Richard Mark Kirkner

BALTIMORE – Neural networks are the building blocks of machine learning and artificial intelligence, and researchers from the University of Minnesota have identified a panel of “simple, readily known” preoperative patient factors that they fed into an artificial neural network model that can be predictive of 30-day outcomes after laparoscopic sleeve gastrectomy, one of the researchers reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“The biggest limitation to using neural networks clinically is the fact that they’re algorithmic complex,” said Eric S. Wise, MD, of the University of Minnesota, Minneapolis, in presenting the research. “There is an underlying algorithm that’s developed, but it’s very difficult to understand.” He called it “a black box problem.”

Nonetheless, the researchers drew upon 101,721 laparoscopic sleeve gastrectomy cases from the 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database to extract factors that were associated with postoperative complications. “More pertinently, we wanted to optimize predictability of a panel of readily obtainable, easily qualifiable preoperative factors and maximize the variants that are contained within those variables to predict the outcome of 30-day morbidity and mortality,” Dr. Wise said.

Essentially, neural networks recognize patterns through a machine-learning process in a manner modeled on the human brain. As Dr. Wise explained, they first emerged in the 1960s to simulate the human brain’s psychological-neurologic systems.

Through bivariate and multivariate analyses, the research identified eight preoperative variables strongly associated with the 30-day endpoints. After univariate analysis, seven of those variables were statistically significant: older age (P = .03), nonwhite race, higher initial body mass index, severe hypertension, history of diabetes, nonindependent functional status, and previous foregut/bariatric surgery (all P less than .001). “Gender was the only factor that was not predictive,” Dr. Wise said.

The factors held up under logistic regression modeling. “We were able to use a traditional logistic regression model that came up with a reasonable area under the curve of 0.572,” he said. Using artificial neural network analysis, the training set, which comprised 80% of patients, was more accurate than logistic regression, with an area under the curve of 0.582.

One limitation was that this was a “small study,” Dr. Wise said, influenced by selection bias inherent in any retrospective data selection. Other major factors that may exist were not considered.

However, he noted, “in the past we’ve had some success translating neural networks into something that’s clinically useful.” His group at Vanderbilt University published a report of artificial neural network modeling to identify five factors predictive of weight loss after Roux-en-Y gastric bypass 2 years ago (Surg Endosc. 2016;30:480-8). “There are ways to translate neural networks clinically,” Dr. Wise said.

Dr. Wise had no financial relationships to disclose.

SOURCE: Wise ES et al. SAGES 2019, Abstract S053.

BALTIMORE – Neural networks are the building blocks of machine learning and artificial intelligence, and researchers from the University of Minnesota have identified a panel of “simple, readily known” preoperative patient factors that they fed into an artificial neural network model that can be predictive of 30-day outcomes after laparoscopic sleeve gastrectomy, one of the researchers reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“The biggest limitation to using neural networks clinically is the fact that they’re algorithmic complex,” said Eric S. Wise, MD, of the University of Minnesota, Minneapolis, in presenting the research. “There is an underlying algorithm that’s developed, but it’s very difficult to understand.” He called it “a black box problem.”

Nonetheless, the researchers drew upon 101,721 laparoscopic sleeve gastrectomy cases from the 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database to extract factors that were associated with postoperative complications. “More pertinently, we wanted to optimize predictability of a panel of readily obtainable, easily qualifiable preoperative factors and maximize the variants that are contained within those variables to predict the outcome of 30-day morbidity and mortality,” Dr. Wise said.

Essentially, neural networks recognize patterns through a machine-learning process in a manner modeled on the human brain. As Dr. Wise explained, they first emerged in the 1960s to simulate the human brain’s psychological-neurologic systems.

Through bivariate and multivariate analyses, the research identified eight preoperative variables strongly associated with the 30-day endpoints. After univariate analysis, seven of those variables were statistically significant: older age (P = .03), nonwhite race, higher initial body mass index, severe hypertension, history of diabetes, nonindependent functional status, and previous foregut/bariatric surgery (all P less than .001). “Gender was the only factor that was not predictive,” Dr. Wise said.

The factors held up under logistic regression modeling. “We were able to use a traditional logistic regression model that came up with a reasonable area under the curve of 0.572,” he said. Using artificial neural network analysis, the training set, which comprised 80% of patients, was more accurate than logistic regression, with an area under the curve of 0.582.

One limitation was that this was a “small study,” Dr. Wise said, influenced by selection bias inherent in any retrospective data selection. Other major factors that may exist were not considered.

However, he noted, “in the past we’ve had some success translating neural networks into something that’s clinically useful.” His group at Vanderbilt University published a report of artificial neural network modeling to identify five factors predictive of weight loss after Roux-en-Y gastric bypass 2 years ago (Surg Endosc. 2016;30:480-8). “There are ways to translate neural networks clinically,” Dr. Wise said.

Dr. Wise had no financial relationships to disclose.

SOURCE: Wise ES et al. SAGES 2019, Abstract S053.

BALTIMORE – Neural networks are the building blocks of machine learning and artificial intelligence, and researchers from the University of Minnesota have identified a panel of “simple, readily known” preoperative patient factors that they fed into an artificial neural network model that can be predictive of 30-day outcomes after laparoscopic sleeve gastrectomy, one of the researchers reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“The biggest limitation to using neural networks clinically is the fact that they’re algorithmic complex,” said Eric S. Wise, MD, of the University of Minnesota, Minneapolis, in presenting the research. “There is an underlying algorithm that’s developed, but it’s very difficult to understand.” He called it “a black box problem.”

Nonetheless, the researchers drew upon 101,721 laparoscopic sleeve gastrectomy cases from the 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database to extract factors that were associated with postoperative complications. “More pertinently, we wanted to optimize predictability of a panel of readily obtainable, easily qualifiable preoperative factors and maximize the variants that are contained within those variables to predict the outcome of 30-day morbidity and mortality,” Dr. Wise said.

Essentially, neural networks recognize patterns through a machine-learning process in a manner modeled on the human brain. As Dr. Wise explained, they first emerged in the 1960s to simulate the human brain’s psychological-neurologic systems.

Through bivariate and multivariate analyses, the research identified eight preoperative variables strongly associated with the 30-day endpoints. After univariate analysis, seven of those variables were statistically significant: older age (P = .03), nonwhite race, higher initial body mass index, severe hypertension, history of diabetes, nonindependent functional status, and previous foregut/bariatric surgery (all P less than .001). “Gender was the only factor that was not predictive,” Dr. Wise said.

The factors held up under logistic regression modeling. “We were able to use a traditional logistic regression model that came up with a reasonable area under the curve of 0.572,” he said. Using artificial neural network analysis, the training set, which comprised 80% of patients, was more accurate than logistic regression, with an area under the curve of 0.582.

One limitation was that this was a “small study,” Dr. Wise said, influenced by selection bias inherent in any retrospective data selection. Other major factors that may exist were not considered.

However, he noted, “in the past we’ve had some success translating neural networks into something that’s clinically useful.” His group at Vanderbilt University published a report of artificial neural network modeling to identify five factors predictive of weight loss after Roux-en-Y gastric bypass 2 years ago (Surg Endosc. 2016;30:480-8). “There are ways to translate neural networks clinically,” Dr. Wise said.

Dr. Wise had no financial relationships to disclose.

SOURCE: Wise ES et al. SAGES 2019, Abstract S053.

BALTIMORE – The upfront costs of laparoscopic magnetic sphincter augmentation are higher than those of laparoscopic Nissen fundoplication, but the cost differential can even out over time because the former procedure is associated with lower medical therapy costs after the procedure.

The finding comes from to a prospective observational study from the Allegheny Health Network in Pittsburgh, reported by Shahin Ayazi, MD, at the annual meeting of the American Society of Gastrointestinal Endoscopic Surgeons.

“Magnetic sphincter augmentation (MSA) results in comparable symptom control, proton-pump inhibitor (PPI) elimination rate, and GERD health-related quality of life and Reflux Symptom Index measures compared to values reported for laparoscopic Nissen fundoplication (LNF) in the literature,” said Dr. Ayazi of the University of Rochester (N.Y.). “Unlike reported values for LNF, the majority of patients after MSA were discharged on the same day of surgery.”

Dr. Ayazi reported on 180 patients who had MSA and 1,131 who had LNF over a 2-year period beginning in September 2015 at Allegheny Health, a network of eight hospitals and related facilities in western Pennsylvania and western New York State. The study analyzed Highmark claims data to calculate costs for 12 months before and after surgery in four categories: total procedure payer cost, payer costs of PPI, disease-related costs, and all medical costs.

Dr. Ayazi noted that many payers have been reluctant to cover the costs of MSA because the device costs around $5,000 on average. “There’s also a paucity of data in the literature in regard to the cost analysis of MSA in the management of reflux disease,” he said, adding that this is the first study that uses payer data to analyze the cost of antireflux surgery.

In this study, MSA costs slightly more up front than LNF ($13,522 vs. $13,388, respectively; P = .02). Per-member/per-month (PMPM) costs in the 12 months before their procedures were higher in the MSA group ($305 vs. $233). After surgery, these costs were significantly lower at $104 for MSA patients versus $126 for LNF patients, Dr. Ayazi said.

In the MSA group, 89% of patients were discharged on the same day as surgery, 90.7% said they were satisfied with the outcome, and 91.8% discontinued PPI therapy, Dr. Ayazi said.

He noted the claims data did not provide access to clinical data, Highmark did not provide information on the etiology of the costs differences, and the follow-up for cost analysis is relatively short-term.

During the discussion, Michel Gagner, MD, of Westmount, Quebec, warned against reading too much into the study because of its short duration and gave the example of experience with the laparoscopic adjustable gastric band. “The 10 years after, when you look at the reoperation, the removal, the conversions, some of the disasters in this area – all this needs to be added to the cost, and then when you looked at this, it was no longer cost effective. So I’m wondering if the same story could happen in the next 10 years. You may find that your conclusions are totally reversed.”

Peter Crookes, MD, of the University of Southern California, Los Angeles, challenged the study’s comparison of procedure cost, noting that the trend is toward same-day discharge after LNF, whereas study patients were hospitalized after LNF. Dr. Ayazi noted that the data presented reported procedure cost, not the hospital stay costs, because Highmark did not provide that data.

Lead researcher Blair Jobe, MD, director of the Esophageal and Lung Institute at Allegheny Health Network, added, “The higher initial cost of a LINX (Ethicon) procedure compared to a Nissen fundoplication is perceived as a drawback by insurers, which can make getting insurance approvals challenging. This study suggests that perception may be short sighted in that insurance plans can provide better care for their GERD patients at a similar cost to laparoscopic Nissen fundoplication when you factor in the greater reductions in medical costs after the procedure.”

Dr. Ayazi has no relevant financial relationships to disclose. Dr. Jobe reported he is a consultant for Ethicon.

SOURCE: Ayazi S et al. SAGES 2019, Session SS04.
 

BALTIMORE – The upfront costs of laparoscopic magnetic sphincter augmentation are higher than those of laparoscopic Nissen fundoplication, but the cost differential can even out over time because the former procedure is associated with lower medical therapy costs after the procedure.

The finding comes from to a prospective observational study from the Allegheny Health Network in Pittsburgh, reported by Shahin Ayazi, MD, at the annual meeting of the American Society of Gastrointestinal Endoscopic Surgeons.

“Magnetic sphincter augmentation (MSA) results in comparable symptom control, proton-pump inhibitor (PPI) elimination rate, and GERD health-related quality of life and Reflux Symptom Index measures compared to values reported for laparoscopic Nissen fundoplication (LNF) in the literature,” said Dr. Ayazi of the University of Rochester (N.Y.). “Unlike reported values for LNF, the majority of patients after MSA were discharged on the same day of surgery.”

Dr. Ayazi reported on 180 patients who had MSA and 1,131 who had LNF over a 2-year period beginning in September 2015 at Allegheny Health, a network of eight hospitals and related facilities in western Pennsylvania and western New York State. The study analyzed Highmark claims data to calculate costs for 12 months before and after surgery in four categories: total procedure payer cost, payer costs of PPI, disease-related costs, and all medical costs.

Dr. Ayazi noted that many payers have been reluctant to cover the costs of MSA because the device costs around $5,000 on average. “There’s also a paucity of data in the literature in regard to the cost analysis of MSA in the management of reflux disease,” he said, adding that this is the first study that uses payer data to analyze the cost of antireflux surgery.

In this study, MSA costs slightly more up front than LNF ($13,522 vs. $13,388, respectively; P = .02). Per-member/per-month (PMPM) costs in the 12 months before their procedures were higher in the MSA group ($305 vs. $233). After surgery, these costs were significantly lower at $104 for MSA patients versus $126 for LNF patients, Dr. Ayazi said.

