of improving patient safety. Our DigitalChecklistBox displays the SSC directly on a patient's surgical drape and enables surgeons to navigate through the checklist using hand gestures. Evaluated with 10 surgeons, it increased the checklist elements' readability and navigation and brought additional functionalities to limit the number of missed elements.

Background Bariatric surgery is a well-tolerated and effective treatment for severe obesity. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. In particular, buttressing of the staple line in sleeve gastrectomy has decreased rates of clinically significant postoperative bleeding. The present study investigates the effectiveness of buttressing the circular stapled anastomosis during laparoscopic Roux-en-Y gastric bypass (LRYGB). Setting Academic, accredited hospital. Methods A total of 253 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 125 of these cases. Demographic information was collected from both groups preoperatively. Surgical characteristics were also obtained analyzed using unpaired t or χ 2 tests. Results Patients in both buttressing and nonbuttressing groups were on average 46 years old and predominantly female (79.2% versus 74.2% female, respectively), with a body mass index of approximately 48 kg/m 2 . Postoperative weight loss did not significantly differ between groups at any time point (buttressing versus nonbuttressing percentage of excess weight loss: 39.5% versus 41.5% at 3 mo, P = .3860; 56.4% versus 56.7% at 6 mo, P = .9341). There were no significant differences for operating time, length of stay, readmissions, or reoperations. Complications due to strictures were found to be lower for the buttressing group (0% buttressing versus 2.3% nonbuttressing, P = .0851). Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was used (0% buttressing versus 3.1% nonbuttressing, P = .0463). Conclusion Buttressing of the gastrojejunal anastomosis during LRYGB significantly reduces bleeding-related complications and increases tolerability of the procedure.

As we embrace personal digital health technology applications, computing power is increasingly exploited for its capacity to improve our quality of life (QoL). Beyond wearables that capture and transmit our vitals, QoL technologies present a variety of opportunities for extending the human health span-not just how long we live, but how well we are.

Many centers have reported excellent short-term efficacy of per-oral endoscopic myotomy (POEM) for the treatment of achalasia. However, long-term data are limited and there are few studies comparing the efficacy of POEM versus Heller Myotomy (HM).To compare the long-term clinical efficacy of POEM versus HM.Using a retrospective, parallel cohort design, all cases of POEM or HM for achalasia between 2010 and 2015 were assessed. Clinical failure was defined as (a) Eckardt Score 3 for at least 4 weeks, (b) achalasia-related hospitalization, or (c) repeat intervention. All index manometries were classified via Chicago Classification v3. Pre-procedural clinical, manometric, radiographic data, and procedural data were reviewed.98 patients were identified (55 POEM, 43 Heller) with mean follow-up of 3.94 years, and 5.44 years, respectively. 83.7% of HM patients underwent associated anti-reflux wrap (Toupet or Dor). Baseline clinical, demographic, radiographic, and manometric data were similar between the groups. There was no statistical difference in overall long-term success (POEM 72.7%, HM 65.1% p = 0.417, although higher rates of success were seen in Type III Achalasia in POEM vs Heller (53.3% vs 44.4%, p 0.05). Type III Achalasia was the only variable associated with failure on a univariate COX analysis and no covariants were identified on a multivariate Cox regression. There was no statistical difference in GERD symptoms, esophagitis, or major procedural complications.POEM and HM have similar long-term (4-year) efficacy with similar adverse event and reflux rates. POEM was associated with greater efficacy in Type III Achalasia.

Digital health through artificial Intelligence, telemedicine, genomics, robotics and many other innovative technologies, is already changing in many ways how medicine is being practiced around the world. Physicians entrepreneurs are adapting to this new reality with growth mindsets, creating innovative value propositions which are very differentiated from present ones. Additionally, a new subset of medical professionals will arise, and physicians and entrepreneurs who do not adopt innovative digital health technologies will be replaced, not by the technologies themselves, but by some others who would adopt them. This chapter will describe in detail these new paradigms in medicine and in entrepreneurship in healthcare.

