Publications by authors named "Geoffrey P Kohn"

22 Publications

  • Page 1 of 1

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

Surg Endosc 2021 Sep 19;35(9):4903-4917. Epub 2021 Jul 19.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.

Methods: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.

Conclusions: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.
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http://dx.doi.org/10.1007/s00464-021-08625-5DOI Listing
September 2021

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines development: standard operating procedure.

Surg Endosc 2021 06 19;35(6):2417-2427. Epub 2021 Apr 19.

Department of Surgery, Stony Brook University, Stony Brook, USA.

Introduction: The mission of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is to innovate, educate, and collaborate to improve patient care. A critical element in meeting this mission is the publishing of trustworthy and current guidelines for the practicing surgeon.

Methods: In this manuscript, we outline the steps of developing high quality practice guidelines using a completely volunteer-based professional organization.

Results: SAGES has developed a standardized approach to train volunteer surgeons and trainees alike to develop clinically pertinent guidelines in a timely manner, without sacrificing quality.

Conclusions: This methodology can be used more widely by volunteer organizations to efficiently develop effective tools for practicing physicians.
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http://dx.doi.org/10.1007/s00464-021-08469-zDOI Listing
June 2021

Chicago Classification update (v4.0): Technical review of high-resolution manometry metrics for EGJ barrier function.

Neurogastroenterol Motil 2021 Mar 2:e14113. Epub 2021 Mar 2.

Department of Medicine, University of California, San Diego, California, USA.

Esophagogastric junction (EGJ) barrier function is of fundamental importance in the pathophysiology of gastroesophageal reflux disease. Impaired EGJ barrier function leads to excessive distal esophageal acid exposure or, in severe cases, esophagitis. Hence, proposed high-resolution manometry (HRM) metrics assessing EGJ integrity are clinically important and were a focus of the Chicago Classification (CC) working group for inclusion in CC v4.0. However, the EGJ is a complex sphincter comprised of both crural diaphragm (CD) and lower esophageal sphincter (LES) component, each of which is subject to independent physiological control mechanisms and pathophysiology. No single metric can capture all attributes of EGJ barrier function. The working group considered several potential metrics of EGJ integrity including LES-CD separation, the EGJ contractile integral (EGJ-CI), the respiratory inversion point (RIP), and intragastric pressure. Strong recommendations were made regarding LES-CD separation as indicative of hiatus hernia, although the numerical threshold for defining hiatal hernia was not agreed upon. There was no agreement on the significance of the RIP, only that it could localize either above the LES or between the LES and CD in cases of hiatus hernia. There was agreement on how to measure the EGJ-CI and that it should be referenced to gastric pressure in units of mmHg cm, but the numerical threshold indicative of a hypotensive EGJ varied widely among reports and was not agreed upon. Intragastric pressure was endorsed as an important metric worthy of further study but there was no agreement on a numerical threshold indicative of abdominal obesity.
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http://dx.doi.org/10.1111/nmo.14113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8410874PMC
March 2021

Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis.

Surg Endosc 2021 05 2;35(5):1949-1962. Epub 2021 Mar 2.

Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA.

Background: Achalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia.

Methods: We conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively.

Results: From 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment "success" RR 1.71, 95% CI 1.34-2.17; 126 patients) and in observational studies (Eckardt score MD - 0.43, 95% CI - 0.71 to - 0.16; 5 studies; I 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08-0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6-12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02-7.00; I 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events.

Conclusions: POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.
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http://dx.doi.org/10.1007/s00464-021-08353-wDOI Listing
May 2021

SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia.

Surg Endosc 2021 05 9;35(5):1931-1948. Epub 2021 Feb 9.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD) OBJECTIVE: These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia.

Results: The panel agreed on 4 recommendations for adults and children with achalasia.

Conclusions: Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III.
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http://dx.doi.org/10.1007/s00464-020-08282-0DOI Listing
May 2021

SAGES guidelines: an appraisal of their quality and value by SAGES members.