In the MSA group, 89% of patients were discharged on the same day as surgery, 90.7% said they were satisfied with the outcome, and 91.8% discontinued PPI therapy, Dr. Ayazi said.

He noted the claims data did not provide access to clinical data, Highmark did not provide information on the etiology of the costs differences, and the follow-up for cost analysis is relatively short-term.

During the discussion, Michel Gagner, MD, of Westmount, Quebec, warned against reading too much into the study because of its short duration and gave the example of experience with the laparoscopic adjustable gastric band. “The 10 years after, when you look at the reoperation, the removal, the conversions, some of the disasters in this area – all this needs to be added to the cost, and then when you looked at this, it was no longer cost effective. So I’m wondering if the same story could happen in the next 10 years. You may find that your conclusions are totally reversed.”

Peter Crookes, MD, of the University of Southern California, Los Angeles, challenged the study’s comparison of procedure cost, noting that the trend is toward same-day discharge after LNF, whereas study patients were hospitalized after LNF. Dr. Ayazi noted that the data presented reported procedure cost, not the hospital stay costs, because Highmark did not provide that data.

Lead researcher Blair Jobe, MD, director of the Esophageal and Lung Institute at Allegheny Health Network, added, “The higher initial cost of a LINX (Ethicon) procedure compared to a Nissen fundoplication is perceived as a drawback by insurers, which can make getting insurance approvals challenging. This study suggests that perception may be short sighted in that insurance plans can provide better care for their GERD patients at a similar cost to laparoscopic Nissen fundoplication when you factor in the greater reductions in medical costs after the procedure.”

Dr. Ayazi has no relevant financial relationships to disclose. Dr. Jobe reported he is a consultant for Ethicon.

SOURCE: Ayazi S et al. SAGES 2019, Session SS04.
 

BALTIMORE – The upfront costs of laparoscopic magnetic sphincter augmentation are higher than those of laparoscopic Nissen fundoplication, but the cost differential can even out over time because the former procedure is associated with lower medical therapy costs after the procedure.

The finding comes from to a prospective observational study from the Allegheny Health Network in Pittsburgh, reported by Shahin Ayazi, MD, at the annual meeting of the American Society of Gastrointestinal Endoscopic Surgeons.

“Magnetic sphincter augmentation (MSA) results in comparable symptom control, proton-pump inhibitor (PPI) elimination rate, and GERD health-related quality of life and Reflux Symptom Index measures compared to values reported for laparoscopic Nissen fundoplication (LNF) in the literature,” said Dr. Ayazi of the University of Rochester (N.Y.). “Unlike reported values for LNF, the majority of patients after MSA were discharged on the same day of surgery.”

Dr. Ayazi reported on 180 patients who had MSA and 1,131 who had LNF over a 2-year period beginning in September 2015 at Allegheny Health, a network of eight hospitals and related facilities in western Pennsylvania and western New York State. The study analyzed Highmark claims data to calculate costs for 12 months before and after surgery in four categories: total procedure payer cost, payer costs of PPI, disease-related costs, and all medical costs.

Dr. Ayazi noted that many payers have been reluctant to cover the costs of MSA because the device costs around $5,000 on average. “There’s also a paucity of data in the literature in regard to the cost analysis of MSA in the management of reflux disease,” he said, adding that this is the first study that uses payer data to analyze the cost of antireflux surgery.

In this study, MSA costs slightly more up front than LNF ($13,522 vs. $13,388, respectively; P = .02). Per-member/per-month (PMPM) costs in the 12 months before their procedures were higher in the MSA group ($305 vs. $233). After surgery, these costs were significantly lower at $104 for MSA patients versus $126 for LNF patients, Dr. Ayazi said.

In the MSA group, 89% of patients were discharged on the same day as surgery, 90.7% said they were satisfied with the outcome, and 91.8% discontinued PPI therapy, Dr. Ayazi said.

He noted the claims data did not provide access to clinical data, Highmark did not provide information on the etiology of the costs differences, and the follow-up for cost analysis is relatively short-term.

During the discussion, Michel Gagner, MD, of Westmount, Quebec, warned against reading too much into the study because of its short duration and gave the example of experience with the laparoscopic adjustable gastric band. “The 10 years after, when you look at the reoperation, the removal, the conversions, some of the disasters in this area – all this needs to be added to the cost, and then when you looked at this, it was no longer cost effective. So I’m wondering if the same story could happen in the next 10 years. You may find that your conclusions are totally reversed.”

Peter Crookes, MD, of the University of Southern California, Los Angeles, challenged the study’s comparison of procedure cost, noting that the trend is toward same-day discharge after LNF, whereas study patients were hospitalized after LNF. Dr. Ayazi noted that the data presented reported procedure cost, not the hospital stay costs, because Highmark did not provide that data.

Lead researcher Blair Jobe, MD, director of the Esophageal and Lung Institute at Allegheny Health Network, added, “The higher initial cost of a LINX (Ethicon) procedure compared to a Nissen fundoplication is perceived as a drawback by insurers, which can make getting insurance approvals challenging. This study suggests that perception may be short sighted in that insurance plans can provide better care for their GERD patients at a similar cost to laparoscopic Nissen fundoplication when you factor in the greater reductions in medical costs after the procedure.”

Dr. Ayazi has no relevant financial relationships to disclose. Dr. Jobe reported he is a consultant for Ethicon.

SOURCE: Ayazi S et al. SAGES 2019, Session SS04.
 

BALTIMORE – The Eckardt score has been established as a tool to evaluate outcomes of surgery for achalasia, but researchers have developed a report card that uses multiple variables that may provide a more accurate picture of surgical outcomes, according to results of study reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“The use of an accurate score to assess outcomes after achalasia surgery shows outstanding results,” said Ealaf Shemmeri, MD, of Swedish Medical Center in Seattle. “Using patient-reported symptoms, objective measures, and rates of reinterventions organized into a report card provides a more comprehensive and informative view.”

The Eckardt score evaluates four symptoms to evaluate outcomes of surgery to treat achalasia: weight loss, retrosternal pain, regurgitation, and dysphagia. “However, it does not address the other changes that can occur after myotomy, including the quality of swallowing and the onset of reflux disease,” she said. “Thus, there is a need for a more comprehensive assessment of quality after achalasia treatment.”

So the Swedish investigators set out to devise a report card that provides “a comprehensive and informative assessment” of surgical myotomy outcomes, she said. This involved a retrospective, single-center chart review of 185 patients who had surgical myotomy for primary achalasia from 2005 to 2017.

To determine patient-reported outcomes, the report card defines success as an Eckardt score below 3, Dakkak dysphagia score above 40, and GERD-HRQL (health-related quality of life) score below 10. The objective measures consisted of DeMeester (pH) score below 14.72, no column at 5 minutes on timed barium swallow, normalized integrated relaxation pressure less than 15 on manometry, and absence of esophagitis on endoscopy. For the third pillar of the report card, no reintervention was recorded as a success, Dr. Shemmeri said.

Regarding the etiology of achalasia in the study population, 42 had type 1, 109 had type 2, and 34 had type 3. A total of 71 patients had per oral endoscopic myotomy and 114 had Heller myotomy, 92 with Dor fundoplication and 20 with Toupet. Major perioperative complications included four per oral endoscopic myotomy patients who developed a leak requiring intervention. Six patients required return to the operating room for persistent dysphagia, Dr. Shemmeri said.

After the procedures, 93% of study patients reported an Eckardt score less than 3. However, only 45% have a Dakkak dysphagia score greater than 40 and 71% had a GERD-HRQL score less than 10, Dr. Shemmeri said. The objective measures told a similar story: Integrated relaxation pressure normalized in 80%, barium clearance was achieved in 61%, normal esophageal mucosa was recorded in 71%, “but pH testing was normal only 50% of the time,” Dr. Shemmeri said.

“The final success of not needing intervention is 79%,” she said. At this point in the study, 139 patients were available for follow-up. Among the 29 who needed reintervention, 19 had dilation below 20 mm Hg, 3 underwent pneumatic dilation, and 2 had botulinum toxin. Two patients required a redo myotomy, two had antireflux surgery, and one had an esophagectomy.

“When you only focus on a singular outcome, you can miss the whole story that occurs after myotomy,” Dr. Shemmeri said. “Providing a comprehensive tool gives you the ability to identify areas for improvement in your achalasia practice. Its simplicity allows it to be applied in various settings.” In the academic setting, it can be a tool for evaluating technologies and approaches for postmyotomy management. In hospitals and surgeons’ practices, it can aid in quality improvement, comparative outcomes research, and in evaluating operative approaches to myotomy.

The outcomes highlight the high prevalence of GERD, thus stressing the importance of pH testing after myotomy, Dr. Shemmeri said. Her study team recommends pH testing at 6-month follow-up because patients may not always self-report the extent of esophagitis present. Coauthor Brian Louie, MD, also of Swedish Medical Center, added during the discussion that ongoing follow-up of achalasia patients is necessary to address issues patients encounter with their swallowing over time.

Dr. Shemmeri had no relevant financial relationships to disclose. Dr. Louie reported relationships with Boston Scientific, ERBE, and Olympus.

SOURCE: Shemmeri E et al. SAGES 2019, Presentation S085.

BALTIMORE – The Eckardt score has been established as a tool to evaluate outcomes of surgery for achalasia, but researchers have developed a report card that uses multiple variables that may provide a more accurate picture of surgical outcomes, according to results of study reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“The use of an accurate score to assess outcomes after achalasia surgery shows outstanding results,” said Ealaf Shemmeri, MD, of Swedish Medical Center in Seattle. “Using patient-reported symptoms, objective measures, and rates of reinterventions organized into a report card provides a more comprehensive and informative view.”

The Eckardt score evaluates four symptoms to evaluate outcomes of surgery to treat achalasia: weight loss, retrosternal pain, regurgitation, and dysphagia. “However, it does not address the other changes that can occur after myotomy, including the quality of swallowing and the onset of reflux disease,” she said. “Thus, there is a need for a more comprehensive assessment of quality after achalasia treatment.”

So the Swedish investigators set out to devise a report card that provides “a comprehensive and informative assessment” of surgical myotomy outcomes, she said. This involved a retrospective, single-center chart review of 185 patients who had surgical myotomy for primary achalasia from 2005 to 2017.

To determine patient-reported outcomes, the report card defines success as an Eckardt score below 3, Dakkak dysphagia score above 40, and GERD-HRQL (health-related quality of life) score below 10. The objective measures consisted of DeMeester (pH) score below 14.72, no column at 5 minutes on timed barium swallow, normalized integrated relaxation pressure less than 15 on manometry, and absence of esophagitis on endoscopy. For the third pillar of the report card, no reintervention was recorded as a success, Dr. Shemmeri said.

Regarding the etiology of achalasia in the study population, 42 had type 1, 109 had type 2, and 34 had type 3. A total of 71 patients had per oral endoscopic myotomy and 114 had Heller myotomy, 92 with Dor fundoplication and 20 with Toupet. Major perioperative complications included four per oral endoscopic myotomy patients who developed a leak requiring intervention. Six patients required return to the operating room for persistent dysphagia, Dr. Shemmeri said.

After the procedures, 93% of study patients reported an Eckardt score less than 3. However, only 45% have a Dakkak dysphagia score greater than 40 and 71% had a GERD-HRQL score less than 10, Dr. Shemmeri said. The objective measures told a similar story: Integrated relaxation pressure normalized in 80%, barium clearance was achieved in 61%, normal esophageal mucosa was recorded in 71%, “but pH testing was normal only 50% of the time,” Dr. Shemmeri said.

“The final success of not needing intervention is 79%,” she said. At this point in the study, 139 patients were available for follow-up. Among the 29 who needed reintervention, 19 had dilation below 20 mm Hg, 3 underwent pneumatic dilation, and 2 had botulinum toxin. Two patients required a redo myotomy, two had antireflux surgery, and one had an esophagectomy.

“When you only focus on a singular outcome, you can miss the whole story that occurs after myotomy,” Dr. Shemmeri said. “Providing a comprehensive tool gives you the ability to identify areas for improvement in your achalasia practice. Its simplicity allows it to be applied in various settings.” In the academic setting, it can be a tool for evaluating technologies and approaches for postmyotomy management. In hospitals and surgeons’ practices, it can aid in quality improvement, comparative outcomes research, and in evaluating operative approaches to myotomy.

The outcomes highlight the high prevalence of GERD, thus stressing the importance of pH testing after myotomy, Dr. Shemmeri said. Her study team recommends pH testing at 6-month follow-up because patients may not always self-report the extent of esophagitis present. Coauthor Brian Louie, MD, also of Swedish Medical Center, added during the discussion that ongoing follow-up of achalasia patients is necessary to address issues patients encounter with their swallowing over time.