BACKGROUND Studies have demonstrated that surgical safety checklists (SSCs) can significantly reduce surgical complications and mortality rates. Such lists rely on traditional posters or paper, and their contents are generic regarding the type of surgery being performed. SSC completion rates and uniformity of content have been reported as modest and widely variable. OBJECTIVE This study aimed to investigate the feasibility and potential of using smart glasses in the operating room to increase the benefits of SSCs by improving usability through contextualized content and, ideally, resulting in improved completion rates. METHODS We prospectively evaluated and compared 80 preoperative time-out events with SSCs at a major academic medical center between June 2016 and February 2017. Participants were assigned to either a conventional checklist approach (poster, memory, or both) or a smart glasses app running on Google Glass. RESULTS Four different surgeons conducted 41 checklists using conventional methods (ie, memory or poster) and 39 using the smart glasses app. The average checklist completion rate using conventional methods was 76%. Smart glasses allowed a completion rate of up to 100% with a decrease in average checklist duration of 18%. CONCLUSIONS Compared with alternatives such as posters, paper, and memory, smart glasses checklists are easier to use and follow. The glasses allowed surgeons to use contextualized time-out checklists, which increased the completion rate to 100% and reduced the checklist execution time and time required to prepare the equipment during surgical cases.

BackgroundStudies have demonstrated that surgical safety checklists (SSCs) can significantly reduce surgical complications and mortality rates. Such lists rely on traditional posters or paper, and their contents are generic regarding the type of surgery being performed. SSC completion rates and uniformity of content have been reported as modest and widely variable. ObjectiveThis study aimed to investigate the feasibility and potential of using smart glasses in the operating room to increase the benefits of SSCs by improving usability through contextualized content and, ideally, resulting in improved completion rates. MethodsWe prospectively evaluated and compared 80 preoperative time-out events with SSCs at a major academic medical center between June 2016 and February 2017. Participants were assigned to either a conventional checklist approach (poster, memory, or both) or a smart glasses app running on Google Glass. ResultsFour different surgeons conducted 41 checklists using conventional methods (ie, memory or poster) and 39 using the smart glasses app. The average checklist completion rate using conventional methods was 76%. Smart glasses allowed a completion rate of up to 100% with a decrease in average checklist duration of 18%. ConclusionsCompared with alternatives such as posters, paper, and memory, smart glasses checklists are easier to use and follow. The glasses allowed surgeons to use contextualized time-out checklists, which increased the completion rate to 100% and reduced the checklist execution time and time required to prepare the equipment during surgical cases.

Wearable technology is an emerging manifestation of consumer electronics that has the potential to revolutionise healthcare. The novel hands-free design and clinically relevant functionalities of various wearable devices hold significant promise for surgery, but the breadth and quality of evidence supporting clinical implementation in the operating room remains unclear. The objective of this article is to provide an objective overview of the available literature regarding the use of wearable technology in surgery, both in clinical and simulated experimental settings. A systematic review examining the use of wearable technology in surgery was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines using the MEDLINE and Web of Science databases from inception through 15 January 2016. Three authors independently screened the titles and abstracts of the retrieved articles and those that satisfied the defined inclusion criteria were selected for a full-text review. A total of 87 publications were included in this review. These articles predominantly described the use of Google Glass, GoPro or customised head-mounted displays (HMDs) in a wide range of intraoperative clinical settings. The included articles were categorised based on the highlighted areas of clinical impact, with the majority (56) discussing various applications for enhancing intraoperative safety and efficiency. Almost all articles cited technological limitations and privacy concerns as serious barriers to the implementation of wearable technology in the operating room. Evidence in the available literature regarding the use of wearable technology in the operating room shows promise, but high-quality clinical trials are needed to fully understand their clinical impact. Further, it will be essential to address existing technological limitations, develop healthcare-specific applications, and integrate privacy-protecting safeguards before it may be feasible for wearable devices to seamlessly integrate into the operative environment.

