February 28 - March 3, 2017 Encore at Wynn Las Vegas

Improving Patient Outcomes with Minimally Invasive Surgery

Each month, MISS eNews brings you the latest on novel minimally invasive techniques and findings from around the world.

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Volume: #8, No. #6
The New MISS eNews!
Welcome to this month’s issue of MISS E-News! This month, we feature an interview with Dr. Phil Schauer, a globally renowned surgeon who also is Executive Director of the Minimally Invasive Surgery Symposium. Dr. Schauer and I cover the topics of current resources for education, online surgeon community development, the evolving role of endoscopy in MIS, education for residents and fellows, and some challenges the established surgeon faces today.
We also continue with Suggested Readings, in which some familiar and some new faces, including Ricardo Cohen, Douglas Adler, Emre Gorgun, Emanuele Lo Menzo, and Meagan Costedio, share their recommendations of critical and timely publications and those articles’ essential takeaways.
Enjoy this issue and Happy Fall!

—Colleen Hutchinson

An Interview with Phil Schauer, MD
Colleen: Tell us your thoughts on endoscopy’s role in surgical innovation and its inclusion now in MISS E-News as its own section focus.
Dr. Schauer: Great question. Endoscopy continues to become a fundamental skill for any MIS surgeon. More and more surgical procedures rely on intraoperative endoscopy, and a growing number of therapeutic options are becoming available and recommended that encompass endoscopy—including the endoscopic balloon, EndoBarrier, and endoscopic suturing devices, to name just a few. Endoscopy’s importance transcends surgical specialties, as we see it become essential in foregut surgery, colon surgery, etc. One of the most valuable components of the Minimally Invasive Surgery Symposium is now the endoscopy workshop, in which all 4 original pillars of the MISS platform (colon, foregut, bariatric, and hernia) are present.

Colleen: What are your thoughts on the development of online surgeon communities in which surgeons both seek and give advice on cases, techniques, surgical advances, etc?
Dr. Schauer: We’ve seen these independent online surgical communities explode really within the last year especially, providing rapid dissemination of innovative solutions and ultimately, improved patient care. They’ve gained such large audiences and have experienced tremendous growth. International Bariatric Club (IBC) is now 3,300 members strong! These communities in my opinion are incredibly effective in providing a rapid, global platform on which surgeons can communicate about what are often complex questions in surgery. Surgeons benefit from the global and rapid sharing of innovative solutions and in addition, they also benefit from the social support they gain online—members are not just sharing knowledge and varied perspectives on clinical questions, but are also lending ideas, experience, and support on related professional issues. I’d like to take this opportunity to announce that IBC is now planning an interactive online program about the new guidelines on metabolic surgery that have been released. We will have key surgeons from various regions around the globe weighing in on these guidelines and soliciting comments and questions live. Stay tuned!

Colleen: How do you get your continuing education? What sources do you rely on?
Dr. Schauer: First, attending MISS is really incredible for education. Even though I help plan it, every single year I sit in presentations and learn not only from these top speakers who are at the forefront of their specialty, but also from the audience who participates and elevates the discussions with their questions and observations. I also really believe still in going to the source—directly to journal articles to read in their entirety. I perform PubMed searches, I also use Medscape, and for me, textbooks still play an important role. In fact, we use one to educate our fellows and residents. I also value education from traveling to meetings, and what I’ve been doing more recently is attending more specialized meetings such as meetings with endocrine and diabetes experts.

Colleen: What do you think about social media as an educational resource?
Dr. Schauer: I think the Internet and social media can provide great educational resources. Some information is more reliable certainly—that’s the nature of the Internet, and so people have to exercise caution. I think it gives the ability to learn from a broad mix of perspectives, and the ease of use and simplicity of finding answers can’t be beat. The other day in the OR, we were doing a Lembert stitch and I asked my fellows: Who was Lembert? Tell me about him. Well, they had Lembert’s biography, information on the stitch technique, and videos on how to perform the stitch pulled up on a device in less than 5 minutes! When I was a resident, finding this information would have required significant effort and time, with maybe a half day in the library researching and recording information—and I wouldn’t have had video! So the Internet, especially for surgeons, can be an amazing, quick, thorough, and cheap tool.

Colleen: What are some of the most significant challenges surgeons face today?
Dr. Schauer: Surgeons are now dealing with incredible, challenging expectations regarding factors such as high quality outcomes, patient satisfaction, and providing "good service" versus just providing a "good outcome." Service can mean being timely, being nice—these factors that are external to what we do technically, which is operate. I think these evolving demands on surgeons add stress to an already stressful career path, and we aren’t taking care of ourselves physically and mentally to balance that new level of stress. Consequently, we are seeing higher burnout rates, higher rates of physician injury, and performance levels being affected, etc. There’s advice on retirement for surgeons, and advice for other stages along this career path, but there is not much advice for this stage of mid-career in which we are seeing these side effects due to the heavier burden of expectations surgeons are now expected to satisfy—and it’s concerning.

Colleen: What is the biggest, or one of the biggest, honors of your career to date?
Dr. Schauer: Wow, fun question. I’d have to say recently winning the Sones Innovation Award, which recognizes innovative practices in healthcare. They awarded it for collaborative advancements in bariatric surgery and diabetes research—mainly the STAMPEDE Trial. An anonymous review committee makes the selection, and the Sones Award is in memory of F. Mason Sones, MD. Dr. Sones was a Cleveland Clinic cardiologist who pioneered the imaging of arterial blockages, and therefore he is credited with laying the groundwork for modern cardiology. It was very rewarding to receive, as it is rare for a surgeon to win this type of award, and it is not awarded every year.