Surg Endosc 2021 04 2;35(4):1493-1499. Epub 2021 Feb 2.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee develops evidence-based guidelines for practicing surgeons using standard methodology. Our objective was to survey the SAGES membership regarding guidelines' quality, use, and value and identify topics of interest for new guideline development.

Methods: An anonymous online survey was emailed in October 2019 to SAGES members. Respondents were asked 18 questions on their use and evaluation of SAGES guidelines and SAGES reviews and to provide suggestions for new guideline topics and areas of improvement. The survey was open for 6 weeks with a 3-week reminder.

Results: Of 548 responders, most were minimally invasive (41%) or general surgeons (33%). There was an even distribution between academic (46%) and non-academic practice (24% private practice, 23% hospital employed). Most used SAGES guidelines frequently (22%) or occasionally (68%) and found them to be of value (83%), above average quality (86%), and easy to use (74%). While most stated it was important (35%) or very important (58%) that SAGES continues to follow "rigorous guidelines development processes," common suggestions were for more timely updates and improved web access. Of 442 overlapping topic suggestions, 60% fell into overarching categories of hernia, bariatric, robotic, HPB, and colorectal surgery.

Conclusions: The SAGES guidelines are used frequently and valued by its users for their quality and content. Topics proposed by SAGES members and valuable insight from this survey can guide creation of new guidelines and refinement of established guidelines and processes.
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http://dx.doi.org/10.1007/s00464-021-08323-2DOI Listing
April 2021

Central Venous Line Placement prior to Gastric Bypass Improves Operating Room Efficiency.

ISRN Surg 2012 8;2012:816871. Epub 2012 Jul 8.

Department of Surgery, The University of North Carolina at Chapel Hill, Campus Box 7081, Chapel Hill, NC 27599, USA.

Background. Bariatric surgery has increased across America. Venous access is difficult in these patients. Anesthesiologists often utilize valuable operating room (OR) time acquiring reliable intravenous lines. Our objective was to determine if outpatient central venous line (CVL) placement improves OR efficiency and professional reimbursement for CVL insertion. Methods. In our bariatric practice, selected surgery patients have outpatient CVLs placed during prophylactic vena cava filter placement. In a cohort of 268 gastric bypass patients operated between 1/01 and 11/06, we compared time-to-incision between 106 with pre-established CVLs and 162 without. In addition, we determined professional compensation rates for CVLs placed outpatient versus CVLs inserted in the OR. Results. Patients with preoperative (outpatient) CVLs required 35.6 ± 12.5 minutes to skin incision compared with 42.5 ± 13.9 minutes for controls (P < 0.0001), and 34.9% had skin incision in <30 minutes compared with 16.4% of controls. Radiologists collected 28.2% of outpatient billings for CPT code 36556, compared with anesthesiologists who collected <1% when placing CVLs in the OR. Conclusions. Outpatient CVLs prior to gastric bypass improve efficiency in the OR with earlier skin incision. Professional reimbursement is better for outpatient CVLs than intraoperative inpatient CVLs.
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http://dx.doi.org/10.5402/2012/816871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399345PMC
August 2012

SAGES guidelines for the surgical treatment of esophageal achalasia.

Surg Endosc 2012 Feb 2;26(2):296-311. Epub 2011 Nov 2.

Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas HealthCare System, CMC Specialty Surgery Center Suite 300, 1025 Morehead Medical Plaza, Charlotte, NC 28204, USA.

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http://dx.doi.org/10.1007/s00464-011-2017-2DOI Listing
February 2012

Treatment options and outcomes for celiac artery compression syndrome.

Surg Innov 2011 Dec 16;18(4):338-43. Epub 2011 Feb 16.

Monash University, Melbourne, Victoria, Australia.

Background: Abdominal pain attributed to compression of the celiac artery at the level of the median arcuate ligament (MAL) of the diaphragm is an uncommon disorder. Although ultrasound investigation and arteriography can be suggestive of the diagnosis, no definitive criteria exist with only cases reports in the literature. This study presents the only known reported case series in which a combination of open and laparoscopic access techniques of MAL decompression are reported.

