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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Vol. 8 No. 8
This month we continue to bring article recommendations to you from thought leaders who are new to MISS E-News. We hope you are enjoying the articles these surgeons have been identifying as critical reading for you to keep up with research and improve your techniques and practices. We again offer article suggestions this month from some new faces, including MISS Foregut Program Co-Chair Bill Richards, Robert Brolin, Ajita Prabhu and Shanu Kothari. Also this month we are lucky to have interviewed MISS keynote speaker Daniel B. Jones, MD, FACS, who is also the incoming SAGES President. He also has served as volume editor for the ACS Multimedia Atlas of Surgery: Bariatric Volume with some other bariatric surgeons who shares article recommendations here in this issue. It is a busy time for Dan and I want to thank him for his time, as well as thank Phil Schauer for asking critical questions for this feature interview. Enjoy the articles you will find links to in this issue, don't forget to make your travel plans for MISS 2017, and most importantly—Happy Holidays!

—Colleen Hutchinson

Feature Interview
What are your goals as SAGES incoming President?
Dr. Jones: Serving as President of SAGES this year is a tremendous personal honor for me. SAGES is the second largest surgical organization in the US after the American College of Surgeons, with over 6,000 members. SAGES attracts inventors, innovators, and early adopters of emerging technologies and procedures. SAGES has embraced endoscopy and laparoscopy, and continues to assess the benefits of NOTES and robotic surgery. SAGES has always had an emphasis on education, training, and research, hosting quality courses and producing amazing educational content such as FLS, FES, and FUSE.

As President, I want to encourage young surgeons to join SAGES and get engaged via committees. I also want to promote mentoring, collaboration, and networking using social media. Another goal is to challenge SAGES to lead in national healthcare advocacy and reform. I hope to see FUSE become a criterion for hospital privileging to promote patient safety, and I’d also like to see the SAGES Masters Program become accepted as a means of lifelong learning after fellowship. I want us to rethink how we use virtual reality simulation to teach and innovate. I want to tap the generosity and talents of SAGES members to grow the Go Global committee and program for teaching to underdeveloped countries.

I plan to collaborate closely with other organizations. In bariatric surgery, we will continue to work with the American Society for Metabolic and Bariatric Surgery (ASMBS) on guidelines and educational initiatives. We will similarly work with the American Hernia Society (AHS) and Association for Surgical Education (ASE). We will also reach out to the AAST for acute care surgeons and the Association of Women Surgeons for joint programming. We will partner with the American College of Surgeons and Society for Surgery of the Alimentary Tract (SSAT) to collaborate on advocacy and health reform.

On April 11 - 14, 2018, SAGES will be hosting its World Congress in Seattle. We hope to attract surgeons from around the globe to share their experiences. I anticipate that SAGES will have a bigger presence in robotic surgery of the pancreas, liver and colon. Program co-chairs (Robert Lim, John Marks, and Liane Feldman) are already at work to make this the most exciting SAGES meeting ever. I am confident it will be fun. Mark your calendars!

What do you consider to likely be your biggest challenge in the position?
Dr. Jones: The ASMBS Essentials App is an online educational program that seeks to teach all who care for patients of size. Log on to Essentials.ASMBS.org and register for free as a physician, nurse or dietician. After completing a pretest, you work through several modules (Preoperative Assessment, Intraoperative Considerations, Perioperative Care, Outcomes, etc) before taking a post-test. CME and CEU credit is optional for an additional fee. I started the Essentials App with my wife, anesthesiologist Dr. Stephanie Jones, in Boston a decade ago. We were sponsored by the Harvard hospital malpractice carrier, CRICO-RMF. A few years ago, we took the project to ASMBS to update and rerelease, and it’s been widely adopted.

What are some of the most promising technologies on the horizon in surgery today?
Dr. Jones: Sleeve gastrectomy has become the platform of bariatric surgery worldwide and will continue to grow. I foresee that 80% of bariatric procedures will become sleeve gastrectomies.