Dr. Shemmeri had no relevant financial relationships to disclose. Dr. Louie reported relationships with Boston Scientific, ERBE, and Olympus.

SOURCE: Shemmeri E et al. SAGES 2019, Presentation S085.

BALTIMORE – The Eckardt score has been established as a tool to evaluate outcomes of surgery for achalasia, but researchers have developed a report card that uses multiple variables that may provide a more accurate picture of surgical outcomes, according to results of study reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“The use of an accurate score to assess outcomes after achalasia surgery shows outstanding results,” said Ealaf Shemmeri, MD, of Swedish Medical Center in Seattle. “Using patient-reported symptoms, objective measures, and rates of reinterventions organized into a report card provides a more comprehensive and informative view.”

The Eckardt score evaluates four symptoms to evaluate outcomes of surgery to treat achalasia: weight loss, retrosternal pain, regurgitation, and dysphagia. “However, it does not address the other changes that can occur after myotomy, including the quality of swallowing and the onset of reflux disease,” she said. “Thus, there is a need for a more comprehensive assessment of quality after achalasia treatment.”

So the Swedish investigators set out to devise a report card that provides “a comprehensive and informative assessment” of surgical myotomy outcomes, she said. This involved a retrospective, single-center chart review of 185 patients who had surgical myotomy for primary achalasia from 2005 to 2017.

To determine patient-reported outcomes, the report card defines success as an Eckardt score below 3, Dakkak dysphagia score above 40, and GERD-HRQL (health-related quality of life) score below 10. The objective measures consisted of DeMeester (pH) score below 14.72, no column at 5 minutes on timed barium swallow, normalized integrated relaxation pressure less than 15 on manometry, and absence of esophagitis on endoscopy. For the third pillar of the report card, no reintervention was recorded as a success, Dr. Shemmeri said.

Regarding the etiology of achalasia in the study population, 42 had type 1, 109 had type 2, and 34 had type 3. A total of 71 patients had per oral endoscopic myotomy and 114 had Heller myotomy, 92 with Dor fundoplication and 20 with Toupet. Major perioperative complications included four per oral endoscopic myotomy patients who developed a leak requiring intervention. Six patients required return to the operating room for persistent dysphagia, Dr. Shemmeri said.

After the procedures, 93% of study patients reported an Eckardt score less than 3. However, only 45% have a Dakkak dysphagia score greater than 40 and 71% had a GERD-HRQL score less than 10, Dr. Shemmeri said. The objective measures told a similar story: Integrated relaxation pressure normalized in 80%, barium clearance was achieved in 61%, normal esophageal mucosa was recorded in 71%, “but pH testing was normal only 50% of the time,” Dr. Shemmeri said.

“The final success of not needing intervention is 79%,” she said. At this point in the study, 139 patients were available for follow-up. Among the 29 who needed reintervention, 19 had dilation below 20 mm Hg, 3 underwent pneumatic dilation, and 2 had botulinum toxin. Two patients required a redo myotomy, two had antireflux surgery, and one had an esophagectomy.

“When you only focus on a singular outcome, you can miss the whole story that occurs after myotomy,” Dr. Shemmeri said. “Providing a comprehensive tool gives you the ability to identify areas for improvement in your achalasia practice. Its simplicity allows it to be applied in various settings.” In the academic setting, it can be a tool for evaluating technologies and approaches for postmyotomy management. In hospitals and surgeons’ practices, it can aid in quality improvement, comparative outcomes research, and in evaluating operative approaches to myotomy.

The outcomes highlight the high prevalence of GERD, thus stressing the importance of pH testing after myotomy, Dr. Shemmeri said. Her study team recommends pH testing at 6-month follow-up because patients may not always self-report the extent of esophagitis present. Coauthor Brian Louie, MD, also of Swedish Medical Center, added during the discussion that ongoing follow-up of achalasia patients is necessary to address issues patients encounter with their swallowing over time.

Dr. Shemmeri had no relevant financial relationships to disclose. Dr. Louie reported relationships with Boston Scientific, ERBE, and Olympus.

SOURCE: Shemmeri E et al. SAGES 2019, Presentation S085.

BALTIMORE – While rates of surgical site infections after bariatric surgery have been reported in the low single digits, SSIs have continued to be a persistent complication.

Richard Kirkner/MDedge News

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons, researchers reported on two strategies to reduce SSI in bariatric surgery: a predictive tool that identifies risk factors for wound infection, allowing surgeons to employ protective measures before and during surgery, and a change in surgical practice leading to a 78% reduction in wound infection rates that resulted from a single-center study.

Jerry Dang, MD, of the University of Alberta, Edmonton, reported that the BariWound predictive tool designed to stratify patients into risk categories showed a high level of accuracy with an area under the curve of 0.73. Cynthia Weber, MD, of University Hospitals, Cleveland, reported that changing the method for performing circular-stapled gastrojejunostomy (GJ) from the transoral to the transabdominal approach along with more vigilant use of wound protection reduced wound infection rates from 6% to 1.3%.

Dr. Dang noted that SSI has been reported as the most common hospital-acquired complication in bariatric surgery, with reported rates of between 1% and 10%. A 2014 analysis of the American College of Surgeons National Surgical Quality Improvement Program database reported an SSI rate of 1.8% (Surg Endosc. 2014;28:3285-92). Although these rates are low, Dr. Dang explained that his group wanted to identify factors associated with SSI within 30 days of bariatric surgery. They analyzed outcomes data of 274,187 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who had bariatric surgery in 2015 and 2016 (196,608 by laparoscopic sleeve gastrectomy [SG] and 77,579 laparoscopic Roux-en-Y gastric bypass [RYGB]). Their analysis determined an incisional SSI rate of 0.47% (n = 1,291). “Incisional SSI rates were four times higher for laparoscopic RYGB: 1.04% vs. 0.25%,” Dr. Dang said.

On multivariable logistic regression, the adjusted odds ratio of SSI after RYGB vs. SG was 3.13 (P less than .001). Other significant risk factors were chronic steroid or immunosuppressant use (odds ratio, 1.75; P = .001), female sex (OR, 1.48; P less than .001) and history of gastroesophageal reflux disease (OR, 1.45; P less than .001). Other factors with a 21%-31% greater risk of SSI were white race (P = .002), history of diabetes (P less than .001), hypertension (P less than .001), obstructive sleep apnea (P = .001), and longer operation times (P less than .001). Each single-digit increase in body mass index increased risk by 3%, and older age actually had a protective effect for unknown reasons, Dr. Dang noted.

The BariWound tool assigns points to each risk factor. Each hour of operation time and each 10 kg/m² of weight carry a value of 1 point, with partial points allowed. RYGB equals 5 points, and chronic steroid/immunosuppressant use, 4 points. The tool assigns risk to four categories based on score and 30-day SSI rate:

• Low, less than 15 (1% risk of SSI).
• Moderate, 15-21.9 (1%-5%).
• High, 22-26.9 (5%-10%).
• Very high, greater than 27 (greater than 10%).

“The BariWound tool can help to inform clinical decision making so patients can know they’re at higher risk, and this could allow for us to target high-risk patients with preventive packages, such as the Cleveland Clinic Technique of wound protection, wound irrigation, and wound packing as a resource-saving measure,” Dr. Dang said. “Targeting high-risk populations can reduce cost and operating time.”

Richard Kirkner/MDedge NEws

Dr. Weber reported on her institution’s study of SSIs using two different methods for circular stapling of GJ that involved two different surgeons who performed 333 RYGB procedures from January 2016 to March 2018. Surgeon “A” had traditionally used the transoral technique without wound protection to insert the anvil of the stapler; surgeon “B” used wound protection and the transabdominal technique for stapler insertion. Wound protection involves draping of the stapler with sterile plastic.

“In a quarterly review, we detected a higher than expected wound complication rate of 6%,” Dr. Weber said. “Of particular concern was the development of five recent wound infection cases, which all occurred in the transoral group for a rate of 8.9% in that cohort.”

That left the quality team questioning the safety profile of the transoral technique, Dr. Weber said. “We wanted to know why and whether or not the main contributor to the development of a wound infection was the technique for the anvil introduction or was it the difference between surgeons using wound protection.”

Halfway through the study period, surgeon A made two modifications: He adopted the transabdominal technique for a subset of patients; and because of the surgeon’s comfort level and expertise with the transoral approach, he continued using that approach but added wound protection. Surgeon B continued with the transabdominal approach with wound protection. The share of transabdominal insertions in the study population increased from 69.2% before the change to 75% after. Demographics between the pre- and postchange patient populations were similar, as were the rates of revision surgery between the two groups.

“We noticed a significant reduction in total wound complications from 6% to 1.3%, and we noticed a complete elimination of surgical site infections after adding wound protection to the transoral technique,” Dr. Weber said.

Dr. Weber noted a number of limitations with the study: its retrospective nature; the lack of control for other intraoperative factors that contribute to SSIs; relatively low incidence of SSI; and surgeon’s choice to determine the technique of anvil insertion.

“We found that our quality improvement intervention was efficacious and decided that it was not the technique of anvil insertion, but it was the wound protection that was key to preventing wound infections, as we saw complete elimination after we added wound protection to the transoral technique,” Dr. Weber said. “Using proper precautions with the circular stapler and anastomosis can be done using either technique for anvil insertion. Overall self-assessment of outcomes leads to best practice.”

Dr. Dang had no financial relationships to disclose. Dr. Weber’s coauthor Leena Khatian, MD, MPH, disclosed relationships with Torax Medical, Medtronic, and Gore.

SOURCES: Weber C et al. SAGES 2109, Presentation S049; Dang J et al. SAGES 2019, Presentation S050.

BALTIMORE – While rates of surgical site infections after bariatric surgery have been reported in the low single digits, SSIs have continued to be a persistent complication.

Richard Kirkner/MDedge News

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons, researchers reported on two strategies to reduce SSI in bariatric surgery: a predictive tool that identifies risk factors for wound infection, allowing surgeons to employ protective measures before and during surgery, and a change in surgical practice leading to a 78% reduction in wound infection rates that resulted from a single-center study.

Jerry Dang, MD, of the University of Alberta, Edmonton, reported that the BariWound predictive tool designed to stratify patients into risk categories showed a high level of accuracy with an area under the curve of 0.73. Cynthia Weber, MD, of University Hospitals, Cleveland, reported that changing the method for performing circular-stapled gastrojejunostomy (GJ) from the transoral to the transabdominal approach along with more vigilant use of wound protection reduced wound infection rates from 6% to 1.3%.

Dr. Dang noted that SSI has been reported as the most common hospital-acquired complication in bariatric surgery, with reported rates of between 1% and 10%. A 2014 analysis of the American College of Surgeons National Surgical Quality Improvement Program database reported an SSI rate of 1.8% (Surg Endosc. 2014;28:3285-92). Although these rates are low, Dr. Dang explained that his group wanted to identify factors associated with SSI within 30 days of bariatric surgery. They analyzed outcomes data of 274,187 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who had bariatric surgery in 2015 and 2016 (196,608 by laparoscopic sleeve gastrectomy [SG] and 77,579 laparoscopic Roux-en-Y gastric bypass [RYGB]). Their analysis determined an incisional SSI rate of 0.47% (n = 1,291). “Incisional SSI rates were four times higher for laparoscopic RYGB: 1.04% vs. 0.25%,” Dr. Dang said.

On multivariable logistic regression, the adjusted odds ratio of SSI after RYGB vs. SG was 3.13 (P less than .001). Other significant risk factors were chronic steroid or immunosuppressant use (odds ratio, 1.75; P = .001), female sex (OR, 1.48; P less than .001) and history of gastroesophageal reflux disease (OR, 1.45; P less than .001). Other factors with a 21%-31% greater risk of SSI were white race (P = .002), history of diabetes (P less than .001), hypertension (P less than .001), obstructive sleep apnea (P = .001), and longer operation times (P less than .001). Each single-digit increase in body mass index increased risk by 3%, and older age actually had a protective effect for unknown reasons, Dr. Dang noted.

The BariWound tool assigns points to each risk factor. Each hour of operation time and each 10 kg/m² of weight carry a value of 1 point, with partial points allowed. RYGB equals 5 points, and chronic steroid/immunosuppressant use, 4 points. The tool assigns risk to four categories based on score and 30-day SSI rate:

• Low, less than 15 (1% risk of SSI).
• Moderate, 15-21.9 (1%-5%).
• High, 22-26.9 (5%-10%).
• Very high, greater than 27 (greater than 10%).