Readmissions are an important quality metric for surgery. Here, we compare characteristics of readmissions across laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), and adjustable gastric band (LAGB).Demographic, intraoperative, anthropometric, and laboratory data were prospectively obtained for 1775 patients at a single academic institution. All instances of readmissions within 1 year were recorded. Data were analyzed using STATA, release 12.For the 1775 patients, 113 (6.37 %) were readmitted. Mean time to readmission was 52.1 days. Of all the readmissions, 64.6 % were within 30 days, 22.1 % from 30 to 90 days, 1.77 % from 90 to 180 days, and 11.5 % from 180 to 365 days. Incidence of 30-day readmissions varied across surgeries (LRYGB: 7.17 %; LAGB: 3.05 %; LSG: 4.25 %, p = 0.04). Time to readmission varied as well, with 90.0 % of LSG and 80.0 % of LABG patients within the first 30 days, versus 60.8 % of LRYGB (p = 0.02). The most common causes of readmissions were gastrointestinal issues related to index procedure (34.5 %) and did not vary across surgeries. In multivariable logistic regression, index hospital length of stay (LOS) was associated with readmission (OR = 1.07, 95 % CI 1.02-1.13, p = 0.01).Readmissions after bariatric surgery are associated with high index hospital LOS, and a measureable proportion of procedure-related readmissions can occur up to 1 year, especially for LRYGB.

Background Bariatric surgery is the most effective treatment for obesity. Guidelines for optimizing postoperative care are emerging, and roles of the surgeon and registered dietician (RD) have opportunities for coordination. Objectives The study objective was to better define the appropriate guidelines for postoperative care by investigating whether a combined surgeon and RD follow-up for the initial postoperative visit within 2 to 6 weeks after surgery improves patient outcomes. Setting The setting was an accredited bariatric hospital in an academic setting. Methods A retrospective analysis of a prospective database was performed on patients who underwent bariatric surgery and were followed up by either a surgeon alone or by a surgeon and RD for initial postoperative visit. Results There were 302 patients in the surgeon follow-up group and 268 in the RD follow-up. Patients in the RD follow-up group had significantly fewer readmissions due to dietary-related problems (9 versus 0; P = .004), more favorable 3-month change in serum thiamine (−30.5 versus−4.04; P = .002), high-density lipoprotein (−3.42 versus−1.67; P = .053), and triglycerides (−17.5 versus−31.5; P = .03), and trended lower number of minor complications (16 versus 6; P = .08). No significant differences in percent excess weight loss were observed at all time points after surgery. Multivariate logistic models controlling for demographic features found that RD follow-up predicted 3-month increase in thiamine (odds ratio=2.49; P P = .01), and decrease in total cholesterol (OR = 1.58; P = .03) and triglycerides (OR = 1.55; P = .03). Conclusions Follow-up with a surgeon and RD for the initial postoperative visit may help improve patient outcomes.

Increasingly, healthcare can get on our wrists. Unhealthy lifestyle habits (e.g., sedentary behavior, nutrient-poor diets) result in higher levels of chronic diseases (e.g., CVD, obesity) and, paradoxically, the first step in disease management requires radical lifestyle changes, away from the unhealthy ones. These changes are difficult for patients and require day-to-day planning and adherence to new behaviors (increased physical activity, special diet programs) for best health outcomes in a long-term. We envision an important role of personalized, miniaturized Information Technologies (IT), specifically smart watches—supporting the patient’s self-management efforts in any daily life context, acting as a reminder for specific activities and documenting the patient’s progress via checklist-based approach. We delineate the requirements and design choices for the WATCH-list—an example of self-management service for obesity patients’ compliance to diet programs. We discuss the chronic illness self-management and role of IT in increasing the patient’s self-efficacy of activities contributing to health, in turn increasing the patient’s compliance to these activities and therefore facilitating better health outcomes in a long term.

The central paradigm in medicine is based on the patient–provider relationship. In these times, previously unheard diseases are being described every day while novel therapies for previously uncured diseases are introduced along with novel state-of-the-art diagnostic and therapeutic technologies. These developments alter the patient–physician relationship, which has remained largely unchanged for thousands of years. Digital Health represents an evolutionary adaptation of the art and science of medicine to pervasive information and communication technologies (ICTs). Without a doubt, this represents a phenomenal opportunity for us to scale access to care to any area in the world where connectivity may be available. This chapter reviews the ways that healthcare has evolved and its conceivable opportunities, challenges, and socioeconomic consequences.