Colleen: What is the biggest challenge for bariatric surgeons today and how does ASMBS meet that challenge?
Dr. Jones: There are many exciting new devices and procedures. I serve as an advisor for Allurion and The Medicines Company. Eight years ago, two third-year medical students rotated on my bariatric surgery service. Convinced that they could provide a safer operation than the laparoscopic gastric bypass, they took a leave from Harvard Medical School and founded Allurion. The Allurion intragastric balloon does not require endoscopy for insertion or removal and was recognized by SAGES as the best emerging technology last year. Also, Drs. Phil Schauer and John Morton lead a research effort into a device to self-administer fentanyl after bariatric surgery. This technology by IONSYS is very interesting as a new concept in better and safer pain control.

Can you touch on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)?
Dr. Jones: A decade ago, the ASMBS and ACS set up separate accreditation processes with the SRC and BSCN, respectively. I was part of the ACS BSCN. A few years ago, the ASMBS and ACS joined to establish the MBSAQIP. Dr. David Provost and I now serve as co-chairs of the Verification Committee. Today we have over 900 accredited centers that submit outcome data on 100% of bariatric operations. MBSAQIP centers assure facility infrastructure, personnel, sensitivity training, oversight, and quality initiatives.

What are your thoughts on social media surgeon groups?
Dr. Jones: Social media is a game changer. Today there are active Facebook sites for hernia surgeons (by Brian Jacobs) and for robotic surgery (by Yusef Kudsi). SAGES is building on their expertise to develop social media sites for hernia, foregut, biliary, colorectal, bariatric, acute care, endoscopy, and robotic surgery as part of the SAGES Masters Program. Surgeons will be able to submit video clips and obtain feedback using crowdsourcing.

What do you do for fun?
Dr. Jones: My wife and I like to travel abroad, except during the spring, when I try to make as many of my daughters’ lacrosse games as possible. This year, we did block out a few days to join Phil Schauer’s MISS meeting in Las Vegas, and have an excuse to play a few slots after the scientific program!

Can you comment on the impact of the new diabetes surgery guidelines?
Dr. Jones: It makes sense to me that as operations get safer and safer, that we reassess the risk-benefit tradeoff for surgical versus medical therapy. For type 2 diabetes, the International Diabetes Summit determined that a lower BMI threshold for weight loss surgery was appropriate (Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations. Diabetes Care. 2016 Jun;39(6):861-77). Despite the success of placing diabetes into remission after weight loss surgery, most third party payers have been reluctant to embrace the new lower BMI standards. Meanwhile many patients will continue to inject insulin and suffer complications of diabetes.

What is your view of the new endoscopic procedures for weight loss?
Dr. Jones: More and more procedures can be done through an endoscope in skilled hands, and I strongly encourage my bariatric fellows to spend time with the GI endoscopist. The endoscopist can clip shut a fistula, tighten a gastrojejunostomy, shrink the gastric pouch, and mimic gastric bypass and sleeve operations. Endoscopy is needed for placement of most intragastric balloons and the endolumenal sleeve. However, until we have randomized, controlled long-term studies comparing endoscopic procedures to laparoscopic counterparts, I remain a bit skeptical.

How would you characterize the importance of training and education in bariatric surgery to improve outcomes?
Dr. Jones: Over the last 20 years, bariatric surgery training has evolved into a respected specialty. When I first joined ASBS, a surgeon had to be preceptored (observed) doing 8 gastric bypass operations. In the era of laparoscopy, we had weekend courses with pigs, then one-week mini-fellowships, and then finally one-year fellowships. During the year, fellows learn more than just the steps of an operation; they learn about clinical care pathways, MBSAQIP accreditation standards, and promoting quality initiatives. Today we have just about replaced the animal vivarium and cadaver lab with virtual reality and the simulation center.

What is your opinion on how to expand insurance coverage for bariatric surgery based on scientific evidence?
Dr. Jones: More than scientific evidence, we need to demonstrate the cost-benefit advantages of early treatment. As patient advocates, we need to make sure that metabolic and weight loss is a universally covered benefit in all health insurance plans. This will require physicians and patients advocating in the political arena.


Suggested Readings:
Article: POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia. Miller HJ, Neupane R, Fayezizadeh M, Majumder A, Marks JM. Surg Endosc. 2016 Aug 17. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/27534662

Dr. Prabhu: This is an interesting article because it examines the cost-effectiveness of POEM, which is a relatively new procedure for achalasia. This is a very important aspect of care that is frequently ignored when new techniques or technologies are unveiled.

Article: Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation. Rebibo L, Bartoli E, Dhahri A, et al. Surg Obes Rel Dis. 2016;12(1):84-93. https://www.ncbi.nlm.nih.gov/pubmed/26070397

Dr. Brolin: Gastric leak is the most feared and challenging postoperative complication of laparoscopic sleeve gastrectomy. The authors reviewed their experience in treatment of 86 patients who developed leaks after sleeve gastrectomy. Endoscopic stenting was employed in 90% of cases. Operative treatment was utilized in 65%, usually within the first few postoperative days. Operative treatment alone was usually unsuccessful. Median healing time was 84 days; 20% of leaks persisted after 120 days. Operations performed for leaks after 120 days usually failed. A large persistent gastric fundus was a factor associated with refractory healing. This experience suggests that early aggressive multimodality treatment should be undertaken for leaks associated with sleeve gastrectomy in order to achieve healing.

Article: Adoption of robotic technology for treating colorectal cancer. Schootman M, Hendren S, Ratnapradipa K, Stringer KL, Davidson N, et al. Dis Colon Rectum 2016;59(11):1011-1018. https://www.ncbi.nlm.nih.gov/pubmed/27749475

Dr. Gorgun: Debate exists regarding the role of robotic assisted surgery in colorectal cancer. Robotic-assisted surgery has been promoted as a strategy to increase the availability of minimally invasive surgery. The study included 2010 and 2012 American Hospital Association surveys, as well as a Nationwide Inpatient Sample. Study results conclude that robotic-assisted surgery uptake remains low for colon cancer but higher for rectal cancer surgery, suggesting a more thoughtful adoption of robotic-assisted surgery for colorectal cancer by focusing its use on more technically challenging cases. Innovation in surgery will continue to evolve, as will scientific evidence of the benefit of such innovations. Robotic rectal surgery may offer advantages in the treatment of selected patients with rectal cancer despite limitations of cost and probable prolonged operative time, which could arguably improve with competition in the market and learning.

Article: Hand-assisted laparoscopic versus standard laparoscopic colectomy: are outcomes and operative time different? J Gastrointest Surg. 2016 Nov;20(11):1854-1860. Gilmore BF, Sun Z, Ong C, Migaly J, et al. https://www.ncbi.nlm.nih.gov/pubmed/27456018

Dr. Wexner: The current robotic platform has consistently failed to show any benefit as compared to laparoscopic colectomy. The consistent findings have been similar outcomes between laparoscopic and robotic colectomy relative to both short-term morbidity and mortality outcomes and short-term surrogate oncologic outcomes, such as circumferential resection margins, distal margins, quality of total mesorectal excision, anastomotic leak rates, and numbers of lymph nodes. This consistent failure of the current iteration of the robotic platform to offer any statistically significant benefit comes at very high prices of increased resource utilization due to increased operative time and increased cost. The most recent further proof of this paradigm was presented in the Journal of Gastrointestinal Surgery article. Dr. Migaly and his team used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. They evaluated short-term perioperative outcomes in a 1:1 propensity-matched analysis and also performed a subset analysis in patients who underwent segmental resection. Almost 16,000 patients underwent assessment, 498 of whom (3.1%) had undergone colectomy by the current robotic platform. After propensity matching, there were no differences between robotic and laparoscopic colectomy relative to morbidity or mortality. However, the operative times were significantly higher when the robotic platform was employed (196 vs. 166 min, p<0.001). Furthermore when the authors analyzed a subset of segmental resections, the operative time still remained longer at 190 versus 153 minutes (p<0.001). Based upon the failure of the robotic platform to deliver any benefit in morbidity, the authors offer several conclusions, including "the use of this technology in straightforward colectomies may not be financially justifiable." In particular, they write: "The similar clinical outcomes do not justify the increased operative time and hospital costs associated with robotic assisted colectomy." Given the current cost constraint climate, we face a perplexing dilemma wherein many surgeons seem eager to incur higher cost to offer similar outcomes to their patients.