Methods: A retrospective review of prospectively collected electronic databases of the University of North Carolina at Chapel Hill was performed for the period February 1999 until February 2009. Patients having undergone operation for celiac artery compression syndrome were identified and participated in a telephone interview. Questions were asked about the success of the operation, the recovery period, and patient satisfaction.

Results: Six patients were identified, 3 were male; mean age was 37.7 years. Four underwent open MAL division and celiac ganglion neurolysis, and 2 underwent a laparoscopic approach. Mean follow-up was 48.6 months. All patients experienced symptomatic improvement and were satisfied with their outcome. No patient had symptoms recurrence.

Conclusion: In this limited experience, MAL division with celiac ganglion neurolysis appears to be an effective treatment for celiac artery compression syndrome in appropriately selected patients. Both the open and laparoscopic approaches are safe with durable midterm follow-up results.
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http://dx.doi.org/10.1177/1553350610397383DOI Listing
December 2011

Guidelines for surgical treatment of gastroesophageal reflux disease.

Surg Endosc 2010 Nov 20;24(11):2647-69. Epub 2010 Aug 20.

Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA.

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http://dx.doi.org/10.1007/s00464-010-1267-8DOI Listing
November 2010

High case volumes and surgical fellowships are associated with improved outcomes for bariatric surgery patients: a justification of current credentialing initiatives for practice and training.

J Am Coll Surg 2010 Jun;210(6):909-18

Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Recent years have seen the establishment of bariatric surgery credentialing processes, center-of-excellence programs, and fellowship training positions. The effects of center-of-excellence status and of the presence of training programs have not previously been examined. The objective of this study was to examine the effects of case volume, center-of-excellence status, and training programs on early outcomes of bariatric surgery.

Study Design: Data were obtained from the Nationwide Inpatient Sample from 1998 to 2006. Quantification of patient comorbidities was made using the Charlson Index. Using logistic regression modeling, annual case volumes were analyzed for an association with each institution's center-of-excellence status and training program status. Risk-adjusted outcomes measures were calculated for these hospital-level parameters.

Results: Data from 102,069 bariatric operations were obtained. Adjusting for comorbidities, greater bariatric case volume was associated with improvements in the incidence of total complications (odds ratio [OR] 0.99937 for each single case increase, p = 0.01), in-hospital mortality (OR 0.99717, p < 0.01), and most other complications. Hospitals with a Fellowship Council-affiliated gastrointestinal surgery training program were associated with risk-adjusted improvements in rates of splenectomy (OR 0.2853, p < 0.001) and bacterial pneumonias (OR 0.65898, p = 0.02). Center-of-excellence status, irrespective of the accrediting entity, had minimal independent association with outcomes. A surgical residency program had a varying association with outcomes.

Conclusions: The hypothesized positive volume-outcomes relationship of bariatric surgery is shown without arbitrarily categorizing hospitals to case volume groups, by analysis of volume as a continuous variable. Institutions with a dedicated fellowship training program have also been shown, in part, to be associated with improved outcomes. The concept of volume-dependent center-of-excellence programs is supported, although no independent association with the credentialing process is noted.
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http://dx.doi.org/10.1016/j.jamcollsurg.2010.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892649PMC
June 2010

Low correlation between subjective and objective measures of knowledge on surgery clerkships.

J Am Coll Surg 2010 May;210(5):680-3, 683-5

Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7081, USA.

Background: Medical student knowledge is assessed during surgical clerkships subjectively and objectively. Subjective evaluation depends on faculty assessment during clinical and didactic interactions. Objective measurement derives from standardized tools, such as the National Board of Medical Examiners Surgery Subject test (shelf). Few efforts have been made to characterize the correlation between subjective and objective measures of medical knowledge.