Suggested Readings:
Article: Effect of resident involvement on patient outcomes in complex laparoscopic gastrointestinal operations. Whealon M, Young M, Phelan M, Nguyen N. J Am Coll Surg. 2016 Jul;223(1):186-92.

Dr. Dana Telem: This article examines resident involvement in complex foregut surgery. The study demonstrates longer operative times, but no difference in patient outcomes. This highlights the importance of education and inclusion of residents in cases to train the next generation.

Article: Standard laparoscopic versus robotic retromuscular ventral hernia repair. Warren JA, Cobb WS, Ewing JA, Carbonell AM. Surg Endosc. 2016 Jun 10. [Epub ahead of print]

Dr. Emanuele Lo Menzo: The advantages of robotic surgery in general surgery remain unclear. In this article Warren et al. report on a retrospective comparison between laparoscopic ventral hernia repair and robotic retromuscular ventral hernia repair. With this technique the authors combined the advantages of an abdominal wall reconstruction (i.e. retromuscular placement of the mesh, medialization of the recti) with the advantages of the laparoscopic repair (no skin flaps, reduced wound morbidity). In addition they had a shorter hospital stay after robotic retromuscular ventral hernia repair, contributing to an overall similar hospital cost in both groups.

Article: Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Rubino F, Nathan DM, Eckel RH, Schauer PR, Alberti KG, Zimmet PZ, Del Prato S, Ji L, Sadikot SM, Herman WH, Amiel SA, Kaplan LM, Taroncher-Oldenburg G, Cummings DE; Delegates of the 2nd Diabetes Surgery Summit. Diabetes Care. 2016 Jun;39(6):861-77.

Related Article: The Diabetes Surgery Summit II Guidelines: a Disease-Based Clinical Recommendation. Cohen R; Shikora S; Petry T, Caravatto P and LeRoux C. Obes Surg. 2016 Aug;26(8):1989-91. https://www.ncbi.nlm.nih.gov/pubmed/27189354

Dr. Ricardo Cohen: This paper is a landmark publication as finally identifies metabolic surgery as an option in the treatment algorithm of type 2 diabetes, defining eligibility based on the severity and degree of type 2 diabetes control, and referring to obesity as a qualifier and not the sole criterion (as is stated in the outdated 1991 NIH guidelines). Last but not least, the guidelines were endorsed by over 45 professional societies worldwide, including the American Diabetes Association. A must-read for all surgeons involved in metabolic surgery.

Article: Revisiting the Role of BMI in the Guidelines for Bariatric Surgery. Segal-Lieberman, G, Segal, P, Dicker D. Diabetes Care 2016 Aug; 39(Supplement 2): S268-S273.

Dr. Ricardo Cohen: Metabolic surgery is gaining mature momentum. It is unquestionable that body mass index alone is a poor criterion to guide treatment of type 2 diabetes as it does not predict the severity of the disease or if any treatment—surgical or medical—will be successful. This paper, published by endocrinologists, comprehensively reviews the evidence that BMI should be secondary regarding the surgical indication for uncontrolled diabetes. Authors highlight that metabolically sick patients who have an increased cardiovascular risk and a BMI over 30 should be considered for metabolic surgery. The authors show that still there is no evidence to support metabolic surgery in non-obese patients.
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Article: Rectal indomethacin reduces pancreatitis in high- and low-risk patients undergoing endoscopic retrograde cholangiopancreatography. Thiruvengadam NR, Forde KA, Ma GK, Ahmad N, Chandrasekhara V, Ginsberg GG, Ho IK, Jaffe D, Panganamamula KV, Kochman ML. Gastroenterology. 2016 Aug;151(2):288-297.

Dr. Douglas Adler: This is a large retrospective study on the use of rectal indomethacin in an unselected cohort of patients undergoing ERCP. The authors found a significant reduction in the rate and severity of post-ERCP pancreatitis, and this study is at odds with a recent study that found the opposite conclusion, highlighting the fact that the role and benefit of NSAIDS in patients undergoing ERCP is still not fully clear.

Article:Article: EUS-guided liver biopsy provides diagnostic samples comparable with those via the percutaneous or transjugular route.
Pineda JJ, Diehl DL, Miao CL, Johal AS, Khara HS, Bhanushali A, Chen EZ. Gastrointest Endosc. 2016 Feb;83(2):360-5.

Dr. Douglas Adler: This is a retrospective analysis of EUS-guided liver biopsies. The authors found that, when comparing specimens obtained by EUS, percutaneous, or transjugular routes, the overall yields and tissue adequacy were similar. EUS-guided liver biopsy is still not widely practiced, but this study gives encouragement to those who do it and assurance that EUS-guided liver biopsy does not produce lesser tissue samples overall.

Article: Prevention of incisional hernias by prophylactic mesh-augmented reinforcement of midline laparotomies for abdominal aortic aneurysm treatment: a randomized controlled trial. Muysoms FE, Detry O, Vierendeels T, Huyghe M, et al. Ann Surg. 2016 Apr;263(4):638-45.