Unmanned aerial vehicles (Drones) were first used in the 1990s by military organizations. However, the decline in cost due to technological advancements has allowed drones to become viable options for a diverse range of services including health services. Currently, health services and medical resources in underserved communities are limited to motor transportation and in-person interactions; however, drones may be a feasible option in providing these services in a more effective manner. Current research has explored the use of drones for natural disaster relief, search and rescue missions, and transfer units. However, there is limited research on how drones could be used as telemedicine and transfer units. This chapter discusses the current research on the use of drones in the health field and presents a pilot research project on drones as telemedicine and transfer units.

Bariatric surgery is an effective and enduring treatment for obesity. Sleeve gastrectomy (SG) has emerged as an increasingly prevalent surgical intervention. Further investigation is required to determine optimal standardization of SG. Data were collected prospectively for 64 patients who underwent a laparoscopic vertical SG between December 2010 and February 2013 at a single academic institution. Demographic, intraoperative, and postoperative (postop) data were collected for all patients including weighing each resected stomach. The total resected gastric weight varied widely. Preoperatively, patients in the upper tercile for resected gastric weight were more likely to be male (lower 10%, middle 23%, upper 52%, P = 0.006) and had greater initial weights (lower 255.9%, middle 245.1%, upper 280.0%, P = 0.019). The resected gastric weight (g) varied by tercile (mean of all, 131.24 ± 39.8; lower, 93.9 ± 10.9; middle, 127.4 ± 11.7; upper 172.7 ± 37.9, P = 0.000). Patients were followed for 1-year postop with follow-up data for 94 per cent (60/64) of participants. Per cent excess weight loss (EWL) was obtained at three, six, and 12 months postop. At 12 months, there was a trend toward increased per cent EWL in the upper tercile (lower 61.1%, middle 54.1%, upper 90.5%, P = 0.057). In conclusion, while the amount of gastric sleeve resected can vary, this study shows that intraoperative assessment of resected sleeve weight can help evaluate adequacy of resection. Improved 12-month per cent EWL in patients with greater resected tissue demonstrate potentially improved outcomes.

Bariatric surgery is an effective and enduring treatment for obesity; however, variation in weight loss may occur following surgery. Many factors beyond technical considerations may influence postoperative outcomes. A better understanding of the influence of adverse childhood experiences (ACE) on surgical weight loss may improve preoperative care. Demographic and preoperative and postoperative data were prospectively obtained for 223 patients undergoing bariatric surgery. All cases were completed laparoscopically without serious complication. Patients completed the ACE questionnaire, which assesses childhood maltreatment. Patients had an average age of 48 years and 77 % were female. There was a significant reduction from preoperative to 12-month postoperative BMI (45 to 31 kg/m(2), p ≤ 0.01). The average ACE score was 2.9 and these patients were more likely than population norms to have an ACE score ≥4 (35.9 vs. 12.5 %, p0.001). There was a positive correlation between the number of preoperative comorbidities and preoperative ACE score (R = 0.112, p = 0.09). Patients with a high ACE score (≥6) vs. patients low ACE scores had a higher postoperative BMI at 6-months (36.9 vs. 33.4 kg/m(2), p = 0.03) and 12-months postoperatively (34.5 vs. 30.5 kg/m(2), p = 0.07). High ACE patients had higher total cholesterol (191 vs. 169 mg/dL, p = 0.02) and LDL cholesterol (116 vs. 94 mg/dL, p = 0.02) than low ACE patients 12-months postoperatively. A high preoperative ACE score decreases weight loss following bariatric surgery and may warrant an increased preoperative counseling.

The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.

Modern laparoscopy, starting with Kurt Semm's insufflators and the first successful appendectomies, has only been around for approximately 30 years. Since those early successes, the technology has grown from the inception of basic laparoscopy to endoscopic surgery through natural orifices, and it continues to evolve by leaps and bounds with computer-assisted surgery and improved robotics in surgery. Without question, laparoscopy has revolutionized the way we perform standard surgery, especially relative to the techniques that had been used for hundreds of years. Despite the development of multiple novel technologies since the 1980s, very little has changed with regard to basic conceptualizations and practice of laparoscopy. In this review article, we will describe the highlights of recent advanced laparoscopic surgery procedures, their potential applications within the field of surgery, and how these advances may impact and improve future quality and patient outcomes.