Study Design: All 308 third-year medical students who completed the 8-week surgery clerkship at the University of North Carolina at Chapel Hill between July 2005 and June 2007 received subjective assessment of knowledge on 3 clinical rotations (one 4-week core and two 2-week elective rotations) and a longitudinal small-group tutorial. Faculty evaluators assigned percentile scores to rate students' knowledge base relative to their peers. In addition, students took the shelf test the last day of clerkship, and percentile scores were assigned based on National Board of Medical Examiners-supplied normative data from first-time test-takers within the same academic quarter. Subjective versus objective knowledge scores were plotted overall, and Pearson product-moment correlation coefficients were generated for core, elective, and tutorial assessments.

Results: There were only weak linear relationships noted between subjective faculty-assigned knowledge scores and objective shelf scores. Pearson correlations were 0.24 for core rotations (4 weeks exposure), 0.14 for elective rotations (2 weeks exposure), and 0.22 for tutorials (1-hour exposure/week during 8 weeks), with p values <0.0001.

Conclusions: Faculty assessment of knowledge is only weakly correlated with shelf performance. Faculty evaluations after 4-week rotations or longitudinal small-group interactions are better correlated with shelf scores than after 2-week electives.
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http://dx.doi.org/10.1016/j.jamcollsurg.2009.12.020DOI Listing
May 2010

Proximal esophageal pH monitoring: improved definition of normal values and determination of a composite pH score.

J Am Coll Surg 2010 Mar;210(3):345-50

Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Background: Patients with respiratory and laryngeal symptoms are commonly referred for evaluation of reflux disease as a potential cause. Dual-probe pH monitoring is often performed, although data on normal acid exposure in the proximal esophagus are limited because of the small number of normal subjects and inconsistent placement of the proximal pH sensor in relation to the upper esophageal sphincter. We measured proximal esophageal acid exposure using dual-probe pH and calculated a composite pH score in a large number of asymptomatic volunteers to better define normal values.

Study Design: Eighty-one normal subjects free of reflux, laryngeal, or respiratory symptoms were recruited. All had video esophagraphy to exclude hiatal hernia. Esophageal pH monitoring was performed using 1 of 3 different dual-probe catheters with sensors spaced 10, 15, or 18 cm apart. The standard components of esophageal acid exposure were measured, excluding meal periods. A composite pH score for the proximal esophagus was calculated using these components.

Results: The final study population consisted of 59 (49% male) subjects, with a median age of 27 years. All had normal distal esophageal acid exposure and no hiatal hernia. The 95(th) percentile values for the percent time the pH was < 4 for the total, upright, and supine periods were 0.9%, 1.2%, and 0.4%, respectively. The 95(th) percentile for the number of reflux episodes was 24 and for the calculated proximal esophageal composite pH score was 16.4.

Conclusions: In a large population of normal subjects, we have defined the normal values and calculated a composite pH score for proximal esophageal acid exposure. The total percent time pH < 4 was similar to previously published normal values, but the number of reflux episodes was greater.
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http://dx.doi.org/10.1016/j.jamcollsurg.2009.12.006DOI Listing
March 2010

Recent trends in bariatric surgery case volume in the United States.

Surgery 2009 Aug;146(2):375-80

Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7081, USA.

Background: Reports of increasing bariatric surgery volumes have driven resource allocation by health care systems and device manufacturers. Professional organizations and third-party payers have embraced credentialing systems to limit frivolous expansion. The underlying data upon which these reports are based are disparate and derived from imperfect methodologies. We queried the Nationwide Inpatient Sample (NIS) using several established search strategies to validate the current understanding of bariatric trends.

Methods: NIS search algorithms capture bariatric admissions by the presence of International Classification of Disease, Ninth-Revision, Clinical Modification (ICD-9-CM) codes for obesity and bariatric procedures, with varying levels of inclusiveness for related foregut procedure codes. We applied 1 novel and 4 established algorithms to NIS data sets from 1998 to 2006 to generate contemporary case-volume curves, and we supplemented our data with industry estimates of ambulatory surgery volumes.