Dr. Michael Rosen: The concept of preventing complications in surgery is very appealing. One of the most common complications associated with any laparotomy is the formation of an incisional hernia. There has been significant interest in finding technical adjuncts to reducing the incidence of incisional hernia formation. For most patients, things like using the small bite suture technique with a 4:1 suture-to-wound length ratio is sufficient to reduce the rate of incisional hernia formation. However, in certain patients who are particularly prone to incisional hernia formation, the potential for prophylactic mesh to reduce the rate of incisional hernia formation is appealing. Muysoms et al have completed a very well designed randomized controlled trial of prophylactic mesh placement during the repair of open abdominal aortic aneurysms. It is well known that the collagen defects that are associated with aneurysm formation contribute to a very high rate of incisional hernia formation in this patient population. They randomized 120 patients to receiving standard laparotomy closure alone versus polypropylene mesh augmentation in the retromuscular position. The placement of the mesh did add 16 minutes to the operative procedure. But at 2 years it seemed well worth the effort as the hernia rate was reduced from 28% (conventional closure) to 0% (mesh augmentation). This well designed study lends further support to the efficacy of placing prophylactic retromuscular mesh during the repair of open abdominal aortic aneurysm. Several ongoing issues with this approach, however, deserve mention. Currently there are no CPT billing codes for reimbursement for placing prophylactic mesh, which might limit the adoption of this technique. Finally, the majority of "routine" aneurysms are often being performed with an endovascular approach today, and those aneurysms being performed open tend to be very complex, undergoing long complicated aortic surgery, which might alter the safety or effectiveness of adding prophylactic mesh at the end of these procedures.

Article: SAGES guidelines for laparoscopic ventral hernia repair.
Earle D, Roth JS, Saber A, Haggerty S, Bradley JF 3rd, Fanelli R, Price R, Richardson WS, Stefanidis D; SAGES Guidelines Committee. Surg Endosc. 2016 Aug;30(8):3163-83.

Dr. Todd Heniford: This article provides a thoughtful look at the landscape of laparoscopic ventral hernia repair. It demonstrates many of the things that we truly know, but also importantly and strongly highlights how much we base practice on "professional opinion." Indeed, it emphasizes the need for further prospective assessment of how we treat one of the most common surgical ailments in the world.

Article: Real-time indocyanine green fluorescence imaging–guided complete mesocolic excision in laparoscopic flexural colon cancer surgery. Watanabe J, Ota M, Suwa Y, Ishibe A, Masui H, Nagahori K. Diseases Colon & Rectum. July 2016, 59(7): 701-705.

Dr. Emre Gorgun: Intraoperative real-time visualization of the lymph flow using infrared during laparoscopic colon cancer surgery, especially flexural colon cancer surgery, may be a helpful technique for identifying appropriate central vessels to be dissected and ligated with possibly higher lymph node harvest. Furthermore, it is possible to clinically apply this method in combination with the concept of complete mesocolic excision and accomplish "image guided surgery;" however, it is yet to be determined whether this would lead to an oncological benefit in the long-term.

Article: Identifying ureters in situ under fluorescence during laparoscopic and open colorectal surgery. Yeung TM1, Volpi D, Tullis ID, Nicholson GA, Buchs N, Cunningham C, Guy R, Lindsey I, George B, Jones O, Wang LM, Hompes R, Vojnovic B, Hamdy F, Mortensen NJ. Ann Surg. 2016 Jan;263(1):e1-2.

Dr. Meagan Costedio: Dr. Meagan Costedio: This is a novel way of identifying the ureters laparoscopically without the cost and morbidity of insertion of ureteral stents. There are potential issues with the use of methylene blue, and further studies are necessary to compare the risks, benefits, and cost of stents versus fluorescence technology.

Volume: #8, No. #5
The New MISS eNews!
Welcome to the next issue of MISS E-News! We’ve gotten some great feedback on the first issue on which MISS E-News and I have partnered. We hope you continue to share your feedback and ideas. This month, we feature a Rapid Fire interview with Manoel Galvao Neto, a globally renowned endoscopist who is at the forefront of several new technologies and surgical advances. In this interview, Dr. Neto responds quickly to questions I threw at him on his OR schedule given the demands of his travel and research activities, his thoughts on new technologies and devices in endoscopy and endolumenal surgery, and his own personal research and opinion on the new Aspire Assist device (thought-provoking, and we will hear more opinion on this device in future issues).
We also continue with some new faces as contributors to the Suggested Readings, including Steven Wexner, Dana Telem, Jaime Ponce, Aurora Pryor, Marina Kurian, Michael Rosen, and others. These contributors share not only their own recommendations of critical and timely publications for you to read, but also the essential article takeaways.
As I mentioned in the last issue, our goal is for MISS E-News to become your go-to source of information in all things minimally invasive surgery. Please contact me at miss@globalacademycme.com with any comments and/or suggestions.

—Colleen Hutchinson

Rapid Fire with Dr. Neto!
Colleen: This year you have completed 21 round-trip flights, traversed 211,845 miles, been to 44 cities in 13 countries and you are traveling 60% of your time. Given these challenging travel and research demands, how often do you spend time in the OR and how many cases total do you perform annually?
Dr. Neto: Nice question. I am a dying species (if I may joke like that) as I am (still) self-employed; therefore, first of all, I can make my own schedule and secondly, I can perform consultations and cases on the schedule I need to in order to maintain this amount of work travel and surgery productivity. In general, every week I travel abroad and spend 2 to 4 weekdays away, and return to have at least 2 to 3 working days. I do work on Saturdays, and I coordinate with three bariatric endoscopy services that enable me to arrive to work, complete consultations in the morning, and do the cases that afternoon/evening. My team completes follow-up in a multidisciplinary fashion and covers emergencies.
In 2015, I attended 120 cases abroad and performed 380 cases (only therapeutic). This year with optimization of the team we plan to grow around 30%.

Colleen: What do you think about the new weight loss device, Aspire Assist? And about the surgeon social media dialogue in online surgeon groups that has followed the announcement of its FDA approval?
Dr. Neto: Much like others have in recent days since the FDA announcement of approval of this device, I had a vocal, negative, angry reaction to it the first time I saw a presentation about it by Shelby Sullivan from the University of Washington, who is the principal investigator. But because I hate to be angry about anything, after some time I decided to try to understand what the device and the logic behind its usage was all about...and it turns out that I had a bad gut reaction to it that wasn’t warranted.
Once I calmed my mind down and opened it to learning about the device, I saw positive points of the procedure and apologized to Shelby. I also researched the company and spoke with them. When I did, I found serious people who really seem to care about patients. Becoming more interested, I then spoke with patients who were using the device, and saw with my own eyes that they were happy and were losing weight. The next step for me was to see it from the technical perspective, so during live cases I had the opportunity to assist and then perform implants and I found it very reproducible. At the end of the day, the researchers have presented evidence on safety and effectiveness that is so solid that they achieved FDA approval–a high bar.
On social media, there were one or two voices that were angry and sarcastic and I feel that frankly some of the comments coming from that type voice lacked good old common sense. Besides this specific voice, I saw a lot of gut reactions from healthcare providers that echoed my first reaction–so it’s a reaction that I understand because I initially had it myself. But, given my own experience following that reaction, my hope is that these surgeons and multidisciplinary staff who feel that anger (as evidenced in their social media comments) can take a step back and rethink it in a more scientific and mature way–with an open mind.
I also saw a lot of support for the procedure online as well.

Colleen: First case of ESG (endoscopic sleeve gastroplasty) with Apollo Overstitch–educate us!
Dr. Neto: We just performed the first ESG case in Brazil at the ABC Medical School within an IRB-approved protocol to treat mildly obese patients. It was a 45-minute procedure that ran smoothly, and the patient is recovering well. We expect that the ESG will be a hit in Brazil if it continues to achieve the solid results of the three trial centers that reported 50% EWL and 19% TBW up to one year (Gontrand Laopez–Nava at Madrid Sanchinarro University Hospital, Madrid, Spain; Barham Abu Dayye at Mayo Clinic in Rochester, Minnesota; and Reem Shariaha at Weill Cornell Medical College, New York).

Colleen: Intragastric Balloon Consensus Meeting–educate us!
Dr. Neto: From June 15th to 18th, 2016, at 9th of July Hospital in Sao Paulo, we had the first Brazilian Intragastric Balloon Consensus (BIB-C). It was a remarkable meeting with 36 bariatric endoscopists to discuss, present, and try to reach consensus on the clinical practice of intragastric balloons. Three hospitals and two universities comprised the data. They were selected based on having performed at least 300 cases, having a solid reputation, and were Brazilian Board-certified specialists. With that we gathered a casuistic of around 40,000 cases with over 17 years experience with the device, which is a massive and impressive amount of data (it is estimated that only in Brazil around 5,000 to 7,000 cases are performed annually). The first day we discussed all of the current literature; the second day we presented and discussed the initial results on the casuistic and on the afternoon and the following day we presented, discussed and voted on 60 questions regarding clinical practice of the intragastric balloon.
That is the first part of it and we expect to have it ready to send to publication later this year.... Stay tuned!

Colleen: Thoughts on the Rubino/Cummings evidence-based guidelines for surgical treatment of T2DM just published in Diabetes Care:
Dr. Neto: A true milestone that will impact the standard of care on diabetes.... Endocrinologists all over the world are opening their minds to surgery as an important component of the treatment algorithm for T2DM

Colleen: Manoel, share your quick thoughts on these devices and advances:
  • EndoBarrier (GI Dynamics): I still believe it has a place in T2DM treatment.
  • Duodenal Mucosal Resurfacing (Fractyl labs): Disruptive technology in endolumenal diabetes treatment with very good results, to be shared shortly—our first–in–human trial paper just gained acceptance to be published in Diabetes Care.
  • Endolumenal magnetic bowel diversion (GI Window): Another disruptive technology with promising initial results....We will start a trial later this year.
  • Single-channel scope OverStitch (Apollo OverStitch): It will universalize endolumenal suturing in its ability to be used in most single-channel scopes of the 3 major brands instead of being restricted to a specific double-channel scope of a single brand....
  • Mentor: Natan Zundel and Kelvin Higa (not bad at all!)
  • Most significant recent advance in endoscopy: On the research side, duodenal mucosal resurfacing (as I mentioned, we just received approval to publish first-in-human trial in Diabetes Care), and endoscopic sleeve gastroplasty on the clinical practice side.
  • Most significant recent advance in bariatrics: The afore-mentioned Rubino/Cummings evidence-based guidelines for surgical treatment of T2DM just published in Diabetes Care.
  • Most significant recent advance in foregut surgery: Electrical stimulation of lower esophageal sphincter for GERD treatment.
  • Most significant recent advance in colorectal surgery: Trans-anal approaches–NOTES is still alive!
  • Most significant recent advance in hernia surgery: New biomeshes.

Dr. Galvao-Neto’s disclosures are Alacer Biomedics, international consultant, scientific advisory board, senior proctor; Apollo Endosurgery, international consultant, senior proctor; Ethicon Endo-Surgery, international consultant; Fractyl Labs, international consultant, scientific advisory board; GI Dynamics, international consultant, scientific advisory board, senior proctor; GI Windows, international consultant; Nitinotes, international consultant.

Suggested Readings:
Article: Arunachalam L, O'Grady H, Hunter IA, Killeen S. A systematic review of outcomes after transanal mesorectal resection for rectal cancer. Dis Colon Rectum. 2016 Apr;59(4):340-50.

Steve Wexner: Arunachalam and associates from the UK performed a systematic literature review of the literature published during ten years between 2005 and 2015 in which taTME was evaluated. They were able to assess 15 mostly retrospective studies. The authors have provided several very nice tables comparing the numbers of patients enrolled, the median ages and genders of these patients as well as their respective BMI’s and ASA classifications. They tried to cull from the literature the pretreatment stage, tumor location, and the use of neoadjuvant therapy. Beyond these clinical parameters they also tried to evaluate and comment upon the various access platforms and techniques used which therefore reflected upon the operative times and numbers of trocars employed. They even included data about splenic flexure mobilization, method of anastomosis, use of pelvic drains, pouch reconstruction, stomas, and fast track protocols. The histologic outcomes which they evaluated included TME grade, distal margin, circumferential resection margin, the ability to achieve R-O resection, the number of nodes evaluated, and the pathologic stage. Some additional clinical variables were conversion, anastomotic leak or stricture, wound complication, the need to re-operate, perioperative blood loss, and other surgical and non-surgical complications. Some quality metrics included the length of stay, morbidity and mortality, and subsequently the functional outcome. Through these tables and this literature review it become quite apparent to the reader that taTME potentially offers safe minimally invasive rectal cancer resection with potentially superior histologic outcome. As is typically stated at the end of any systematic review of retrospective data the authors note that "controlled studies are required." Nonetheless, the authors are to be commended on their excellent work. The significant volume of data in their article precludes my detailed discussion of it. I instead recommend that surgeons interested in taTME read this excellent recent publication.

Article: Gietelink L1, Henneman D, van Leersum NJ, Dutch Surgical Colorectal Cancer Audit Group, et al. The influence of hospital volume on circumferential resection margin involvement: results of the Dutch surgical colorectal audit. Ann Surg. 2016 Apr;263(4):745-50.

Steve Wexner: During the last 30 years, the evolution of rectal cancer surgery has proven that it is not the distal but rather the circumferential resection margin that is of significant prognostic value. Patients in whom the circumferential resection margin is involved by tumor are more likely to experience local recurrence than in patients in whom the circumferential resection margin is free of tumor. (Quirke, Beck) Gietelink et al recently published this article in Annals of Surgery in which they presented a population based assessment between hospital volume and CRM involvement. They defined CRM positivity as ≤ 1 mm. This factor is important as other such as Nagtegaal that while Gina Brown et al, Quirke et al, and Berho et al employ the 1 mm distance as positive, Nagtegaal and others have relied upon 2 mm. Nonetheless, using this 1 mm standard, the authors have evaluated 5,161 patients operated on in 91 hospitals.
The hospitals were categorized into 3 volume groups, low volume as being less than 20 annual cases, medium volume as being 20 to 40 cases, and higher volume hospitals as being ≥ 40 cases. According to these definitions, there were 25 low volume, 47 medium volume, and 19 high volume hospitals. Interestingly, in the medium and high volume hospitals, more advanced tumors were operated on and, perhaps contrary to logic, high volume hospitals had a significantly higher percentage of patients in whom no record was noted of preoperative imaging. As might be expected, higher volume hospitals had an increased use of chemo radiotherapy and a decreased use of short course radiotherapy. Perhaps also contrary to logic, there were no differences in the rates of abdominal perineal resection amongst the volume groups; but again as might be expected, medium and high volume hospitals showed a higher percentage of patients with more than 10 lymph nodes examined.
In all 5,161 patients, the CRM was recorded in 86% of patients. The CRM was involved in 11% of the patients operated upon in low volume hospitals versus 7.7% and 7.9% in the medium and high volume hospitals. Even after adjustment, the influence of hospital volume on CRM involvement was significant. The authors concluded that low hospital volume was independently associated with a higher risk of CRM involvement. These data help further substantiate the need for the new American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer (Dietz, Monson, Wexner). As has been the case in many other countries, this article supports the annual minimal volume standard of 20 rectal cancer resections per hospital per year as was implemented by the Association of Surgeons in the Netherlands. The current iteration of the proposed standards in the National Accreditation for Rectal Cancer Program does not currently require a minimum number, but perhaps a minimum of 20 annual total mesorectal excision procedures for rectal cancer may be appropriate.

Article: Bechara R, Ikeda H, Onimaru M, Inoue H. Peroral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc. 2016 Mar 25 [epub ahead of print]

Dana Telem: This article shares the learning curve and major pitfalls to avoid from a pioneer and NOTES. Tips and tricks included in this article will help current surgeons performing NOTES as well as those interested in starting a program. Extraordinarily helpful and practical.

Article: Liang WT, Wu JM, Wang F, Hu ZW, Wang ZG. Stretta radiofrequency for gastroesophageal reflux disease-related respiratory symptoms: a prospective 5-year study. Minerva Chir. 2014 Oct;69(5):293-9.

Marina Kurian: This is a great article. It is important data for the anti-reflux surgeon. Stretta is another treatment in our armamentarium and is successful in several clinical scenarios. Stretta can be used in primary GERD and some data is now being collected in the post-bariatric surgery patient with GERD. This is a technique to learn and keep in the toolkit, as there are many situations in which it can be helpful and presents a viable endoscopic approach.

Article: G. Lopez-Nava, M. Galvao, I. Bautista–Castaño, J. P. Fernandez-Corbelle, and M. Trell. Endoscopic Sleeve Gastroplasty (ESG) with 1–year follow–up: factors predictive of success (Endoscopy International Endosc Int Open. 2016 Feb; 4(2): E222–E227.).

Manoel Galvao Neto: The endoscopic sleeve gastroplasty has its first one-year follow-up publication with a very good safety profile and good results in a multidisciplinary support team environment. In 25 subjects, (20 female) with an initial mean 38.5±4.6kg/m2 (range 30–47) the body mass index (BMI) loss was 7.3±4.2kg/m2, and mean percentage of total body weight loss (TBWL) was 18.7±10.7 at 1 year. In the linear regression analysis, adjusted by initial BMI, variables associated with % TBWL involved the frequency of nutritional contacts (β= 0.563, P=0.014) and psychological contacts (β= 0.727, P=0.025). The numbers of nutritional and psychological contacts were predictive of good weight loss results. It is interesting to see those initial good results, but it is important to remember that this is a single-center, non–randomized trial and it has yet to be shown to be reproducible by others with randomized control groups and longer follow–up. The initial results presented and published in different centers across US, Latin America, and Europe are encouraging enough to continue research to make it "time-tested" in follow–up in order to define its future role among endolumenal procedures.

Article: Moura D, Oliveira J, De Moura EG, et al. Effectiveness of intragastric balloon for obesity: A systematic review and meta-analysis based on randomized control trials. Surg Obes Relat Dis. 2016 Feb;12(2):420-9.

Manoel Galvao Neto: Intragastric balloons were finally approved by the FDA last year and there is a lot of hype over it in the US. This paper presents a meta-analysis of 9 randomized control trials (RCT) that shows benefit in favor of balloons when compared with controls. The importance of a paper like this is to demonstrate solid evidence, and the most rigorous way to do that is a meta–analysis of RCTs, which ar really scarce in the fields of bariatric surgery and endoscopy. The modest weight lost obtained by balloons over control groups can be explained by the authors’ words on limitations of the study, which read: "As with any systematic review, even with the careful use of only RCTs, this review has some limitations. The main limitation comes from the variation of the BMI of the patients between 27 > BMI > 50. Another limitation is the variation in IGB usage follow-up, which range from 13 to 24 weeks. Considering the IGB was typically used for 6 months, most studies evaluated the weight loss after 4 months, which could affect the final results."
Intragastric balloons are a "hot topic" now in the US and have to be incorporated and tested in the country’s clinical practice, but the technology has positioned itself to potentially fulfill the huge gap in between the clinical treatment offered to low BMI patients and bariatric surgery options offered to morbidly obese patients.

Article: Machytka E, Chuttani R, Bojkova M, et al. A procedureless gastric balloon for weight loss: a proof-of-concept pilot study. Obes Surg. 2016 Mar;26(3):512-6.

Jaime Ponce: The intragastric balloon has been around for close to 20 years with some minor improvements. The concept of having a procedure-less balloon is innovative and demonstrates that we can still improve on patient satisfaction, cost and invasiveness in a proven technology.

Neylan, C. J., Dempsey, D. T., Tewksbury, C. M., Williams, N. N., et al. Endoscopic treatments of obesity: a comprehensive review. Surg Obes Relat Dis. 2016 Feb 11 [epub ahead of print]

Aurora Pryor/Andrew Bates: Most of the newest innovations in bariatric surgery have been through endoscopic interventions, utilizing devices that employ gastric restriction or delayed gastric emptying. This review provides a good summation of the current technologies that are under investigation.

Article: Burgmans JP, Voorbrood CE, Simmermacher RK, et al. Long-term results of a randomized double-blinded prospective trial of a lightweight (Ultrapro) versus a heavyweight mesh (Prolene) in laparoscopic total extraperitoneal inguinal hernia repair (TULP-trial). Ann Surg. 2016 May;263(5):862-6.

Mike Rosen: Today there is a plethora of meshes available to repair inguinal hernias. While many have marketing claims of superior outcomes with reduction in chronic pain, hernia recurrence, and foreign body sensation, few have been put to the test of a randomized controlled trial with appropriate outcome measures to discern a difference in outcomes that matter to patients. It has been a general perhaps misconception since the introduction of lightweight polypropylene mesh that the heavyweight version is too stiff, causes long-term discomfort as a result of mesh sensation, and is "over-engineered" to do the job. Burgmans et al have challenged the notion that lightweight polypropylene mesh is superior to heavyweight mesh for laparoscopic inguinal hernia repairs. They have reported the results of a well-designed randomized controlled trial of 950 patients undergoing laparoscopic TEP inguinal hernia repairs with either lightweight polypropylene mesh (Ultrapro) or heavyweight polypropylene mesh. The results are strikingly in favor of heavyweight mesh, with a significant reduction in long-term hernia recurrence rate and groin pain, with no difference in mesh sensation. This study certainly supports that a 10x15 cm piece of heavyweight polypropylene mesh seems to be the most effective option in repairing laparoscopic inguinal hernias. It does deserve some mention, however, that the results of a midweight polypropylene mesh were not evaluated in this study. Those materials that are 40-60 gm/m2 might offer other distinct advantages over heavyweight materials and certainly should be studied in future well-designed trials.

Article: Novitsky, Y. W., Fayezizadeh, M., Majumder, A., et al. Outcomes of posterior component separation with transversus abdominis muscle release and synthetic mesh sublay reinforcement. Ann Surg 2016 March 3 [epub ahead of print]

Aurora Pryor/Andrew Bates: The latest trend in abdominal wall hernia repair has been the avoidance of intraperitoneal mesh and the utilization of component separations with sublay mesh placement. The posterior component release (transversus abdominis muscle release) has gained traction in recent years as an effective repair that allows for preperitoneal mesh placement, component release, and can be performed as a laparoscopic or robotic surgery.
Volume: #8, No. #4
The New MISS eNews!
Welcome to MISS eNews. I am excited to take on the editorial management of this publication, with this issue being my first! As you will see in this issue and those to come, we have some changes in store for you that I think you will find beneficial. First, we’ve added an Endoscopy section to the existing 4 MISS focus areas of colon, foregut, hernia, and bariatric minimally invasive surgery, and we’ve enlisted the help of 2016 MISS faculty member Matthew Kroh, MD, of Cleveland Clinic to help develop this new endoscopic focus. In this first issue, Matt gives his thoughts on endoscopy’s role in minimally invasive surgery.

We also have invited some new faces to be contributors, and have made some adjustments to the format of Suggested Readings. From now on, you will see new contributors share not only their own recommendations of suggested articles for you to read, but also the critical article takeaways as well. It’s one thing to read a list of what we should be reading, but it’s totally another to know what the experts think are the best new publications and why they think so.

We are also adding some new quarterly segments to this newsletter that will include focuses on residents and fellows, social media, an industry spotlight, and more. Get ready to be engaged and entertained, as well as educated, in the coming months. We have great things in store for you.

Here’s to a new and improved MISS eNews, to the new names and faces you will see in these issues, and to developing a lasting rapport with you, the readership! We want to be your go–to source of information in all things minimally invasive surgery. Please contact us at MISS@globalacademycme.com with any comments and/or suggestions.

—Colleen Hutchinson


Colon Suggested Readings
Medicine and Robotics
John Marks, MD: Operating in the pelvis for rectal cancer remains a challenge facing surgeons today that is most apparent when treating disease in the distal rectum. A transanal approach to total mesorectal excision (taTME) has become popular to address these challenges. This is the largest study published to date examining pathologic and early oncologic outcomes using taTME in rectal cancer. The study results confirm that taTME is a safe operation with good quality pathologic outcomes, while not promising that the oncologic outcomes are meaningful—as follow–up is only 15 months.
Article: Bravo R, Lacy AM. Medicine and robotics. Med Clin (Barc). 2015 Dec 7;145(11):493-5. [Article in Spanish].
Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial
John Marks, MD: This trial highlights the challenges facing surgeons operating in the pelvis for rectal cancer. The study compares open versus laparoscopic total mesorectal excision approaches to total mesorectal excision, and while the paper fails to establish the non-inferiority of laparoscopy based on pathologic outcomes, it is unclear how these findings will ultimately translate into long-term oncologic and survival outcomes. What the study does bring to the fore is the need to explore other surgical techniques, such as robotics and transanal total mesorectal excision, for rectal cancer surgery.
Article: Fleshman J, Branda M, Sargent DJ, et al. Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial. JAMA. 2015 Oct 6;314(13):1346-55.

Endoscopy Suggested Readings
Early human experience with per-oral endoscopic pyloromyotomy (POP)
Matthew Kroh, MD, FACS: Gastroparesis is an increasingly common disease, with multiple etiologies and treatments that span from medical to surgical therapies. Often, existing therapy may be unsuccessful and evolving strategies are needed to improve patient symptoms. Shlomovitz et al describe their initial human experience with endoluminal therapy by means of per oral endoscopic pyloromyotomy. Based on techniques derived from ESD (endoscopic submucosal dissection) and POEM (per oral endoscopic myotomy), the Oregon group has demonstrated feasibility and safety in a small cohort of patients.
Article: Shlomovitz E1, Pescarus R, Cassera MA, et al. Early human experience with per-oral endoscopic pyloromyotomy (POP). Surg Endosc. 2015 Mar;29(3):543-51.
The REDUCE pivotal trial: a prospective, randomized controlled pivotal trial of a dual intragastric balloon for the treatment of obesity
Matthew Kroh, MD, FACS: The increasing obesity epidemic has prompted development of new endoscopic therapies for treating obese patients and improving weight-related comorbid disease. Two intragastric balloon therapy devices have recently been approved for use in patients with BMI 30-40. The REDUCE pivotal trial is a multi-institutional study that showed endoscopically placed dual balloon therapy plus exercise and diet modification was more effective than diet and exercise alone.
Article: Ponce J, Woodman G, Swain J, et al. The REDUCE pivotal trial: a prospective, randomized controlled pivotal trial of a dual intragastric balloon for the treatment of obesity. Surg Obes Relat Dis. 2015 Jul-Aug;11(4):874-81.

Foregut Suggested Readings
Laparoscopic magnetic sphincter augmentation vs laparoscopic Nissen fundoplication: a matched-pair analysis of 100 patients
Marina Kurian, MD: While I may not agree with the conclusions, there is symptomatic improvement with both techniques. We see less gas bloating and belching issues with LINX®, which is what we expected compared to Nissen. It would be great to see studies one year out in a case-matched analysis—but it’s challenging to get patients do that testing.
Article: Reynolds JL, Zehetner J, Wu P, Shah S, Bildzukewicz N, Lipham JC. Laparoscopic magnetic sphincter augmentation vs laparoscopic nissen fundoplication: a matched-pair analysis of 100 patients. J Am Coll Surg. 2015 Jul;221(1):123-8.
Revisional paraesophageal hernia repair outcomes compare favorably to initial operations
Dana Telem, MD: This article studies outcomes of revisional versus primary paraesophageal hernia repair. Given the rate of recurrence following this procedure, this is important data to help counsel patients who are undergoing revisional operations.
Article: Wennergren J, Levy S, Bower C, Miller M, Borman D, Davenport D, Plymale M, Scott Roth J. Revisional paraesophageal hernia repair outcomes compare favorably to initial operations. Surg Endosc. 2015 Dec 10.

Hernia Suggested Readings
Novel Uses of Video to Accelerate the Surgical Learning Curve
Aurora Pryor, MD/Andrew Bates, MD: Social media is increasingly used to disseminate ideas and surgical techniques, for better or for worse. The most prominent example is the International Hernia Collaboration, which is hosted by Facebook. Social media's role as an educational tool remains hotly debated.
Article: Ibrahim AM, Varban OA, Dimick JB. Novel Uses of Video to Accelerate the Surgical Learning Curve. J Laparoendosc Adv Surg Tech A. 2016 Mar 31. [Epub ahead of print]
Benefits of Multimodal Enhanced Recovery Pathway in Patients Undergoing Open Ventral Hernia Repair
Guy Voeller, MD: The effectiveness of enhanced recovery after surgery (ERAS) pathways is well established in the field of colorectal surgery. The evaluation of the ERAS pathways relative to hernia surgery is in its infancy. These investigators evaluated the ERAS pathways to see if they would accelerate functional recovery and shorten hospital stay in patients undergoing open ventral hernia repair. They evaluated consecutive patients undergoing open major ventral hernia repair with the use of their ERAS pathway and compared them to a historical cohort before implementation of the ERAS.
They compared 100 patients undergoing ventral hernia repair with the ERAS implementation to a similar historical cohort. The ERAS group demonstrated significantly shorter times to diet (1.1 vs. 2.7 days) and significantly shorter times to bowel function. Average length of stay was reduced from 6 to 4 days and the ERAS Group had significantly fewer 90-day readmissions. The ERAS pathways are well established in the colorectal surgical arena, and this study supports their use in major abdominal wall reconstruction and the notion that practitioners should consider ERAS protocols.
Article: Majumder A, Fayezizadeh M, Neupane R, Elliot HL, Novitsky YW. Benefits of Multimodal Enhanced Recovery Pathway in Patients Undergoing Open Ventral Hernia Repair. J Am Coll Surg. 2016 Mar 3. (ePub).
Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial
Todd Heniford, MD: An incisional hernia is the most frequent long-term complication following abdominal surgery. This results in more than 600,000 ventral, incisional hernia repairs per year in the US and Europe. The STITCH trial, a randomized, prospective, multi-center trial hosted by the outstanding Rotterdam group, compared small bite-small walk suture closure (5mm bite and 5mm walk) of the abdominal midline fascia with standard 1cm walk-1cm bite closure in primary laparotomies. With a 97% one-year followup, the small bite-small walk closure reduced the incidence of ventral hernia formation by more than a third. The adjusted odds ratio was 0.52. Small bite-small walk laparotomy closure should be considered a means to reduce ventral hernia formation.
Article: Eva B Deerenberg, MD, Dr Joris J Harlaar, MD, Prof Ewout W Steyerberg, PhD, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet. 2015 Sep 26;386(10000):1254-60.

Bariatric/Metabolic Suggested Readings
Effectiveness of intragastric balloon for obesity: A systematic review and meta-analysis based on randomized control trials
Jaime Ponce, MD, FACS, FASMBS: It has been proven in several randomized clinical trials that a diet becomes more effective with an intragastric balloon. The balloon is not intended to compete or replace surgery. It does enable mild to moderate obese patients to have access to more management options and keeps them engaged. Based on this meta-analysis, we should consider offering diet management associated with the balloon to some of our growing obese population.
Article: Moura D, Oliveira J, De Moura EG, Bernardo W, Manoel Galvao Neto M, Campos J, Popov VB, Thompson C. Effectiveness of intragastric balloon for obesity: A systematic review and meta-analysis based on randomized control trials. Surg Obes Relat Dis. 2016 Feb;12(2):420-9.
Mental Health Conditions Among Patients Seeking and Undergoing Bariatric Surgery: A Meta-analysis
Aurora Pryor, MD/Andrew Bates, MD: There has been a newfound academic interest in the psychiatric confounders within the bariatric surgery population. Bariatric surgeons have previously noted anecdotal evidence of increased incidence of psychiatric comorbidities within the population, but only now are we establishing the prevalence and impact on surgical outcome.
Article: Dawes, A. J., Maggard-Gibbons, M., Maher, A. R., Booth, M. J., Miake-Lye, I., Beroes, J. M., & Shekelle, P. G. (2016). Mental Health Conditions Among Patients Seeking and Undergoing Bariatric Surgery: A Meta-analysis. JAMA,315(2), 150-163.