Many payors require an additional attempt at nonsurgical weight loss before approval of bariatric procedures. This study evaluates this requirement by characterizing the prior weight loss attempts (WLAs) undergone by bariatric surgery patients and correlating those attempts to postoperative weight loss outcomes. Number and duration of WLAs were obtained from a preoperative clinic assessment. Body mass index (BMI) and percentage of excess weight loss (%EWL) were used to assess weight loss. Kruskal-Wallis and Spearman Correlation tests were performed to analyze data using GraphPad Prism 6. Mean number of WLAs before surgery was 3.5 ± 0.2 attempts, with an average duration of 15.2 ± 1.1 years. There was a significant negative correlation between duration of WLAs and preoperative BMI ( r = -0.2637, P = 0.0025). No significant difference was found for preoperative BMI or mean 12-month %EWL among any WLA groups. The number and duration of dietary attempts before surgery do not significantly affect long-term weight loss outcomes after bariatric surgery. Given these data, an additional preoperative WLA may not be efficacious in improving patients’ chances at weight loss.

Bariatric surgery is an effective and enduring treatment for obesity. Sleeve gastrectomy (SG) has emerged as an increasingly prevalent surgical intervention. Further investigation is required to determine optimal standardization of SG. Data were collected prospectively for 64 patients who underwent a laparoscopic vertical SG between December 2010 and February 2013 at a single academic institution. Demographic, intraoperative, and postoperative (postop) data were collected for all patients including weighing each resected stomach. The total resected gastric weight varied widely. Preoperatively, patients in the upper tercile for resected gastric weight were more likely to be male (lower 10%, middle 23%, upper 52%, P = 0.006) and had greater initial weights (lower 255.9%, middle 245.1%, upper 280.0%, P = 0.019). The resected gastric weight (g) varied by tercile (mean of all, 131.24 ± 39.8; lower, 93.9 ± 10.9; middle, 127.4 ± 11.7; upper 172.7 ± 37.9, P = 0.000). Patients were followed for 1-year postop with follow-up data for 94 per cent (60/64) of participants. Per cent excess weight loss (EWL) was obtained at three, six, and 12 months postop. At 12 months, there was a trend toward increased per cent EWL in the upper tercile (lower 61.1%, middle 54.1%, upper 90.5%, P = 0.057). In conclusion, while the amount of gastric sleeve resected can vary, this study shows that intraoperative assessment of resected sleeve weight can help evaluate adequacy of resection. Improved 12-month per cent EWL in patients with greater resected tissue demonstrate potentially improved outcomes.

Many surgeons attempting Laparo-Endoscopic Single Site (LESS) cholecystectomy have found the operation difficult, which is inconsistent with our experience. This article is an attempt to promote a standardized approach that we feel surgeons with laparoscopic skills can perform safely and efficiently. This is a four-trocar approach consistent with the four incisions utilized in conventional laparoscopic cholecystectomy. After administration of general anesthesia, marcaine is injected at the umbilicus and a 12-mm vertical incision is made through the already existing anatomical scar of the umbilicus. A single four-trocar port is inserted. A 5-mm deflectable-tip laparoscope is placed through the trocar at the 8 o'clock position, a bariatric length rigid grasper is inserted through the trocar at the 4 o'clock position (to grasp the fundus), and a rigid bent grasper is placed through the 10-mm port (to grasp the infundibulum). This arrangement of the instruments promotes minimal internal and external instrument clashing with simultaneous optimization of the operative view. This orientation allows retraction of the gallbladder in a cephalad and lateral direction, development of a window between the gallbladder and the liver which promotes the "critical view" of the cystic duct and artery, and provides triangulation with excellent visualization of the operative field. The operation is concluded with diaphragmatic irrigation of marcaine solution to minimize postoperative pain. Standardization of LESS cholecystectomy will speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach.