Stauffer, John

The objective of this study was to examine whether preoperative recommendation for specific reductions in body mass index (BMI) influenced weight loss in obese surgical patients. We retrospectively reviewed the electronic medical records of 48 patients who enrolled between January 2007 to June 2010 in an 800-calorie per day liquid meal replacement (LMR) weight loss program. Of these, 9 patients (surgical group) enrolled as a result of general surgeon-directed weight loss to enable nonbariatric surgery and 39 enrolled seeking weight loss (medical group). Patients enrolled in the LMR program before bariatric surgery were excluded from analysis. All patients were seen in the setting of a comprehensive weight loss program supervised by a medical bariatrician and followed for a period of 4 months. There were no significant differences in mean initial BMI between surgical and medical patients (41.7 ± 4.55 and 41.6 ± 8.54 kg/m 2 , respectively) or participation time in the weight loss program (120 days vs 133 days). Of the nine surgical patients, only five (56%) reached their weight goal and underwent the planned surgical procedure. Weight loss was significantly less in the surgical compared with medical patients (BMI reduction 4.03 ± 3.99 vs 7.75 ± 4.90 kg/m 2 , respectively; P < 0.05). Weight loss was significantly lower in patients directed to undergo BMI reduction to enable a general surgical procedure. Future studies are needed to assess factors influencing weight loss (metabolism, exercise capacity, motivation) in patients requiring weight loss to enable a surgical procedure.

Introduction: Minimally invasive major hepatic resection (MIMHR) is increasingly being performed in tertiary centers using either hand-assisted laparoscopic surgery (HALS) or totally laparoscopic surgery (TLS). The outcomes data of MIMHR are scarce, especially in comparison to open major hepatic resection (OMHR). Our aim was to compare 90-day outcomes in major hepatic resections when minimally invasive approaches are attempted. Methods and Procedures: At our institution, minimally invasive liver resection was formally introduced in January 2007, initially using the HALS approach. Since then, the use of TLS approach has increased. We collected data on all patients who underwent major liver resection between January 2007 and December 2017 at our institution. In an intention to treat fashion, we then compared MIMHR to OMHR. Results: From January 2007 to December 2017, 669 patients underwent liver resection. Of these, 203 patients (30%) underwent major hepatic resection and MIMHR and OMHR were performed in 68 (33%) and 135 (67%) patients, respectively. The rate of conversion from minimally invasive to open was 30.9%. Overall, there were no significant differences in 90-day mortality (2.9% versus 1.5%; P = .499) or major complications (14.7% versus 14.8%; P = .985). MIMHR was associated with a shorter average postoperative hospital stay (6.2 days versus 7.9 days; P = .0110) and shorter average ICU stay (0.66 days versus 0.90 days; P = .0299) compared with OMHR. Conclusions: The minimally invasive approach to major liver resection is a safe and reasonable alternative to an open approach when performed by a surgeon experienced with the relevant surgical techniques. MIMHR may be associated with similar outcomes and a shorter postoperative hospital stay with no increase in 90-day postoperative complications to OMHR.

AbstractEfforts to improve mortality associated with locally advanced pancreatic cancer (LAPC) have shown minimal gains despite advances in surgical technique, systemic treatments, and radiation therapy. Locoregional therapy with ablation has not been routinely adopted due to the high risk of complications associated with thermal destruction of the pancreas. Irreversible electroporation (IRE) is an emerging, nonthermal, ablative technology that has demonstrated the ability to generate controlled ablation of LAPC while preserving pancreatic parenchymal integrity. IRE may be performed percutaneously or via laparotomy and will commonly involve multidisciplinary treatment teams. This article will describe the technical aspects of how multidisciplinary IRE is performed during laparotomy at a single tertiary care institution.

Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. Results: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. Conclusion: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Abstract Objective The Superior Mesenteric Artery Syndrome (SMAS) was first described by Rokitansky in 1842. Clinical symptoms include postprandial pain, nausea, vomiting and weight loss. Duodenojejunostomy is the treatment of choice for patients with SMAS. We now present a case of a young female with SMAS who successfully underwent laparoscopic duodenojejunostomy. Indications The first line treatment for SMAS is medical management, which includes infusion therapy, bowel rest, parenteral nutrition and a nasojejunal feeding tube inserted into the jejunum past the obstruction. If medical therapy fails, surgery is recommended. Procedure A symptomatic patient with body mass index (BMI) of 19.4 kg/m2 underwent laparoscopic duodenojejunostomy. The patient tolerated the procedure well. The post-operative period was uneventful and the patient was discharged after three days. On six month follow up, the patient had gained weight and her symptoms were completely resolved. Conclusion SMAS is still a poorly recognised pathology. A high index of suspicion should be given for patients with unclear causes of postprandial nausea, vomiting and abdominal pain, especially in young females. A laparoscopic approach seems to be safe and effective for patients with SMAS.