Results: From 1998 to 2003, the number of bariatric operations increased markedly by all search strategies. Since then, a greater variation was observed in case volume estimates but no evidence of continuing growth was identified, irrespective of the search protocol employed.

Conclusion: Bariatric procedures peaked in 2003 and have since plateaued. The estimation of case volumes is limited by deficiencies in data and nonuniform search criteria. These factors should be considered by surgeons, professional organizations, hospitals, and third-party payers when planning for the future.
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http://dx.doi.org/10.1016/j.surg.2009.06.005DOI Listing
August 2009

Prevalence of thrombophilias in patients presenting for bariatric surgery.

Obes Surg 2009 Sep 5;19(9):1278-85. Epub 2009 Jul 5.

Department of Surgery, University of North Carolina at Chapel Hill, Campus Box 7081, Chapel Hill, NC 27599-7081, USA.

Background: The rise in bariatric surgery has driven an increased number of complications from venous thromboembolism (VTE). Evidence supports obesity as an independent risk factor for VTE, but the specific derangements underlying the hypercoagulability of obesity are not well defined. To better characterize VTE risk for the purpose of tailoring prophylactic strategies, we developed a protocol for thrombophilia screening in patients presenting for bariatric surgery at our institution.

Methods: Between April 2004 and April 2006, 180 bariatric surgery candidates underwent serologic screening for inherited thrombophilias (Factor V-Leiden mutation, low Protein C activity, low Protein S activity, Free Protein S deficiency) and acquired thrombophilias (D-Dimer elevation, Fibrinogen elevation, elevation of coagulation factors VIII, IX, and XI, elevation of Lupus anticoagulants and homocysteine level, and Antithrombin III deficiency). Prevalence rate of each thrombophilia in the subject group was compared to the actual prevalence rate of the general population.

Results: Most plasma markers of both inherited and acquired thrombophilias were identified in higher than expected proportions, including D-Dimer elevation in 31%, Fibrinogen elevation in 40%, Factor VIII elevation in 50%, Factor IX elevation in 64%, Factor XI elevation in 50%, and Lupus anticoagulant in 13%.

Conclusions: Obesity is a well-described demographic risk factor for VTE. In bariatric surgery candidates routinely screened for serologic markers, both inherited and acquired thrombophilias occurred more frequently than in the general population, and may therefore prove to be useful for individualized VTE risk assessment and prophylaxis.
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http://dx.doi.org/10.1007/s11695-009-9906-7DOI Listing
September 2009

The impact of socioeconomic factors on patient preparation for bariatric surgery.

Obes Surg 2009 Aug 11;19(8):1089-95. Epub 2009 Jun 11.

Presbyterian General Surgery, Albuquerque, NM, USA.

Background: Socioeconomic factors (SEF) influence bariatric surgery access and outcomes perhaps because of variations in patient knowledge and behaviors. This study examines the associations between income, formal education, race, health insurance, employment status, and patient self-educational and behavioral activities prior to bariatric surgery.

Methods: From March 2005 through January 2006, we surveyed 127 individuals who contacted our office seeking bariatric surgery. Study participants were asked to report their income, formal education, health insurance, employment status, height, weight, and standard demographic data. The type and number of self-educational resources utilized were elicited; a description of current eating and exercise behaviors was obtained; and an objective assessment (OA) of knowledge of the risks of both obesity and bariatric procedures was completed.

Results: The most valuable self-educational resource cited by respondents was the internet (41.2%) and was unaffected by SEF. Individuals who were employed, privately insured, white, and earning>or=$20,000/year reported using a greater number of self-educational resources than their peers, while subjects who were privately insured, had higher formal educational levels, and earned>or=$20,000/year demonstrated greater proficiency on the OA instrument. Engagement in healthy eating and exercise behaviors was unaffected by any SEF. On multivariate analysis, higher income was the sole significant factor directly related to the number of educational resources utilized and proficiency on OA.

Conclusion: Obese patients from lower-income households may benefit from additional preoperative education. All individuals, regardless of socioeconomic factors, must be encouraged to implement healthy eating and exercise behaviors preoperatively.
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http://dx.doi.org/10.1007/s11695-009-9889-4DOI Listing
August 2009

Laparoscopic robot-assisted completion cholecystectomy: a report of three cases.

Int J Med Robot 2009 Dec;5(4):406-9

Department of Surgery, University of North Carolina at Chapel Hill, NC 27599-7081, USA.

Background: Gangrenous cholecystitis remains a serious, life-threatening, surgical emergency. Surgeons are occasionally forced to perform a subtotal cholecystectomy and forego formal dissection of the cystic duct and artery, in an attempt to avoid iatrogenic injury to the common bile duct. Not infrequently, a patient may develop a persistent biliary fistula or symptomatic gall bladder remnant, which may ultimately require operative intervention.

Methods: Three patients were referred to the University of North Carolina Hospitals for evaluation and treatment. All patients initially presented with gangrenous cholecystitis and had undergone open cholecystectomies and placement of surgical drains at outside medical facilities. All three patients had subsequently developed persistent biliary leaks or had significant gall bladder remnants. Due to the anticipated difficulty and complexity of performing a laparoscopic completion cholecystectomy in this setting, the DaVinci robot (Intuitive Surgical, Sunnyvale, CA, USA) was utilized for these three consecutive patients. Dissection was performed using two robotic instrument arms, as well as assistant ports for suction/irrigation devices, clips and endostaplers.

Results: All three patients were found to have significant gall bladder and cystic duct remnants, some with sizeable retained stones in the infundibulum. All procedures were completed laparoscopically with robotic assistance, with no complications. At follow-up, all patients were without biliary leaks or symptoms.

Conclusion: Laparoscopic robot-assisted completion cholecystectomy is a feasible option in the setting of a reoperative, hostile abdomen following gangrenous cholecystitis.
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http://dx.doi.org/10.1002/rcs.270DOI Listing
December 2009

Risk-group targeted inferior vena cava filter placement in gastric bypass patients.

Obes Surg 2009 Apr 6;19(4):451-5. Epub 2009 Jan 6.

Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7081, USA.

Background: Despite a growing body of evidence guiding appropriate perioperative thromboprophylaxis in the general population, few data direct strategies to reduce deep venous thrombosis (DVT) and pulmonary embolism (PE) in the morbidly obese. We have implemented a novel protocol for venous thromboembolism (VTE) risk stratification in Roux-en-Y gastric bypass (RYGB) candidates at our institution, which augments clinical assessment with screening for thrombophilias, to guide retrievable inferior vena cava (IVC) filter utilization.

Methods: A retrospective review of prospectively collected data from patients who underwent primary RYGB between 2001 and 2008 at the University of North Carolina at Chapel Hill was completed. During that time, clinical assessment of VTE risk was amplified by focused plasma screening for common thrombophilias (factors VIII, IX, and XI, d-dimer, fibrinogen). Preoperative prophylactic IVC filters were offered to high-risk patients. The database was reviewed for perioperative DVTs, PEs, and filter-related complications.

Results: Of 330 patients, in 162 attempts, 160 had prophylactic IVC filters placed with four complications overall (2.47%). No patient had symptoms of PE during the planned 6-week filter period, though one had a PE occur immediately after filter removal (0.63%); in contrast, five of 170 patients (2.94%) without prophylactic IVC filters presented with symptomatic PE (p = 0.216). In total, 147 (91.88%) prophylactic filters were removed.

Conclusions: Risk-group targeted prophylactic inferior vena cava filter placement prior to RYGB is safe with a trend towards reduced occurrence of PE.
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http://dx.doi.org/10.1007/s11695-008-9794-2DOI Listing
April 2009

Clinical application of laparoscopic bariatric surgery: an evidence-based review.

Surg Endosc 2009 May 6;23(5):930-49. Epub 2009 Jan 6.

Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7081, USA.