“The BariWound tool can help to inform clinical decision making so patients can know they’re at higher risk, and this could allow for us to target high-risk patients with preventive packages, such as the Cleveland Clinic Technique of wound protection, wound irrigation, and wound packing as a resource-saving measure,” Dr. Dang said. “Targeting high-risk populations can reduce cost and operating time.”

Richard Kirkner/MDedge NEws

Dr. Weber reported on her institution’s study of SSIs using two different methods for circular stapling of GJ that involved two different surgeons who performed 333 RYGB procedures from January 2016 to March 2018. Surgeon “A” had traditionally used the transoral technique without wound protection to insert the anvil of the stapler; surgeon “B” used wound protection and the transabdominal technique for stapler insertion. Wound protection involves draping of the stapler with sterile plastic.

“In a quarterly review, we detected a higher than expected wound complication rate of 6%,” Dr. Weber said. “Of particular concern was the development of five recent wound infection cases, which all occurred in the transoral group for a rate of 8.9% in that cohort.”

That left the quality team questioning the safety profile of the transoral technique, Dr. Weber said. “We wanted to know why and whether or not the main contributor to the development of a wound infection was the technique for the anvil introduction or was it the difference between surgeons using wound protection.”

Halfway through the study period, surgeon A made two modifications: He adopted the transabdominal technique for a subset of patients; and because of the surgeon’s comfort level and expertise with the transoral approach, he continued using that approach but added wound protection. Surgeon B continued with the transabdominal approach with wound protection. The share of transabdominal insertions in the study population increased from 69.2% before the change to 75% after. Demographics between the pre- and postchange patient populations were similar, as were the rates of revision surgery between the two groups.

“We noticed a significant reduction in total wound complications from 6% to 1.3%, and we noticed a complete elimination of surgical site infections after adding wound protection to the transoral technique,” Dr. Weber said.

Dr. Weber noted a number of limitations with the study: its retrospective nature; the lack of control for other intraoperative factors that contribute to SSIs; relatively low incidence of SSI; and surgeon’s choice to determine the technique of anvil insertion.

“We found that our quality improvement intervention was efficacious and decided that it was not the technique of anvil insertion, but it was the wound protection that was key to preventing wound infections, as we saw complete elimination after we added wound protection to the transoral technique,” Dr. Weber said. “Using proper precautions with the circular stapler and anastomosis can be done using either technique for anvil insertion. Overall self-assessment of outcomes leads to best practice.”

Dr. Dang had no financial relationships to disclose. Dr. Weber’s coauthor Leena Khatian, MD, MPH, disclosed relationships with Torax Medical, Medtronic, and Gore.

SOURCES: Weber C et al. SAGES 2109, Presentation S049; Dang J et al. SAGES 2019, Presentation S050.

BALTIMORE – While rates of surgical site infections after bariatric surgery have been reported in the low single digits, SSIs have continued to be a persistent complication.

Richard Kirkner/MDedge News

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons, researchers reported on two strategies to reduce SSI in bariatric surgery: a predictive tool that identifies risk factors for wound infection, allowing surgeons to employ protective measures before and during surgery, and a change in surgical practice leading to a 78% reduction in wound infection rates that resulted from a single-center study.

Jerry Dang, MD, of the University of Alberta, Edmonton, reported that the BariWound predictive tool designed to stratify patients into risk categories showed a high level of accuracy with an area under the curve of 0.73. Cynthia Weber, MD, of University Hospitals, Cleveland, reported that changing the method for performing circular-stapled gastrojejunostomy (GJ) from the transoral to the transabdominal approach along with more vigilant use of wound protection reduced wound infection rates from 6% to 1.3%.

Dr. Dang noted that SSI has been reported as the most common hospital-acquired complication in bariatric surgery, with reported rates of between 1% and 10%. A 2014 analysis of the American College of Surgeons National Surgical Quality Improvement Program database reported an SSI rate of 1.8% (Surg Endosc. 2014;28:3285-92). Although these rates are low, Dr. Dang explained that his group wanted to identify factors associated with SSI within 30 days of bariatric surgery. They analyzed outcomes data of 274,187 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who had bariatric surgery in 2015 and 2016 (196,608 by laparoscopic sleeve gastrectomy [SG] and 77,579 laparoscopic Roux-en-Y gastric bypass [RYGB]). Their analysis determined an incisional SSI rate of 0.47% (n = 1,291). “Incisional SSI rates were four times higher for laparoscopic RYGB: 1.04% vs. 0.25%,” Dr. Dang said.

On multivariable logistic regression, the adjusted odds ratio of SSI after RYGB vs. SG was 3.13 (P less than .001). Other significant risk factors were chronic steroid or immunosuppressant use (odds ratio, 1.75; P = .001), female sex (OR, 1.48; P less than .001) and history of gastroesophageal reflux disease (OR, 1.45; P less than .001). Other factors with a 21%-31% greater risk of SSI were white race (P = .002), history of diabetes (P less than .001), hypertension (P less than .001), obstructive sleep apnea (P = .001), and longer operation times (P less than .001). Each single-digit increase in body mass index increased risk by 3%, and older age actually had a protective effect for unknown reasons, Dr. Dang noted.

The BariWound tool assigns points to each risk factor. Each hour of operation time and each 10 kg/m² of weight carry a value of 1 point, with partial points allowed. RYGB equals 5 points, and chronic steroid/immunosuppressant use, 4 points. The tool assigns risk to four categories based on score and 30-day SSI rate:

• Low, less than 15 (1% risk of SSI).
• Moderate, 15-21.9 (1%-5%).
• High, 22-26.9 (5%-10%).
• Very high, greater than 27 (greater than 10%).

“The BariWound tool can help to inform clinical decision making so patients can know they’re at higher risk, and this could allow for us to target high-risk patients with preventive packages, such as the Cleveland Clinic Technique of wound protection, wound irrigation, and wound packing as a resource-saving measure,” Dr. Dang said. “Targeting high-risk populations can reduce cost and operating time.”

Richard Kirkner/MDedge NEws

Dr. Weber reported on her institution’s study of SSIs using two different methods for circular stapling of GJ that involved two different surgeons who performed 333 RYGB procedures from January 2016 to March 2018. Surgeon “A” had traditionally used the transoral technique without wound protection to insert the anvil of the stapler; surgeon “B” used wound protection and the transabdominal technique for stapler insertion. Wound protection involves draping of the stapler with sterile plastic.

“In a quarterly review, we detected a higher than expected wound complication rate of 6%,” Dr. Weber said. “Of particular concern was the development of five recent wound infection cases, which all occurred in the transoral group for a rate of 8.9% in that cohort.”

That left the quality team questioning the safety profile of the transoral technique, Dr. Weber said. “We wanted to know why and whether or not the main contributor to the development of a wound infection was the technique for the anvil introduction or was it the difference between surgeons using wound protection.”

Halfway through the study period, surgeon A made two modifications: He adopted the transabdominal technique for a subset of patients; and because of the surgeon’s comfort level and expertise with the transoral approach, he continued using that approach but added wound protection. Surgeon B continued with the transabdominal approach with wound protection. The share of transabdominal insertions in the study population increased from 69.2% before the change to 75% after. Demographics between the pre- and postchange patient populations were similar, as were the rates of revision surgery between the two groups.

“We noticed a significant reduction in total wound complications from 6% to 1.3%, and we noticed a complete elimination of surgical site infections after adding wound protection to the transoral technique,” Dr. Weber said.

Dr. Weber noted a number of limitations with the study: its retrospective nature; the lack of control for other intraoperative factors that contribute to SSIs; relatively low incidence of SSI; and surgeon’s choice to determine the technique of anvil insertion.

“We found that our quality improvement intervention was efficacious and decided that it was not the technique of anvil insertion, but it was the wound protection that was key to preventing wound infections, as we saw complete elimination after we added wound protection to the transoral technique,” Dr. Weber said. “Using proper precautions with the circular stapler and anastomosis can be done using either technique for anvil insertion. Overall self-assessment of outcomes leads to best practice.”

Dr. Dang had no financial relationships to disclose. Dr. Weber’s coauthor Leena Khatian, MD, MPH, disclosed relationships with Torax Medical, Medtronic, and Gore.

SOURCES: Weber C et al. SAGES 2109, Presentation S049; Dang J et al. SAGES 2019, Presentation S050.

BALTIMORE – A staging scale developed by the bariatric team at the University of Alberta has shown potential as a tool to accurately predict major complications 1 year after Roux-en-Y gastric bypass (RYGB) surgery, surpassing the predictability of body mass index alone, a researcher reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

monkeybusinessimages/Thinkstock

Researchers at the university validated the predictive utility of the scale, known as the Edmonton Obesity Staging System (EOSS), in a retrospective chart review of 378 patients who had RYGB between December 2009 and November 2015 at Royal Alexandra Hospital in Edmonton, Alt. The EOSS uses a scale from 0 to 4 to score a patient’s risk for complications: the higher the score, the greater the risk of complications.

“The EOSS may help determine risk of major complications after RYGB, and, given its overall simplicity, you can also think of it as analogous to the American Society of Anesthesiologists physical status classification system or the New York Heart Association classification system for congestive heart failure,” said Samuel Skulsky, a 3rd-year medical student at the University of Alberta. “It may have utility as well in communicating to patients their overall risk.”

A previous study applied the EOSS score to the National Health and Human Nutrition Examination Survey to compare it to use of body mass index (BMI) as a predictive marker of mortality (CMAJ. 2011;183:E1059-66). Where the four BMI classifications were clustered on the Kaplan-Meier between 0.7 and 0.9 at 200 months post examination, the four EOSS stages analyzed, 0-3, showed more of a spread, from around 0.55 for stage 3 to near 1.0 for stage 0. This gave the researchers the idea that EOSS could also be used to predict morbidity and mortality specifically in obese patients scheduled for surgery, Mr. Skulsky said. “With the Kaplan-Meier survival curves, the EOSS actually nicely stratifies the patients with their overall survival,” he said. “In comparison, BMI did not do as well in stratifying overall mortality.”

The study reported the following 1-year complication rates in the EOSS stages:

• Stage 0 (n = 14), 7.1%.
• Stage 1 (n = 41), 4.9%.
• Stage 2 (n = 297), 8.8%.
• Stage 3 (n = 26), 23.1%.

There were no stage 4 patients in the study population.

SOURCE: Skulsky SL et al. SAGES 2019, Session SS12.

BALTIMORE – A staging scale developed by the bariatric team at the University of Alberta has shown potential as a tool to accurately predict major complications 1 year after Roux-en-Y gastric bypass (RYGB) surgery, surpassing the predictability of body mass index alone, a researcher reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

monkeybusinessimages/Thinkstock

Researchers at the university validated the predictive utility of the scale, known as the Edmonton Obesity Staging System (EOSS), in a retrospective chart review of 378 patients who had RYGB between December 2009 and November 2015 at Royal Alexandra Hospital in Edmonton, Alt. The EOSS uses a scale from 0 to 4 to score a patient’s risk for complications: the higher the score, the greater the risk of complications.

“The EOSS may help determine risk of major complications after RYGB, and, given its overall simplicity, you can also think of it as analogous to the American Society of Anesthesiologists physical status classification system or the New York Heart Association classification system for congestive heart failure,” said Samuel Skulsky, a 3rd-year medical student at the University of Alberta. “It may have utility as well in communicating to patients their overall risk.”

A previous study applied the EOSS score to the National Health and Human Nutrition Examination Survey to compare it to use of body mass index (BMI) as a predictive marker of mortality (CMAJ. 2011;183:E1059-66). Where the four BMI classifications were clustered on the Kaplan-Meier between 0.7 and 0.9 at 200 months post examination, the four EOSS stages analyzed, 0-3, showed more of a spread, from around 0.55 for stage 3 to near 1.0 for stage 0. This gave the researchers the idea that EOSS could also be used to predict morbidity and mortality specifically in obese patients scheduled for surgery, Mr. Skulsky said. “With the Kaplan-Meier survival curves, the EOSS actually nicely stratifies the patients with their overall survival,” he said. “In comparison, BMI did not do as well in stratifying overall mortality.”

The study reported the following 1-year complication rates in the EOSS stages:

• Stage 0 (n = 14), 7.1%.
• Stage 1 (n = 41), 4.9%.
• Stage 2 (n = 297), 8.8%.
• Stage 3 (n = 26), 23.1%.

There were no stage 4 patients in the study population.

SOURCE: Skulsky SL et al. SAGES 2019, Session SS12.

BALTIMORE – A staging scale developed by the bariatric team at the University of Alberta has shown potential as a tool to accurately predict major complications 1 year after Roux-en-Y gastric bypass (RYGB) surgery, surpassing the predictability of body mass index alone, a researcher reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

monkeybusinessimages/Thinkstock

Researchers at the university validated the predictive utility of the scale, known as the Edmonton Obesity Staging System (EOSS), in a retrospective chart review of 378 patients who had RYGB between December 2009 and November 2015 at Royal Alexandra Hospital in Edmonton, Alt. The EOSS uses a scale from 0 to 4 to score a patient’s risk for complications: the higher the score, the greater the risk of complications.

“The EOSS may help determine risk of major complications after RYGB, and, given its overall simplicity, you can also think of it as analogous to the American Society of Anesthesiologists physical status classification system or the New York Heart Association classification system for congestive heart failure,” said Samuel Skulsky, a 3rd-year medical student at the University of Alberta. “It may have utility as well in communicating to patients their overall risk.”

A previous study applied the EOSS score to the National Health and Human Nutrition Examination Survey to compare it to use of body mass index (BMI) as a predictive marker of mortality (CMAJ. 2011;183:E1059-66). Where the four BMI classifications were clustered on the Kaplan-Meier between 0.7 and 0.9 at 200 months post examination, the four EOSS stages analyzed, 0-3, showed more of a spread, from around 0.55 for stage 3 to near 1.0 for stage 0. This gave the researchers the idea that EOSS could also be used to predict morbidity and mortality specifically in obese patients scheduled for surgery, Mr. Skulsky said. “With the Kaplan-Meier survival curves, the EOSS actually nicely stratifies the patients with their overall survival,” he said. “In comparison, BMI did not do as well in stratifying overall mortality.”

The study reported the following 1-year complication rates in the EOSS stages:

• Stage 0 (n = 14), 7.1%.
• Stage 1 (n = 41), 4.9%.
• Stage 2 (n = 297), 8.8%.
• Stage 3 (n = 26), 23.1%.

There were no stage 4 patients in the study population.

SOURCE: Skulsky SL et al. SAGES 2019, Session SS12.

BALTIMORE – Most male surgeons welcome and support their female colleagues in the workplace, but a survey of male surgeons reports that bias against women in surgery persists, and may be even more acute among younger surgeons, according to a presentation at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“Is there a bias against women in surgery?” asked Michalina Jadick, who presented the results on behalf of AdventHealth Hospital Tampa. “Yes, there is, and understanding this problem is imperative when learning how to fix it.”

A freshman at Boston University who conducted the survey of male surgeons as part of a mentoring program for young women at AdventHealth, Ms. Jadick reported on results of an online survey completed by 190 male surgeons. She noted that, while women represent more than 50% of medical school students, they constitute only 19% of general surgeons in the United States. “Especially in the face of a projected shortage of practicing surgeons, it is more important now than ever to investigate, understand, and work to eliminate the barriers encountered by this large and unique talent pool,” she said.

The anonymous survey was extensive, including 70 five-point Likert-scale questions and 63 multiple choice and binary answers. Regarding the male surgeons who completed the survey, 84% were attendings with more than 5 years of experience, and 8% had less than 5 years in surgery. The remainder were residents, fellows and interns.

When asked if women are as capable as their male counterparts, 80% agreed, with the remainder split between “disagree” or “no opinion.”

“Although this is very small in comparison, that’s actually pretty significant,” Ms. Jadick said of the 10% who disagreed.

When asked if women make good surgeons, 67% agreed, 10% disagreed, and 23% selected neither. “We found that older male surgeons were more likely to believe women make successful surgeons, as opposed to younger male doctors,” Ms. Jadick said. She called this finding “surprising” because younger doctors are expected to have more progressive ideas. “However, this response seems to indicate otherwise, and that’s an important part of the conversation.”

When asked if women have the same advancement opportunities as men, 75% agreed and 9% disagreed. When the question was flipped – that is, if men have more opportunities than women – 32% agreed and 43% disagreed. Half of responders concurred that women are discouraged from entering surgery because program directors question their ability to complete surgical training, yet 95% agreed that men and women residents receive equal training. “This is especially a problem,” Ms. Jadick said of the latter finding.

The survey also found wide disparities in how male surgeons feel about family roles. A high percentage – 80% – agreed that a woman can be both a good surgeon and a good parent. But an even higher percentage – 96% – said a man could be good in both roles. “When looking at the disagreement to these statements, 13% said it is not possible for a woman to be both a good surgeon and a good parent, while not one single male respondent said the same for men,” Ms. Jadick said. Of the men surveyed, 84% agreed that female surgeons are under greater pressure than men to balance work and family life.

Exploring the family issue even deeper, 46% of the respondents said that having children adversely affects a female surgeon professionally, whereas only 9% said the same of men. Conversely, 31% said children do not affect a female surgeon’s career, but 81% said children do not affect a male surgeon’s career.

“Clearly the topic of family obligations is a huge issue in the context of gender discrimination against women in surgery, and this is the case even though many have indicated that women and men have similar commitment to families outside of work,” Ms. Jadick said. “This has proven to be a big part of the issue in the past and likely moving forward as well. That’s why it’s of paramount importance for us to take this into consideration and understand that it’s happening.”

When asked about working with women in the operating room, 20% of male respondents agreed that women surgeons are aggressive coworkers, and 19% said that it’s easier to work with male colleagues. This attitude may be a function of the stereotype of women being deferential to leadership rather than assuming it, she said.

When asked frankly if discrimination exists in surgery today, 43% answered “yes” – but 57% said “no” or “unsure.”

“This finding clearly portrays the problem does persist in surgery, and therefore, it’s very important for [male] surgeons in particular to remain aware of that problem and actively work to eliminate that disparity within that work environment,” Ms. Jadick said.

However, the 57% who said discrimination is not a problem is more unsettling, she said. “That’s incredibly significant because the first step to solving any problem is recognizing that there is one,” Ms. Jadick said. “However, then we must commit to solving it. Only by promoting an equitable and inclusive work environment that promotes the engagement of women can we improve the future of surgery for the betterment of all of its stakeholders, especially patients.”

Ms. Jadick had no financial relationships to disclose.

BALTIMORE – Most male surgeons welcome and support their female colleagues in the workplace, but a survey of male surgeons reports that bias against women in surgery persists, and may be even more acute among younger surgeons, according to a presentation at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“Is there a bias against women in surgery?” asked Michalina Jadick, who presented the results on behalf of AdventHealth Hospital Tampa. “Yes, there is, and understanding this problem is imperative when learning how to fix it.”

A freshman at Boston University who conducted the survey of male surgeons as part of a mentoring program for young women at AdventHealth, Ms. Jadick reported on results of an online survey completed by 190 male surgeons. She noted that, while women represent more than 50% of medical school students, they constitute only 19% of general surgeons in the United States. “Especially in the face of a projected shortage of practicing surgeons, it is more important now than ever to investigate, understand, and work to eliminate the barriers encountered by this large and unique talent pool,” she said.

The anonymous survey was extensive, including 70 five-point Likert-scale questions and 63 multiple choice and binary answers. Regarding the male surgeons who completed the survey, 84% were attendings with more than 5 years of experience, and 8% had less than 5 years in surgery. The remainder were residents, fellows and interns.

When asked if women are as capable as their male counterparts, 80% agreed, with the remainder split between “disagree” or “no opinion.”

“Although this is very small in comparison, that’s actually pretty significant,” Ms. Jadick said of the 10% who disagreed.

When asked if women make good surgeons, 67% agreed, 10% disagreed, and 23% selected neither. “We found that older male surgeons were more likely to believe women make successful surgeons, as opposed to younger male doctors,” Ms. Jadick said. She called this finding “surprising” because younger doctors are expected to have more progressive ideas. “However, this response seems to indicate otherwise, and that’s an important part of the conversation.”

When asked if women have the same advancement opportunities as men, 75% agreed and 9% disagreed. When the question was flipped – that is, if men have more opportunities than women – 32% agreed and 43% disagreed. Half of responders concurred that women are discouraged from entering surgery because program directors question their ability to complete surgical training, yet 95% agreed that men and women residents receive equal training. “This is especially a problem,” Ms. Jadick said of the latter finding.

The survey also found wide disparities in how male surgeons feel about family roles. A high percentage – 80% – agreed that a woman can be both a good surgeon and a good parent. But an even higher percentage – 96% – said a man could be good in both roles. “When looking at the disagreement to these statements, 13% said it is not possible for a woman to be both a good surgeon and a good parent, while not one single male respondent said the same for men,” Ms. Jadick said. Of the men surveyed, 84% agreed that female surgeons are under greater pressure than men to balance work and family life.

Exploring the family issue even deeper, 46% of the respondents said that having children adversely affects a female surgeon professionally, whereas only 9% said the same of men. Conversely, 31% said children do not affect a female surgeon’s career, but 81% said children do not affect a male surgeon’s career.

“Clearly the topic of family obligations is a huge issue in the context of gender discrimination against women in surgery, and this is the case even though many have indicated that women and men have similar commitment to families outside of work,” Ms. Jadick said. “This has proven to be a big part of the issue in the past and likely moving forward as well. That’s why it’s of paramount importance for us to take this into consideration and understand that it’s happening.”

When asked about working with women in the operating room, 20% of male respondents agreed that women surgeons are aggressive coworkers, and 19% said that it’s easier to work with male colleagues. This attitude may be a function of the stereotype of women being deferential to leadership rather than assuming it, she said.

When asked frankly if discrimination exists in surgery today, 43% answered “yes” – but 57% said “no” or “unsure.”

“This finding clearly portrays the problem does persist in surgery, and therefore, it’s very important for [male] surgeons in particular to remain aware of that problem and actively work to eliminate that disparity within that work environment,” Ms. Jadick said.

However, the 57% who said discrimination is not a problem is more unsettling, she said. “That’s incredibly significant because the first step to solving any problem is recognizing that there is one,” Ms. Jadick said. “However, then we must commit to solving it. Only by promoting an equitable and inclusive work environment that promotes the engagement of women can we improve the future of surgery for the betterment of all of its stakeholders, especially patients.”

Ms. Jadick had no financial relationships to disclose.

BALTIMORE – Most male surgeons welcome and support their female colleagues in the workplace, but a survey of male surgeons reports that bias against women in surgery persists, and may be even more acute among younger surgeons, according to a presentation at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“Is there a bias against women in surgery?” asked Michalina Jadick, who presented the results on behalf of AdventHealth Hospital Tampa. “Yes, there is, and understanding this problem is imperative when learning how to fix it.”

A freshman at Boston University who conducted the survey of male surgeons as part of a mentoring program for young women at AdventHealth, Ms. Jadick reported on results of an online survey completed by 190 male surgeons. She noted that, while women represent more than 50% of medical school students, they constitute only 19% of general surgeons in the United States. “Especially in the face of a projected shortage of practicing surgeons, it is more important now than ever to investigate, understand, and work to eliminate the barriers encountered by this large and unique talent pool,” she said.

The anonymous survey was extensive, including 70 five-point Likert-scale questions and 63 multiple choice and binary answers. Regarding the male surgeons who completed the survey, 84% were attendings with more than 5 years of experience, and 8% had less than 5 years in surgery. The remainder were residents, fellows and interns.

When asked if women are as capable as their male counterparts, 80% agreed, with the remainder split between “disagree” or “no opinion.”

“Although this is very small in comparison, that’s actually pretty significant,” Ms. Jadick said of the 10% who disagreed.

When asked if women make good surgeons, 67% agreed, 10% disagreed, and 23% selected neither. “We found that older male surgeons were more likely to believe women make successful surgeons, as opposed to younger male doctors,” Ms. Jadick said. She called this finding “surprising” because younger doctors are expected to have more progressive ideas. “However, this response seems to indicate otherwise, and that’s an important part of the conversation.”

When asked if women have the same advancement opportunities as men, 75% agreed and 9% disagreed. When the question was flipped – that is, if men have more opportunities than women – 32% agreed and 43% disagreed. Half of responders concurred that women are discouraged from entering surgery because program directors question their ability to complete surgical training, yet 95% agreed that men and women residents receive equal training. “This is especially a problem,” Ms. Jadick said of the latter finding.

The survey also found wide disparities in how male surgeons feel about family roles. A high percentage – 80% – agreed that a woman can be both a good surgeon and a good parent. But an even higher percentage – 96% – said a man could be good in both roles. “When looking at the disagreement to these statements, 13% said it is not possible for a woman to be both a good surgeon and a good parent, while not one single male respondent said the same for men,” Ms. Jadick said. Of the men surveyed, 84% agreed that female surgeons are under greater pressure than men to balance work and family life.

Exploring the family issue even deeper, 46% of the respondents said that having children adversely affects a female surgeon professionally, whereas only 9% said the same of men. Conversely, 31% said children do not affect a female surgeon’s career, but 81% said children do not affect a male surgeon’s career.

“Clearly the topic of family obligations is a huge issue in the context of gender discrimination against women in surgery, and this is the case even though many have indicated that women and men have similar commitment to families outside of work,” Ms. Jadick said. “This has proven to be a big part of the issue in the past and likely moving forward as well. That’s why it’s of paramount importance for us to take this into consideration and understand that it’s happening.”

When asked about working with women in the operating room, 20% of male respondents agreed that women surgeons are aggressive coworkers, and 19% said that it’s easier to work with male colleagues. This attitude may be a function of the stereotype of women being deferential to leadership rather than assuming it, she said.

When asked frankly if discrimination exists in surgery today, 43% answered “yes” – but 57% said “no” or “unsure.”

“This finding clearly portrays the problem does persist in surgery, and therefore, it’s very important for [male] surgeons in particular to remain aware of that problem and actively work to eliminate that disparity within that work environment,” Ms. Jadick said.

However, the 57% who said discrimination is not a problem is more unsettling, she said. “That’s incredibly significant because the first step to solving any problem is recognizing that there is one,” Ms. Jadick said. “However, then we must commit to solving it. Only by promoting an equitable and inclusive work environment that promotes the engagement of women can we improve the future of surgery for the betterment of all of its stakeholders, especially patients.”

Ms. Jadick had no financial relationships to disclose.

BALTIMORE – Patients who take benzodiazepines for anxiety and have laparoscopic Nissen fundoplication for gastroesophageal reflux disease achieve similar outcomes as other patients, but also have much lower rates of postop satisfaction, according to a study from the Ohio State University presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

DAJ/Thinkstock

Carla Holcomb, MD, a minimally invasive surgery/bariatric fellow at the Ohio State’s Wexner Medical Center, Columbus, reported the upshot of the study findings. “Preoperative counseling is especially important regarding postoperative expectations in patients with anxiety,” she said.

The retrospective study evaluated 271 patients who had laparoscopic Nissen fundoplication (LNF) during 2011-2016 at the medical center, comparing outcomes in patients who were on serotonin-modulating medication for depression (n = 103), benzodiazepines for anxiety (n = 44), or neither (n = 124). The researchers evaluated a number of metrics – DeMeester score of esophageal acid exposure, pre- and postoperative health-related quality of life, and postoperative antacid use and need for endoscopic dilation – across all cohorts. While some scores among the anxiety cohort trended higher (DeMeester score of 43 vs. 38 for the no-anxiety patients) they were not statistically significant, Dr. Holcomb noted. Patients taking antidepressants reported similar subjective outcomes and satisfaction rates to those not taking antidepressants.

However, when patients were queried about their overall satisfaction after laparoscopic Nissen fundoplication 77%-87% in the no-depression, depression, and no-anxiety groups reported they were satisfied, while only 37% of those in the anxiety group did so. That is based on a response rate of 53% to a telephone inquiry 15 months after LNF.

“The patients who had anxiety looked vastly different from the rest of the population,” said Dr. Holcomb. “Patients taking antidepressants reported similar objective outcomes and high satisfaction rates, [compared with] patients not taking antidepressants after LNF, and although LNF does improve gastroesophageal reflux disease symptoms in patients taking anxiolytics, they rarely achieve satisfaction in long-term follow-up.”

Among the study limitations Dr. Holcomb acknowledged were the 53% long-term response rate and not knowing if an anatomical reason may explain the higher health-related quality of life scores in the anxiety group – 7 vs. 4 in the no-anxiety group – at long-term follow-up, although the overall score was low at 5.

Dr. Holcomb had no relevant financial disclosures.

SOURCE: Holcomb CN et al. SAGES 2019, Session SS04.

BALTIMORE – Patients who take benzodiazepines for anxiety and have laparoscopic Nissen fundoplication for gastroesophageal reflux disease achieve similar outcomes as other patients, but also have much lower rates of postop satisfaction, according to a study from the Ohio State University presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

DAJ/Thinkstock

Carla Holcomb, MD, a minimally invasive surgery/bariatric fellow at the Ohio State’s Wexner Medical Center, Columbus, reported the upshot of the study findings. “Preoperative counseling is especially important regarding postoperative expectations in patients with anxiety,” she said.

The retrospective study evaluated 271 patients who had laparoscopic Nissen fundoplication (LNF) during 2011-2016 at the medical center, comparing outcomes in patients who were on serotonin-modulating medication for depression (n = 103), benzodiazepines for anxiety (n = 44), or neither (n = 124). The researchers evaluated a number of metrics – DeMeester score of esophageal acid exposure, pre- and postoperative health-related quality of life, and postoperative antacid use and need for endoscopic dilation – across all cohorts. While some scores among the anxiety cohort trended higher (DeMeester score of 43 vs. 38 for the no-anxiety patients) they were not statistically significant, Dr. Holcomb noted. Patients taking antidepressants reported similar subjective outcomes and satisfaction rates to those not taking antidepressants.

However, when patients were queried about their overall satisfaction after laparoscopic Nissen fundoplication 77%-87% in the no-depression, depression, and no-anxiety groups reported they were satisfied, while only 37% of those in the anxiety group did so. That is based on a response rate of 53% to a telephone inquiry 15 months after LNF.

“The patients who had anxiety looked vastly different from the rest of the population,” said Dr. Holcomb. “Patients taking antidepressants reported similar objective outcomes and high satisfaction rates, [compared with] patients not taking antidepressants after LNF, and although LNF does improve gastroesophageal reflux disease symptoms in patients taking anxiolytics, they rarely achieve satisfaction in long-term follow-up.”

Among the study limitations Dr. Holcomb acknowledged were the 53% long-term response rate and not knowing if an anatomical reason may explain the higher health-related quality of life scores in the anxiety group – 7 vs. 4 in the no-anxiety group – at long-term follow-up, although the overall score was low at 5.

Dr. Holcomb had no relevant financial disclosures.

SOURCE: Holcomb CN et al. SAGES 2019, Session SS04.

BALTIMORE – Patients who take benzodiazepines for anxiety and have laparoscopic Nissen fundoplication for gastroesophageal reflux disease achieve similar outcomes as other patients, but also have much lower rates of postop satisfaction, according to a study from the Ohio State University presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

DAJ/Thinkstock

Carla Holcomb, MD, a minimally invasive surgery/bariatric fellow at the Ohio State’s Wexner Medical Center, Columbus, reported the upshot of the study findings. “Preoperative counseling is especially important regarding postoperative expectations in patients with anxiety,” she said.

The retrospective study evaluated 271 patients who had laparoscopic Nissen fundoplication (LNF) during 2011-2016 at the medical center, comparing outcomes in patients who were on serotonin-modulating medication for depression (n = 103), benzodiazepines for anxiety (n = 44), or neither (n = 124). The researchers evaluated a number of metrics – DeMeester score of esophageal acid exposure, pre- and postoperative health-related quality of life, and postoperative antacid use and need for endoscopic dilation – across all cohorts. While some scores among the anxiety cohort trended higher (DeMeester score of 43 vs. 38 for the no-anxiety patients) they were not statistically significant, Dr. Holcomb noted. Patients taking antidepressants reported similar subjective outcomes and satisfaction rates to those not taking antidepressants.

However, when patients were queried about their overall satisfaction after laparoscopic Nissen fundoplication 77%-87% in the no-depression, depression, and no-anxiety groups reported they were satisfied, while only 37% of those in the anxiety group did so. That is based on a response rate of 53% to a telephone inquiry 15 months after LNF.

“The patients who had anxiety looked vastly different from the rest of the population,” said Dr. Holcomb. “Patients taking antidepressants reported similar objective outcomes and high satisfaction rates, [compared with] patients not taking antidepressants after LNF, and although LNF does improve gastroesophageal reflux disease symptoms in patients taking anxiolytics, they rarely achieve satisfaction in long-term follow-up.”

Among the study limitations Dr. Holcomb acknowledged were the 53% long-term response rate and not knowing if an anatomical reason may explain the higher health-related quality of life scores in the anxiety group – 7 vs. 4 in the no-anxiety group – at long-term follow-up, although the overall score was low at 5.

Dr. Holcomb had no relevant financial disclosures.

SOURCE: Holcomb CN et al. SAGES 2019, Session SS04.

While most outcomes are similar between robotic surgery and laparoscopic surgery for sleeve gastrectomy, the robotic approach carried a greater risk of organ space infection, according to the findings from a large clinical trial of more than 100,000 patients.

The study’s authors analyzed 107,726 sleeve gastrectomy operations in the Metabolic and Bariatric Surgery Association and Quality Improvement Program data registry (MBSAQIP), 7,385 of which were robotic sleeve gastrectomy (RSG). Peter William Lundberg, MD, and his coauthors of St. Luke’s University Health Network, Bethlehem, Pa., evaluated the safety of RSG vs. laparoscopic sleeve gastrectomy (LSG). The study was the first and largest comparing the two approaches to sleeve gastrectomy, the researchers noted.

“According to the MBSAQIP database, the robotic approach demonstrates a significantly higher rate of organ space infection while trending toward a lower rate of bleeding and 30-day reoperation and intervention,” Dr. Lundberg and his coauthors said.

Overall mortality was 0.07% in both groups (P = .49). The overall rates of significant adverse events were similar in both groups – 1.3% for LSG and 1.1% for RSG (P = .14) – as were bleeding rates – 0.5% and 0.4% (P = .003), respectively. The investigators characterized the slightly lower rates for RSG as “insignificant.”

RSG, however, had three times the rate of organ space infection than did the laparoscopic approach, 0.3% vs. 0.1% (P = .79). “Considering the enthusiasm with which robotics has been adopted by some bariatric surgeons, this is a sobering finding,” Dr. Lundberg noted.

The study determined that the use of staple-line reinforcement (SLR) alone significantly reduced the rate of bleeding regardless of approach by 31% on average (P = .0005). “This risk reduction was enhanced when SLR was combined with oversewing of the staple line,” Dr. Lundberg and his colleagues noted – an average reduction of 42% (P = .0009).

RSG took longer on average, 89 minutes vs. 63 minutes (P less than .0001), and the average length of stay was almost identical, 1.7 for RSG vs. 1.6 days for LSG. Reoperation rates within 30 days were also similar: 0.7% for RSG vs. 0.8% for LSG (P = .003).

“As surgeons continue to adopt and develop new technology, ongoing monitoring and reporting of safety and outcomes data are advised to maintain the high standards for outcomes in bariatric surgery,” Dr. Lundberg and his coauthors said.

The study researchers had no financial conflicts.

SOURCE: Lundberg PW et al. Surg Obes Relat Dis. 2018 Oct 25. doi:10.1016/j.soard.2018.10.015.
 

While most outcomes are similar between robotic surgery and laparoscopic surgery for sleeve gastrectomy, the robotic approach carried a greater risk of organ space infection, according to the findings from a large clinical trial of more than 100,000 patients.

The study’s authors analyzed 107,726 sleeve gastrectomy operations in the Metabolic and Bariatric Surgery Association and Quality Improvement Program data registry (MBSAQIP), 7,385 of which were robotic sleeve gastrectomy (RSG). Peter William Lundberg, MD, and his coauthors of St. Luke’s University Health Network, Bethlehem, Pa., evaluated the safety of RSG vs. laparoscopic sleeve gastrectomy (LSG). The study was the first and largest comparing the two approaches to sleeve gastrectomy, the researchers noted.

“According to the MBSAQIP database, the robotic approach demonstrates a significantly higher rate of organ space infection while trending toward a lower rate of bleeding and 30-day reoperation and intervention,” Dr. Lundberg and his coauthors said.

Overall mortality was 0.07% in both groups (P = .49). The overall rates of significant adverse events were similar in both groups – 1.3% for LSG and 1.1% for RSG (P = .14) – as were bleeding rates – 0.5% and 0.4% (P = .003), respectively. The investigators characterized the slightly lower rates for RSG as “insignificant.”

RSG, however, had three times the rate of organ space infection than did the laparoscopic approach, 0.3% vs. 0.1% (P = .79). “Considering the enthusiasm with which robotics has been adopted by some bariatric surgeons, this is a sobering finding,” Dr. Lundberg noted.

The study determined that the use of staple-line reinforcement (SLR) alone significantly reduced the rate of bleeding regardless of approach by 31% on average (P = .0005). “This risk reduction was enhanced when SLR was combined with oversewing of the staple line,” Dr. Lundberg and his colleagues noted – an average reduction of 42% (P = .0009).

RSG took longer on average, 89 minutes vs. 63 minutes (P less than .0001), and the average length of stay was almost identical, 1.7 for RSG vs. 1.6 days for LSG. Reoperation rates within 30 days were also similar: 0.7% for RSG vs. 0.8% for LSG (P = .003).

“As surgeons continue to adopt and develop new technology, ongoing monitoring and reporting of safety and outcomes data are advised to maintain the high standards for outcomes in bariatric surgery,” Dr. Lundberg and his coauthors said.

The study researchers had no financial conflicts.

SOURCE: Lundberg PW et al. Surg Obes Relat Dis. 2018 Oct 25. doi:10.1016/j.soard.2018.10.015.
 

While most outcomes are similar between robotic surgery and laparoscopic surgery for sleeve gastrectomy, the robotic approach carried a greater risk of organ space infection, according to the findings from a large clinical trial of more than 100,000 patients.

The study’s authors analyzed 107,726 sleeve gastrectomy operations in the Metabolic and Bariatric Surgery Association and Quality Improvement Program data registry (MBSAQIP), 7,385 of which were robotic sleeve gastrectomy (RSG). Peter William Lundberg, MD, and his coauthors of St. Luke’s University Health Network, Bethlehem, Pa., evaluated the safety of RSG vs. laparoscopic sleeve gastrectomy (LSG). The study was the first and largest comparing the two approaches to sleeve gastrectomy, the researchers noted.

“According to the MBSAQIP database, the robotic approach demonstrates a significantly higher rate of organ space infection while trending toward a lower rate of bleeding and 30-day reoperation and intervention,” Dr. Lundberg and his coauthors said.

Overall mortality was 0.07% in both groups (P = .49). The overall rates of significant adverse events were similar in both groups – 1.3% for LSG and 1.1% for RSG (P = .14) – as were bleeding rates – 0.5% and 0.4% (P = .003), respectively. The investigators characterized the slightly lower rates for RSG as “insignificant.”

RSG, however, had three times the rate of organ space infection than did the laparoscopic approach, 0.3% vs. 0.1% (P = .79). “Considering the enthusiasm with which robotics has been adopted by some bariatric surgeons, this is a sobering finding,” Dr. Lundberg noted.

The study determined that the use of staple-line reinforcement (SLR) alone significantly reduced the rate of bleeding regardless of approach by 31% on average (P = .0005). “This risk reduction was enhanced when SLR was combined with oversewing of the staple line,” Dr. Lundberg and his colleagues noted – an average reduction of 42% (P = .0009).

RSG took longer on average, 89 minutes vs. 63 minutes (P less than .0001), and the average length of stay was almost identical, 1.7 for RSG vs. 1.6 days for LSG. Reoperation rates within 30 days were also similar: 0.7% for RSG vs. 0.8% for LSG (P = .003).

“As surgeons continue to adopt and develop new technology, ongoing monitoring and reporting of safety and outcomes data are advised to maintain the high standards for outcomes in bariatric surgery,” Dr. Lundberg and his coauthors said.

The study researchers had no financial conflicts.

SOURCE: Lundberg PW et al. Surg Obes Relat Dis. 2018 Oct 25. doi:10.1016/j.soard.2018.10.015.
 

CHICAGO – A European clinical trial that targeted a mean arterial blood pressure after cardiac arrest higher than what the existing guidelines recommend found that the approach was safe, improved blood flow and oxygen to the brain, helped patients recover quicker, and reduced the number of adverse cardiac events, although it did not reduce the extent of anoxic brain damage or improve functional outcomes, the lead investigator reported at the American Heart Association scientific sessions.

The Neuroprotect trial randomly assigned 112 adult survivors of an out-of-hospital cardiac arrest who were unconscious upon admission to two study groups: early goal-directed hemodynamic optimization (EGDHO), in which researchers used a targeted mean arterial pressure (MAP) of 85-100 mm Hg and mixed venous oxygen saturation between 65% and 75% during the first 36 hours after ICU admission; and the standard care group, in which they used the guideline-recommended MAP target of 65 mm Hg, said Koen Ameloot, MD, of East Limburg Hospital in Genk, Belgium.

“EGDHO clearly improved cerebral perfusion and oxygenation, thereby for the first time providing the proof of concept for this new hemodynamic target,” Dr. Ameloot said. “However, this did not result in the reduction of the extent of anoxic brain hemorrhage or effusion rate on MRI or an improvement in functional outcome at 180 days.”

He noted the trial was predicated on improving upon the so-called “two-hit” model of cardiac arrest sequelae: the first hit being the no-flow and low-flow period before achieving restoration of spontaneous circulation; the second hit being hypoperfusion and reperfusion injury during ICU stay.

Dr. Ameloot referenced a study in which he and other coauthors reported that patients with a MAP target of 65 mm Hg “experience a profound drop of cerebral oxygen saturation during the first 12 hours of ICU stay that may cause additional brain damage” (Resuscitation. 2018;123:92-7).

The researchers explored the question of what is the optimal MAP if a target of 65 mm Hg is too low, Dr. Ameloot said. “We showed that maximal brain oxygenation is achieved with a MAP of 100 mm Hg, while lower MAPs were associated with submaximal brain perfusion and higher MAPs with excessive after-load, a reduction in stroke volume, and suboptimal cerebral oxygenation.”

During the 36-hour intervention period, the EGDHO patients received higher doses of norepinephrine, Dr. Ameloot said. “This resulted in significant improvement of cerebral oxygenation during the first 12 hours and was paralleled by significantly higher cerebral perfusion in the subset of patients in whom Doppler measurements were performed,” he said. “While patients allocated to the MAP 65 mm Hg target experienced a profound drop of cerebral oxygenation during the critical first 6-12 hours of ICU stay, cerebral oxygenation was maintained at 67% in patients assigned to EGDHO.”

However, the rate of anoxic brain damage, measured as the percentage of irreversibly damaged anoxic voxels on diffusion-weighted MRI – the primary endpoint of the study – was actually higher in the EGDHO group, 16% vs. 12%, Dr. Ameloot said. “The percentage of anoxic voxels was only a poor predictor of favorable neurological outcome at 180 days, questioning the validity of the primary endpoint,” he said. He also noted that 23% of the trial participants did not have an MRI scan because of higher than expected 5-day rates of death.

“The percentage of patients with favorable neurological outcome tended to be somewhat higher in the intervention arm, although this did not reach statistical significance at ICU discharge and at 180 days,” Dr. Ameloot said. He noted that 42% of the intervention group and 33% of controls in the full-analysis set (P = .30) and 43% and 27%, respectively, in the per-protocol set (P = .15) had a favorable neurological outcome, as calculated using the Glasgow-Pittsburgh Cerebral Performance Category scores of 1 or 2, at 180 days.

The study did not reveal any noteworthy differences in ICU stay (7 vs. 8 days, P = .13) or days on mechanical ventilation (5 vs. 7, P = .31), although fewer patients in the EGDHO group required a tracheostomy (4% vs. 18%, P = .02). The intervention group also had lower rates of cardiac events, including recurrent cardiac arrest, limb ischemia, new atrial fibrillation, and pulmonary edema (13% vs. 33%; P = .02), Dr. Ameloot said.

Future post-hoc analyses of the data will explore the hypothesis that higher blood pressure leads to improved coronary perfusion and reduced infarct size, thus improving prognosis, he added.

“Should this trial therefore be the definite end to the promising hypothesis that improving brain oxygenation might reduce the second hit in post–cardiac arrest patients? I don’t think so,” Dr. Ameloot said. He noted a few limits to the study: that the perfusion rate on MRI was a poor predictor of 180-day outcome; that more patients than expected entered the trial without receiving basic life support and with nonshockable rhythms; and that there was possibly less extensive brain damage among controls at baseline. “Only an adequately powered clinical trial can provide an answer about the effects of EGDHO in post–cardiac arrest patients,” Dr. Ameloot said.

Dr. Ameloot had no financial relationships to disclose.

SOURCE: Ameloot K et al. AHA 2018, Abstract 18620
 

CHICAGO – A European clinical trial that targeted a mean arterial blood pressure after cardiac arrest higher than what the existing guidelines recommend found that the approach was safe, improved blood flow and oxygen to the brain, helped patients recover quicker, and reduced the number of adverse cardiac events, although it did not reduce the extent of anoxic brain damage or improve functional outcomes, the lead investigator reported at the American Heart Association scientific sessions.

The Neuroprotect trial randomly assigned 112 adult survivors of an out-of-hospital cardiac arrest who were unconscious upon admission to two study groups: early goal-directed hemodynamic optimization (EGDHO), in which researchers used a targeted mean arterial pressure (MAP) of 85-100 mm Hg and mixed venous oxygen saturation between 65% and 75% during the first 36 hours after ICU admission; and the standard care group, in which they used the guideline-recommended MAP target of 65 mm Hg, said Koen Ameloot, MD, of East Limburg Hospital in Genk, Belgium.

“EGDHO clearly improved cerebral perfusion and oxygenation, thereby for the first time providing the proof of concept for this new hemodynamic target,” Dr. Ameloot said. “However, this did not result in the reduction of the extent of anoxic brain hemorrhage or effusion rate on MRI or an improvement in functional outcome at 180 days.”

He noted the trial was predicated on improving upon the so-called “two-hit” model of cardiac arrest sequelae: the first hit being the no-flow and low-flow period before achieving restoration of spontaneous circulation; the second hit being hypoperfusion and reperfusion injury during ICU stay.

Dr. Ameloot referenced a study in which he and other coauthors reported that patients with a MAP target of 65 mm Hg “experience a profound drop of cerebral oxygen saturation during the first 12 hours of ICU stay that may cause additional brain damage” (Resuscitation. 2018;123:92-7).

The researchers explored the question of what is the optimal MAP if a target of 65 mm Hg is too low, Dr. Ameloot said. “We showed that maximal brain oxygenation is achieved with a MAP of 100 mm Hg, while lower MAPs were associated with submaximal brain perfusion and higher MAPs with excessive after-load, a reduction in stroke volume, and suboptimal cerebral oxygenation.”

During the 36-hour intervention period, the EGDHO patients received higher doses of norepinephrine, Dr. Ameloot said. “This resulted in significant improvement of cerebral oxygenation during the first 12 hours and was paralleled by significantly higher cerebral perfusion in the subset of patients in whom Doppler measurements were performed,” he said. “While patients allocated to the MAP 65 mm Hg target experienced a profound drop of cerebral oxygenation during the critical first 6-12 hours of ICU stay, cerebral oxygenation was maintained at 67% in patients assigned to EGDHO.”

However, the rate of anoxic brain damage, measured as the percentage of irreversibly damaged anoxic voxels on diffusion-weighted MRI – the primary endpoint of the study – was actually higher in the EGDHO group, 16% vs. 12%, Dr. Ameloot said. “The percentage of anoxic voxels was only a poor predictor of favorable neurological outcome at 180 days, questioning the validity of the primary endpoint,” he said. He also noted that 23% of the trial participants did not have an MRI scan because of higher than expected 5-day rates of death.

“The percentage of patients with favorable neurological outcome tended to be somewhat higher in the intervention arm, although this did not reach statistical significance at ICU discharge and at 180 days,” Dr. Ameloot said. He noted that 42% of the intervention group and 33% of controls in the full-analysis set (P = .30) and 43% and 27%, respectively, in the per-protocol set (P = .15) had a favorable neurological outcome, as calculated using the Glasgow-Pittsburgh Cerebral Performance Category scores of 1 or 2, at 180 days.

The study did not reveal any noteworthy differences in ICU stay (7 vs. 8 days, P = .13) or days on mechanical ventilation (5 vs. 7, P = .31), although fewer patients in the EGDHO group required a tracheostomy (4% vs. 18%, P = .02). The intervention group also had lower rates of cardiac events, including recurrent cardiac arrest, limb ischemia, new atrial fibrillation, and pulmonary edema (13% vs. 33%; P = .02), Dr. Ameloot said.

Future post-hoc analyses of the data will explore the hypothesis that higher blood pressure leads to improved coronary perfusion and reduced infarct size, thus improving prognosis, he added.

“Should this trial therefore be the definite end to the promising hypothesis that improving brain oxygenation might reduce the second hit in post–cardiac arrest patients? I don’t think so,” Dr. Ameloot said. He noted a few limits to the study: that the perfusion rate on MRI was a poor predictor of 180-day outcome; that more patients than expected entered the trial without receiving basic life support and with nonshockable rhythms; and that there was possibly less extensive brain damage among controls at baseline. “Only an adequately powered clinical trial can provide an answer about the effects of EGDHO in post–cardiac arrest patients,” Dr. Ameloot said.

Dr. Ameloot had no financial relationships to disclose.

SOURCE: Ameloot K et al. AHA 2018, Abstract 18620
 

CHICAGO – A European clinical trial that targeted a mean arterial blood pressure after cardiac arrest higher than what the existing guidelines recommend found that the approach was safe, improved blood flow and oxygen to the brain, helped patients recover quicker, and reduced the number of adverse cardiac events, although it did not reduce the extent of anoxic brain damage or improve functional outcomes, the lead investigator reported at the American Heart Association scientific sessions.

The Neuroprotect trial randomly assigned 112 adult survivors of an out-of-hospital cardiac arrest who were unconscious upon admission to two study groups: early goal-directed hemodynamic optimization (EGDHO), in which researchers used a targeted mean arterial pressure (MAP) of 85-100 mm Hg and mixed venous oxygen saturation between 65% and 75% during the first 36 hours after ICU admission; and the standard care group, in which they used the guideline-recommended MAP target of 65 mm Hg, said Koen Ameloot, MD, of East Limburg Hospital in Genk, Belgium.

“EGDHO clearly improved cerebral perfusion and oxygenation, thereby for the first time providing the proof of concept for this new hemodynamic target,” Dr. Ameloot said. “However, this did not result in the reduction of the extent of anoxic brain hemorrhage or effusion rate on MRI or an improvement in functional outcome at 180 days.”

He noted the trial was predicated on improving upon the so-called “two-hit” model of cardiac arrest sequelae: the first hit being the no-flow and low-flow period before achieving restoration of spontaneous circulation; the second hit being hypoperfusion and reperfusion injury during ICU stay.

Dr. Ameloot referenced a study in which he and other coauthors reported that patients with a MAP target of 65 mm Hg “experience a profound drop of cerebral oxygen saturation during the first 12 hours of ICU stay that may cause additional brain damage” (Resuscitation. 2018;123:92-7).

The researchers explored the question of what is the optimal MAP if a target of 65 mm Hg is too low, Dr. Ameloot said. “We showed that maximal brain oxygenation is achieved with a MAP of 100 mm Hg, while lower MAPs were associated with submaximal brain perfusion and higher MAPs with excessive after-load, a reduction in stroke volume, and suboptimal cerebral oxygenation.”

During the 36-hour intervention period, the EGDHO patients received higher doses of norepinephrine, Dr. Ameloot said. “This resulted in significant improvement of cerebral oxygenation during the first 12 hours and was paralleled by significantly higher cerebral perfusion in the subset of patients in whom Doppler measurements were performed,” he said. “While patients allocated to the MAP 65 mm Hg target experienced a profound drop of cerebral oxygenation during the critical first 6-12 hours of ICU stay, cerebral oxygenation was maintained at 67% in patients assigned to EGDHO.”

However, the rate of anoxic brain damage, measured as the percentage of irreversibly damaged anoxic voxels on diffusion-weighted MRI – the primary endpoint of the study – was actually higher in the EGDHO group, 16% vs. 12%, Dr. Ameloot said. “The percentage of anoxic voxels was only a poor predictor of favorable neurological outcome at 180 days, questioning the validity of the primary endpoint,” he said. He also noted that 23% of the trial participants did not have an MRI scan because of higher than expected 5-day rates of death.

“The percentage of patients with favorable neurological outcome tended to be somewhat higher in the intervention arm, although this did not reach statistical significance at ICU discharge and at 180 days,” Dr. Ameloot said. He noted that 42% of the intervention group and 33% of controls in the full-analysis set (P = .30) and 43% and 27%, respectively, in the per-protocol set (P = .15) had a favorable neurological outcome, as calculated using the Glasgow-Pittsburgh Cerebral Performance Category scores of 1 or 2, at 180 days.

The study did not reveal any noteworthy differences in ICU stay (7 vs. 8 days, P = .13) or days on mechanical ventilation (5 vs. 7, P = .31), although fewer patients in the EGDHO group required a tracheostomy (4% vs. 18%, P = .02). The intervention group also had lower rates of cardiac events, including recurrent cardiac arrest, limb ischemia, new atrial fibrillation, and pulmonary edema (13% vs. 33%; P = .02), Dr. Ameloot said.

Future post-hoc analyses of the data will explore the hypothesis that higher blood pressure leads to improved coronary perfusion and reduced infarct size, thus improving prognosis, he added.

“Should this trial therefore be the definite end to the promising hypothesis that improving brain oxygenation might reduce the second hit in post–cardiac arrest patients? I don’t think so,” Dr. Ameloot said. He noted a few limits to the study: that the perfusion rate on MRI was a poor predictor of 180-day outcome; that more patients than expected entered the trial without receiving basic life support and with nonshockable rhythms; and that there was possibly less extensive brain damage among controls at baseline. “Only an adequately powered clinical trial can provide an answer about the effects of EGDHO in post–cardiac arrest patients,” Dr. Ameloot said.

Dr. Ameloot had no financial relationships to disclose.

SOURCE: Ameloot K et al. AHA 2018, Abstract 18620
 

The conversion rate from minimally invasive to open surgery for liver resection has been known to be high, but researchers from the University of Illinois, Chicago, have reported that conversion rates are considerably lower in robot-assisted liver resections, which may ultimately improve survival and complication rates.

Master Video/Shutterstock

Their study, published in the International Journal of Medical Robotics and Computer Assisted Surgery, found that the overall conversion rate of robot-assisted to open surgery for liver resection was 4.4%, considerably lower than that for the pure laparoscopic approach. “The robotic assist could potentially help in decreasing the conversion rate,” said Federico Gheza, MD, and his coauthors. They claimed that this is the first paper to focus on reasons for conversion from robot-assisted liver resection to open surgery.

The study findings are based on a systematic review of 29 series of 1,091 patients who had robot-assisted liver resection, including Dr. Gheza’s and his coauthors’ own series of 139 patients who had the operation from 2007 to 2017. The series were published from 2009 to 2017.

Dr. Gheza’s and his coauthors’ series had a conversion rate of 7.9%. When their results were included with those of the previously published studies, the conversion rate was 4.8%.

Dr. Gheza and his coauthors noted that the conversion rate for minimally invasive hepatic operations is one of the highest among all types of laparoscopic operations, with rates reported as high as 23% in published series (Ann Surg. 2016;263:761-77). “More importantly, preliminary database analysis and large series review suggested an association between conversion and higher morbidity and mortality,” the study noted.

The purpose of the systematic review was to better understand reasons for conversion from robotic to open in liver resections, Dr. Gheza and his coauthors said. They noted a study of 2,861 laparoscopic resections reported that more than one-third of patients were converted for bleeding, and almost one-fifth (18.9%) for peritoneal adhesions (Ann Surg. 2017;268:1051-7). “In the whole literature on hepatic robotic surgery, no conversion due to adhesion was reported,” Dr. Gheza and his coauthors said.

A subanalysis of nine series that included both robotic (360 patients) and laparoscopic (462 patients) surgeries found conversion rates of 2.5% vs. 8%, respectively (P less than .01).

Dr. Gheza and his coauthors called for a prospective trial to further define the impact of robotic surgery on conversions, but the clinical implications of conversions to open surgery in minimally invasive hepatic surgery remain unclear.

Dr. Gheza disclosed relationships with Medtronic. Coauthor P. C. Giulianotti, MD, reported financial relationships with Intuitive, Covidien/Medtronic and Ethicon/Johnson & Johnson. The other coauthors had no relationships to disclose.

SOURCE: Gheza F et al. Intl J Med Robotics Comp Assisted Surg. 2018; doi:10.1002/rcs.1976.

The conversion rate from minimally invasive to open surgery for liver resection has been known to be high, but researchers from the University of Illinois, Chicago, have reported that conversion rates are considerably lower in robot-assisted liver resections, which may ultimately improve survival and complication rates.

Master Video/Shutterstock

Their study, published in the International Journal of Medical Robotics and Computer Assisted Surgery, found that the overall conversion rate of robot-assisted to open surgery for liver resection was 4.4%, considerably lower than that for the pure laparoscopic approach. “The robotic assist could potentially help in decreasing the conversion rate,” said Federico Gheza, MD, and his coauthors. They claimed that this is the first paper to focus on reasons for conversion from robot-assisted liver resection to open surgery.

The study findings are based on a systematic review of 29 series of 1,091 patients who had robot-assisted liver resection, including Dr. Gheza’s and his coauthors’ own series of 139 patients who had the operation from 2007 to 2017. The series were published from 2009 to 2017.

Dr. Gheza’s and his coauthors’ series had a conversion rate of 7.9%. When their results were included with those of the previously published studies, the conversion rate was 4.8%.

Dr. Gheza and his coauthors noted that the conversion rate for minimally invasive hepatic operations is one of the highest among all types of laparoscopic operations, with rates reported as high as 23% in published series (Ann Surg. 2016;263:761-77). “More importantly, preliminary database analysis and large series review suggested an association between conversion and higher morbidity and mortality,” the study noted.

The purpose of the systematic review was to better understand reasons for conversion from robotic to open in liver resections, Dr. Gheza and his coauthors said. They noted a study of 2,861 laparoscopic resections reported that more than one-third of patients were converted for bleeding, and almost one-fifth (18.9%) for peritoneal adhesions (Ann Surg. 2017;268:1051-7). “In the whole literature on hepatic robotic surgery, no conversion due to adhesion was reported,” Dr. Gheza and his coauthors said.

A subanalysis of nine series that included both robotic (360 patients) and laparoscopic (462 patients) surgeries found conversion rates of 2.5% vs. 8%, respectively (P less than .01).

Dr. Gheza and his coauthors called for a prospective trial to further define the impact of robotic surgery on conversions, but the clinical implications of conversions to open surgery in minimally invasive hepatic surgery remain unclear.

Dr. Gheza disclosed relationships with Medtronic. Coauthor P. C. Giulianotti, MD, reported financial relationships with Intuitive, Covidien/Medtronic and Ethicon/Johnson & Johnson. The other coauthors had no relationships to disclose.

SOURCE: Gheza F et al. Intl J Med Robotics Comp Assisted Surg. 2018; doi:10.1002/rcs.1976.

The conversion rate from minimally invasive to open surgery for liver resection has been known to be high, but researchers from the University of Illinois, Chicago, have reported that conversion rates are considerably lower in robot-assisted liver resections, which may ultimately improve survival and complication rates.

Master Video/Shutterstock

Their study, published in the International Journal of Medical Robotics and Computer Assisted Surgery, found that the overall conversion rate of robot-assisted to open surgery for liver resection was 4.4%, considerably lower than that for the pure laparoscopic approach. “The robotic assist could potentially help in decreasing the conversion rate,” said Federico Gheza, MD, and his coauthors. They claimed that this is the first paper to focus on reasons for conversion from robot-assisted liver resection to open surgery.

The study findings are based on a systematic review of 29 series of 1,091 patients who had robot-assisted liver resection, including Dr. Gheza’s and his coauthors’ own series of 139 patients who had the operation from 2007 to 2017. The series were published from 2009 to 2017.

Dr. Gheza’s and his coauthors’ series had a conversion rate of 7.9%. When their results were included with those of the previously published studies, the conversion rate was 4.8%.

Dr. Gheza and his coauthors noted that the conversion rate for minimally invasive hepatic operations is one of the highest among all types of laparoscopic operations, with rates reported as high as 23% in published series (Ann Surg. 2016;263:761-77). “More importantly, preliminary database analysis and large series review suggested an association between conversion and higher morbidity and mortality,” the study noted.

The purpose of the systematic review was to better understand reasons for conversion from robotic to open in liver resections, Dr. Gheza and his coauthors said. They noted a study of 2,861 laparoscopic resections reported that more than one-third of patients were converted for bleeding, and almost one-fifth (18.9%) for peritoneal adhesions (Ann Surg. 2017;268:1051-7). “In the whole literature on hepatic robotic surgery, no conversion due to adhesion was reported,” Dr. Gheza and his coauthors said.

A subanalysis of nine series that included both robotic (360 patients) and laparoscopic (462 patients) surgeries found conversion rates of 2.5% vs. 8%, respectively (P less than .01).

Dr. Gheza and his coauthors called for a prospective trial to further define the impact of robotic surgery on conversions, but the clinical implications of conversions to open surgery in minimally invasive hepatic surgery remain unclear.

Dr. Gheza disclosed relationships with Medtronic. Coauthor P. C. Giulianotti, MD, reported financial relationships with Intuitive, Covidien/Medtronic and Ethicon/Johnson & Johnson. The other coauthors had no relationships to disclose.

SOURCE: Gheza F et al. Intl J Med Robotics Comp Assisted Surg. 2018; doi:10.1002/rcs.1976.