Article: Laparoscopic Roux-en-Y gastric bypass for failed gastric banding: outcomes in 642 patients. Fournier P, Gero D, Dayer-Jankechova A, Allemann P, Demartines N, Marmuse JP, Suter M. SOARD 2016;12(2):231-239. https://www.ncbi.nlm.nih.gov/pubmed/26077700

Dr. Felix: Laparoscopic Roux-en-Y gastric bypass after failed gastric banding has become fairly well accepted to revise the original procedure for complications of banding and weight loss failure. The timing of this second operation is still hotly debated. Some European studies have suggested that the revision be done in stages, while in the US the majority of surgeons perform a single-staged procedure. This French and Swiss 14-year study appears to be more in line with the American approach. The authors, however, point out that the study was not randomized and that the decision to do a one- or two-staged procedure was biased by the surgeon’s discretion.

Article: Bariatric surgery in women of childbearing age, timing between an operation and birth, and associated perinatal complications. Parent B, Martopullo I, Weiss NS, Khandelwal S, Fay EE, Rowhani-Rahbar A. JAMA Surg. 2016 Oct 19. (Epub ahead of print) https://www.ncbi.nlm.nih.gov/pubmed/27760265

Dr. Kothari: Based on the results of this cohort study, the authors concluded that women of child-bearing age who had prior bariatric surgery had infants with higher risks of prematurity, small for gestational age status, higher neonatal intensive care unit admission rates, and lower Apgar scores compared to a control group. This was particularly evident among mothers who became pregnant in less than two years from the time of their bariatric surgical procedure. Perinatal risks were similar between the control group and post-bariatric surgery group for pregnancies at postoperative year two and later. This is important, as perhaps our traditional recommendation for women of child-bearing age to avoid pregnancy in the first 12 to 18 months after surgery during the rapid weight loss phase should be extended to 2 or 3 years during our informed consent process with prospective bariatric surgery patients. The strengths of this study lie in its large sample size from a statewide database and rigorous statistical analysis to determine the confidence intervals. However, the results need to be interpreted with caution as body mass index (BMI) values were missing for 25% of the patients in both cohorts, and the authors "filled in the gaps" in the data with statistical imputation. Also, the authors were unable to break down the results by various bariatric surgical procedures; therefore, it is unknown if any one bariatric surgical procedure is associated with increased perinatal risks compared to another, as only aggregate data were reported. Finally, this study does not consider the potential perinatal risks if the mothers had not undergone bariatric surgery. It is well known that obesity during pregnancy is associated with significant morbidity, including macrosomia and gestational diabetes. An analysis of mothers who did not undergo bariatric surgery but had BMIs similar to the preoperative BMIs of patients undergoing bariatric surgery would be beneficial in the future. Clearly this is an opportunity for further research and the American Society for Metabolic and Bariatric Surgery (ASMBS), the American Society for Reproductive Medicine, and the American College of Obstetrics and Gynecologists will be working together on future collaborative projects.
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Article: Comparison of Stretta procedure and toupet fundoplication for gastroesophageal reflux disease-related extra-esophageal symptoms. Yan C, Liang WT, Wang ZG, Hu ZW, Wu JM, Zhang C, Chen MP. World J Gastroenterol. 2015 Dec 7;21(45):12882-7. https://www.ncbi.nlm.nih.gov/pubmed/26668513

Dr. Kurian: This is an interesting finding lending credence to the effectiveness of Stretta for GERD. It is interesting that the study group that underwent laparoscopic toupet fundoplication had better quality of life.

Article: One-and ten-year outcome of laparoscopic anterior 120° versus total fundoplication: a double-blind, randomized multicenter study. Djerf P, Montgomery A, Hallerbäck B, Hâkansson H, Johnsson F. Surgical Endosc 2016;30(1):168-177. https://www.ncbi.nlm.nih.gov/m/pubmed/25829064

Dr. Richards: This is a long-term follow-up on patients with mild to moderate GERD who underwent either partial 1200 anterior fundoplication or 3600 Nissen fundoplication. The authors found more patients who could belch and vomit in the partial fundoplication group compared to the Nissen group. Both procedures offered good long-term control of reflux symptoms and both had very modest post fundoplication symptoms of dysphagia. The authors suggest the anterior partial fundoplication should be considered as an alternative to Nissen fundoplication in the treatment of mild-moderate GERD.

Hernia 2
Article: SAGES guidelines for laparoscopic ventral hernia repair. Earle D, Roth JS, Saber A, Haggerty S, Bradley JF, Fanelli R, Price R, Richardson WS, Stefanidis D; SAGES Guidelines Committee. Surg Endosc (216) 30:3163-3183 and editorial by Todd Heniford. Surg Endosc 2016;30:3161-3162. https://www.ncbi.nlm.nih.gov/pubmed/27405477

Dr. Felix: I am not a big fan of guidelines, but everyone should read these guidelines. The committee has done an outstanding job of looking at a very confusing field of surgery. They have reviewed all the pertinent literature and been very critical in their analysis of these studies. Not everyone will be in agreement with each of the 31 guidelines, but there is no question that a great deal of work and thought went into their production. In addition, the accompanying editorial by Todd Heniford makes some valid criticisms that should be reviewed after reading the guidelines.

Article: Location of recurrent groin hernias at TEP after Lichtenstein repair: a study based on the Swedish Hernia Register. Bringman S, Holmberg H, Österberg J Hernia. 2016;20(3):387-91. https://www.ncbi.nlm.nih.gov/pubmed/27094763

Dr. Towfigh: Interesting paper that is describing the history of recurrent inguinal hernias. I was always taught that it is important to get excellent medial mesh coverage during open inguinal hernia repair, even for indirect hernia repairs, because when recurrences happen, it's a direct recurrence. Seems not to be entirely accurate. The Swedish Hernia database was perused over a span of 20 years! Laparoscopic repairs were performed after failure of open inguinal hernia repairs, and what the surgeons saw was very telling: if the original hernia was an indirect hernia, the recurrence was also indirect. Same with direct hernias: the hernia recurrence after open repair of a direct inguinal hernia is again direct. Interestingly also, direct hernias are more likely to present with a recurrence as an indirect hernia than vice versa. I would not have thought that.


Vol. 8 No. 7
The New MISS eNews!
Welcome to the November MISS E-News. This month, we feature an interview with Dr. Raul Rosenthal, a globally renowned surgeon and expert in sleeve gastrectomy who has just completed his term as President of the American Society for Metabolic and Bariatric Surgery (ASMBS). In this short interview, we cover Dr. Rosenthal’s term and its challenges, the state of sleeve gastrectomy and fellowship developments, challenges for bariatric surgeons today, and some words on his mentors. In Suggested Readings, some new contributors, including Flavia Soto, Natan Zundel, Shirin Towfigh, and Edward Felix, share recommendations of critical and timely publications and those articles’ essential takeaways. Enjoy this issue and please visit Minimally Invasive Surgery Symposium for more information on the upcoming 2017 Minimally Invasive Surgery Symposium!

—Colleen Hutchinson

An Interview with Raul Rosenthal, MD
I’m happy to conduct this ASMBS President’s interview with you, having worked with you for 15 years and being able to call you my mentor for all of them. It has been enjoyable to watch you advance to this position of President. I am proud of your having achieved the milestone of serving as President, and I know how much time you continue to put into many other volunteer endeavors as you simultaneously gave maximum effort to this position over the last year. I really don’t know how you do it all!

Colleen: What are you most proud of accomplishing over the past year as the 30th ASMBS President?
Dr. Rosenthal: Many things to be proud of... First and foremost I am proud to lead ASMBS together with an unbelievable group of board members. They made my job an easy one. Second, I am proud to have the opportunity to highlight some of ASMBS’s superstar members that have delivered incredible projects, including Stephanie and Dan Jones’ development of the Essentials App, Cori McBride’s work on the Milestones-based fellowship training curriculum, and Dana Telem’s efforts on the ASMBS laparoscopic sleeve gastrectomy Care Pathway development. This year we also expanded our Executive Council, added 7 new committees, and are currently working on 88 projects.

Colleen: What was an unexpected challenge?
Dr. Rosenthal: Dr. Sugerman’s accident was probably the most difficult situation we had to face as a society. We are glad he is alive and recovering.

Colleen: In 2012, I interviewed Jaime Ponce, who was incoming ASMBS President. In that article, one topic discussed was whether sleeve should be covered by CMS. Now sleeve gastrectomy has become the most popular bariatric procedure in the US. Given this trajectory, what do you foresee on the horizon for sleeve gastrectomy in the next few years?
Dr. Rosenthal: Sleeve gastrectomy has become the platform of bariatric surgery worldwide and will continue to grow. I foresee that 80% of bariatric procedures will become sleeve gastrectomies.

Colleen: What is the biggest challenge for bariatric surgeons today and how does ASMBS meet that challenge?
Dr. Rosenthal: The low number of patients that choose bariatric surgery as the best treatment modality compared to the affected population continues to be our main challenge. Fear and denial are the two most important reasons for this, and we need to figure out how can we relate to these people that bariatric surgery is one of the safest surgical approaches today.

Colleen: As President of the Fellowship Council, do you have any comment on fellowship training development?
Dr. Rosenthal: Yes, I can relate how critical ASMBS has been to paving the road for other surgical fellowship programs to adjust to the new training models. We currently have a nationwide pilot project in conjunction with the ABS that is exploring a new training curriculum that was developed by the ASMBS Training Committee.

Colleen: Who are your mentors and why?
Dr. Rosenthal: My journey in surgery has been a wonderful one, thanks to a diversity of mentors. In Argentina, Aldo Trossero MD, who taught me that in order to stay a good surgeon, I should always "try to do the surgery of today better than the one from yesterday, regardless of its complexity." Additonal mentors Ewald Marz, MD, and Herrman Bockhorn, MD, were master technicians and preached that "To trust is good, but to check is better." Finally, there is Ed Phillips, MD, a master surgeon who opened the doors of America to me, and Steven Wexner, MD, a friend, mentor and role model who has made my dreams and journey to the top become a reality.


Suggested Readings:
Article: Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: A systematic review and meta-analysis. Oor J, Roks DJ, Untu C, Hazebroek E. Am J Surg. 2016 Jan;211(1):250-67.

Natan Zundel: GERD after LSG has recently become a very hot topic. This paper reviewed publications examining GERD and LSG, in search of answers regarding the true incidence of reflux after the procedure. After study of the final 33 papers related to the issue in question, authors drew the conclusion that the effect of LSG on the prevalence of GERD remains unanswered. Careful study of preoperative GERD, adequate surgical technique, and more prospective data are needed to address this problem and advance discussions beyond anecdotal.

Video Presentation: Tips and tricks in diaphragmatic hernia repair. Amiki Szold, MD, FACS.

Dr. Kurian: Dr. Szold originally posted a 14-minute You Tube video in the SAGES Foregut online forum that provides an overview of a new way of looking at antireflux. It is a beautiful video and overview, and Dr. Szold makes excellent points in this piece.

Article: Personalized indirect calorimeter for energy expenditure (EE) measurement. Xian X, Quach A, Bridgeman D, Tsow F, Erica Forzani E, Tao N. Glob J Obes Diabetes Metab Syndr 2015;2(1): 004-008.

Dr. Soto: Obesity is not a disease of the ins and outs; it is a metabolic and multifactorial condition. The Breezing is a portable wireless, Bluetooth technology device that measures resting energy expenditure (REE) and qualitative respiratory quotient (RQ), using a sensor cartridge and flow meter to determine rate of consumed oxygen and produced carbon dioxide in the breath. The data obtained in the mobile device is processed and will determine energy expenditure (EE) from the measurement of VO2 and VCO2. This paper reviews this device compared with the Douglas bag method, the gold standard for EE measurement. The device can potentially replace other indirect methods used for basal metabolic rate (BMR) due to its practicality and accuracy, and aid in nutritional plans for pre- and postoperative weight loss, and cases of plateau.

Article: Effects of various gastrointestinal procedures on Beta–cell function in obesity and type 2 diabetes. Malin SK, Kashyap SR. Surg Obes Relat Dis. 2016 Jul;12(6):1213-9.

Dr. Lo Menzo: The July special issue of Surgery for Obesity and Related Diseases was dedicated to obesity and diabetes. Among the many interesting articles, Malin et al. gave us a great overview of the complex relationship between Beta–cell function, enteroendocrine pathways, gut microbiota, circulating bile, adipose-derived factors and diabetes resolution. Although none of the science described in the article is new, I found this work clear and concise, so the article can be use as a quick reference.

Article: A pre-clinical animal study of combined intragastric balloon and duodenal-jejunal bypass sleeve for obesity and metabolic disease. Ghoz H, Acosta A, Topazian M, et al. Gastroenterology. 2016;150(4):S231–S232.

Dr. Galvao Neto: Bariatric endoscopists seek experimental data on the understanding of how bariatric surgery works, in terms of how the combination of restriction and metabolic changes intersect endolumenally.

Article: Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Bechara R, Onimaru M, Ikeda H, Inoue H. Gastrointest Endosc. 2016 Aug;84(2):330-8.

Dr. Adler: Per-oral endoscopic myotomy (POEM) was unheard of just a few years ago, but is now an area of intense clinical and research interest. The authors of this paper review their experience with 1,000 POEM procedures and share some lessons learned as well as some thoughts on where the practice of POEM is going with regard to the treatment of achalasia.
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Article: Ventral hernia management: expert consensus guided by systematic review. Liang MK , Holihan JL , Itani K , et al. Annals of Surgery 2016 Mar 15. [Epub ahead of print]

Dr. Towfigh: There are so many studies evaluating repair of ventral hernias and their associated outcomes. So what are the best practices for this population? Who should be offered repair? When should you absolutely consider mesh? This article nicely summarizes areas where there is little to no debate, as well as dicey topics where we cannot even achieve expert consensus. Interestingly, even with Grade A evidence, experts may not practice what they preach. In summary: reduce risk factors for failure prior to a hernia repair (e.g., nicotine use, glucose control [HbA1c 8%+], obesity [BMI 40+]) and use mesh if hernia is 2 cm or greater. Watchful waiting may be acceptable in poor candidates.

Article: Laparoscopic ventral hernia repair with primary fascial closure versus bridged prepare: a risk-adjusted comparative study. Wennergren E, Askenasy E, Greenberg J, et al. Surg Endosc (2016) 30:3231-3238.

Dr. Felix: There has been recent interest in primary fascial closure of ventral hernia defects when performing IPOM laparoscopic hernia repair. On social media there is no question that the bias has shifted toward closure of defects before performing a laparoscopic IPOM procedure. Whether this is based on data or just a clinical perception of improved outcomes is now hotly argued in online forums. Although this article is a retrospective review, it is probably the first to look at outcomes after bridged and primarily closed defects following laparoscopic IPOM. The results of the study suggest that there is no difference in the outcomes that were measured. These outcomes included recurrence, seroma, and surgical site infection. The study, however, did not really evaluate patient outcomes in terms of pain function as basis and overall satisfaction. Anyone interested in this topic needs to review this article, whether they agree or disagree with its findings.

Article: Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: The first results from the randomized controlled trial DILALA. Angenete E, Thornell A, Burcharth J, et al. Ann Surg. 2016 Jan;263(1):117-22.

Dr. Wexner: Laparoscopic lavage as the treatment for Hinchey III diverticulitis (purulent peritonitis with colonic inflammation) has been an acceptable alternative for the last several years. Many surgeons have expressed reluctance to use the technique because of absence of a randomized controlled trial demonstrating its safety. In this Annals article, authors published the results of the long awaited DIverticulitis-LAparoscopic LAvage versus resection (Hartmann procedure) for acute diverticulitis with peritonitis (DILALA). Nine surgical departments in Sweden and Denmark enrolled 83 patients between February 2010 and February 2014. Patients with documented Hinchey III diverticulitis were eligible for randomization. Ultimately 39 patients underwent laparoscopic lavage whereas 36 patients underwent a Hartmann’s procedure. The publication describes the methodology within each of the interventions. The groups were well matched for blood cell count, C reactive protein level, preoperative body temperature abdominal examination findings, CT findings, and the length of time between the decision to operate and surgery. Laparoscopic lavage was much more quickly performed than was the laparoscopic Hartmann’s procedure. Most of the other variables were similar between the groups except for the fact that the colonic perforation was visible in only 2 of the 38 patients who underwent laparoscopic lavage (5.2%) as compared to 18 of the 36 patients who underwent a Hartmann’s procedure (50%). The authors concluded that "laparoscopic lavage in Hinchey III perforated diverticulitis was feasible and in the short term as safe as the Hartmann’s procedure." However, they also end on a cautionary note that "we suggest that widespread implementation of the technique should await long-term results from the ongoing randomized trials". I completely concur and in part feel that this ten-fold difference in the incidence of visible colonic perforation identified during surgery may have imbalanced the trial to such a degree as to unfortunately render these many years of hard work from 9 renown expert centers less clinically relevant than I had hoped. Nonetheless, the investigators and authors are to be congratulated as their study is the largest published randomized controlled trial in which laparoscopic lavage has been compared with the Hartmann’s procedure for treatment of Hinchey III diverticulitis.

Article: Minimally invasive versus open low anterior resection: equivalent survival in a national analysis of 14,033 patients with rectal cancer. Sun Z, Kim J, Adam MA, Nussbaum DP, et al. Ann Surg. 2016 Jun;263(6):1152-8.

Dr. Wexner: There has been much debate about the optimal surgical approach for total mesorectal excision (TME) and restorative anastomosis for patients with rectal cancer. This article details results of 14,033 patients whose data were registered in the national cancer database. Authors performed numerous high quality data analyses. In conclusion, authors noted that their "findings support the ongoing adoption of minimally invasive techniques for rectal adenocarcinoma." Based upon this well designed powerful analysis, I concur with their findings. Laparoscopy does offer at least equivalent and, in many studies, superior oncologic outcomes (Boutros et al) as compared to laparotomy. As I have noted previously, the robotic minimally invasive approach fails to demonstrate any significant benefit as compared to laparoscopy. Therefore, considering all of these data, and given the global short-term and long-term advantages of laparoscopy, such as decreased pain and adhesions, laparoscopic low anterior resection should be the preferred method of treatment of rectal carcinoma.


Vol. 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.


Vol. 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.

Vol. 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.
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