Background: Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

Methods: This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

Results: Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

Conclusions: Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.
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http://dx.doi.org/10.1007/s00464-008-0217-1DOI Listing
May 2009

Endoscopic retrograde cholangiopancreatography with single-balloon enteroscopy is feasible in patients with a prior Roux-en-Y anastomosis.

Dig Dis Sci 2009 Aug 7;54(8):1798-803. Epub 2008 Nov 7.

Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, 130 Mason Farm Rd., Chapel Hill, NC 27599-7080, USA.

The purpose of this study is to describe the feasibility of using single-balloon enteroscopy (SBE) to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who had a prior Roux-en-Y (RY) anastomosis. This case series describes four patients, one with RY gastric bypass, two with RY due to bile duct injury, and one with RY after liver transplantation, who underwent ERCP with SBE. Cholangiography was successful in three of the four patients. In the procedure that was not successful, the enteroenterostomy site could not be located. The successful procedures ranged from 65-91 min in duration. Medication doses were higher than with typical ERCPs. No procedural complications occurred. SBE for ERCP is a feasible option for endoscopic access to the biliary tree in patients with prior RY anastomoses. Limitations of this technique include the time requirement, delay in identification of the enteroenterostomy site, potential learning curve, and immature technology lacking accessories.
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http://dx.doi.org/10.1007/s10620-008-0538-xDOI Listing
August 2009

Robotic choledochojejunostomy with intracorporeal Roux limb construction.

Int J Med Robot 2008 Sep;4(3):263-7

Division of Gastrointestinal Surgery, University of North Carolina at Chapel Hill, NC 27599-7081, USA.

Background: Biliary surgery can often be very complex, with difficult access issues, small structures to be manipulated and sutured and proximity to major vessels. Additionally, biliary surgery is often reoperative. All of these issues have the potential to be aided by the use of technology which provides three-dimensional (3D) vision, excellent illumination and access, with steady instrument control under maximal magnification. The robot is such a technology which is currently available.

Methods: The Da Vinci robot was used to perform a robotic choledochojejunostomy, using five ports and a totally intracorporeal technique.

Results: Two patients were studied. There were no conversions to open operation. There was no mortality. One patient experienced a postoperative bile leak, which was successfully managed endoscopically.

Conclusions: Robotic choledochojejunostomy with intracorporeal Roux-en-Y anastomosis is a feasible operation with a definite learning curve. It has potential benefits to the patient.
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http://dx.doi.org/10.1002/rcs.206DOI Listing
September 2008

Endoscopic management of recurrent primary bile duct stones.

ANZ J Surg 2008 Jul;78(7):579-82

Hepatobiliary/Upper Gastrointestinal Surgical Unit, Box Hill Hospital, Melbourne, Victoria, Australia.

Background: The management of recurrent choledocholithiasis today remains as challenging as in the pre-endoscopic era. Between 2 and 7% of affected patients have historically required surgical intervention for the treatment of recurrent or retained choledocholithiasis and of these, as many as 24% develop biliary complications. To avoid surgery, repeated endoscopic management of the problem has been suggested. In this study, we evaluate our policy of repeated endoscopic management of recurrent primary bile duct stones.

Methods: This study examined a cohort of nine patients identified from a prospective database with recurrent choledocholithiasis. Demographic, clinical and investigative details were recorded and data were analysed. Complications were determined from a review of the patient's file.

Results: There were nine patients and 66 procedures were carried out. Mean age at time of first endoscopy was 70.1 years (36-91 years). Three patients were of male sex (33.3%). The mean number of endoscopies carried out per patient was 7.3 (3-13). Failure to completely clear the duct occurred in 36.4% of all endoscopies. There were no periprocedural complications.

Conclusion: Repeated endoscopic stone extraction by endoscopic retrograde cholangiopancreatography when required is a safe policy. However, this technique will only provide temporary relief from primary duct stones and repeated endoscopic treatment, again safe, will be required.
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http://dx.doi.org/10.1111/j.1445-2197.2008.04577.xDOI Listing
July 2008
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