Alan A Saber’s research while affiliated with Beth Israel Medical Center and other places

Objective Recently, there has been a burgeoning interest in the utilization of customized bariatric stents (CBS) for management of sleeve gastrectomy leak (SGL). We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these new stents and to compare them with the conventional esophageal stents (CES). Methods A systematic literature search of the PubMed, Cochrane Library, Scopus, Web of Science and Google Scholar databases was conducted through May 1, 2020. Primary outcomes were technical and clinical success and post-procedure adverse events of CBS and CES. Secondary outcomes were number of stents and endoscopic sessions per patient, and time to leak closure. A proportion meta-analysis was performed on outcomes using a random-effects model, and the weighted pooled rates (WPRs) or mean difference with 95% confidence interval (CI) were calculated. Results The WPR with 95% CI of technical success, clinical success, and stent migration for CBS were 99% (93–100%) I² = 34%, 82% (69–93%) I² = 58%, and 32% (17–49%), I² = 69%, respectively. For CES, the WPR (95% CI) for technical success, clinical success, and stent migration were 100% (97–100%) I² = 19%, 93% (85–98%) I² = 30%, and 15% (7–25%), I² = 41%, respectively. Adverse events other than migration were very low with both types of stents. On proportionate difference, CBS had lower clinical success (11%) and higher migration rate (17%) in comparison to CES. In successfully treated patients, CBS was associated with lower mean number of stents and endoscopic sessions, and shorter time to leak closure compared to CES. The overall quality of evidence was very low. Conclusions In treatment of SGL, there is very low level evidence that CES are superior to CBS in terms of clinical success and migration rate, though may require more stent insertions and endoscopic procedures. The evidence however remains very uncertain. Perhaps relevant to some types of stents, CBS are promising; however design modification is strongly recommended to improve outcomes.

Background: The efficacy of transversus abdominis plane (TAP) block compared with thoracic epidural analgesia (TEA) in abdominal surgery has been controversial. We conducted this systematic review and meta-analysis to assess outcomes of TAP block and TEA in a procedure-specific manner in colorectal surgery. Methods: A systematic literature search of the PubMed, Embase, Cochrane Library, and Scopus databases was conducted through July 10, 2020, to identify randomized controlled trials (RCTs) comparing TAP block with TEA in colorectal surgery. Primary outcomes were pain scores at rest and movement at 24 h postoperatively. Secondary outcomes included postoperative pain scores at 0-2 and 48 h, opioid consumption, postoperative nausea and vomiting (PONV), functional recovery, hospital stay, and adverse events. Results: Six RCTs with 568 patients were included. Methodological quality of these RCTs ranged from moderate to high. TAP block provided comparable pain control, lower 24 h and total opioid consumption, shorter time to ambulation and urinary catheter time, and lower incidence of sensory disturbance and postoperative hypotension compared with TEA. Meanwhile, the 48-h opioid consumption, PONV incidence, and hospital stay were similar between groups. When laparoscopic surgery was the only surgical approach employed, TAP block provided additional benefits of shorter time to first flatus and lower incidence of PONV compared with TEA. Conclusions: Perhaps more germane to minimally invasive procedures, TAP block is equivalent to TEA in terms of postoperative pain control and provides better functional recovery with lower incidence of adverse events in patients undergoing colorectal surgery.

Controversy exists regarding the use of minimally invasive surgery (MIS) during the corona virus disease 2019 (COVID-19) pandemic. Several surgical societies have issued recommendations regarding precaution measures during MIS, nonetheless these recommendations were conflicting with respect to the use of laparoscopy with little or no inference to natural-orifice endoscopic surgery. A comprehensive literature search was performed to explore the available evidence pertinent to the novel coronavirus 2 (SARS-CoV-2) transmission dynamics in MIS, and benefits of MIS procedures in patients with transmissible viral diseases. According to the current evidence, SARS-CoV-2 has a multi-route transmission, including fecal-oral transmission. Evidence on airborne transmission in the operative setting are however limited. In addition to nasopharyngeal screening, it would seem prudent to perform routine fecal testing for SARS-CoV-2 in patients undergoing positive-pressure transanal minimally invasive procedures. This is particularly relevant to regions with high level of epidemicity. In patients with confirmed SARS-CoV-2 infection, conventional laparoscopic and robotic approaches, and atmospheric transanal surgery with high volume smoke evacuation may be safer alternatives. Considering the high rates of postoperative pulmonary complications and mortality associated with SARS-CoV-2 infection, use of laparoscopy is advised in suspected or confirmed COVID-19 patients who require abdominal surgery, particularly older patients and those with comorbidities. Laparoscopy may decrease the probability of postoperative disease exacerbation, and provide earlier recovery, less morbidity and mortality, and shorter hospital stay with subsequent decreased risk of in-hospital secondary transmission. High index of suspicion in postoperative patients with fever or respiratory symptoms is necessary to timely diagnose COVID-19. Chest computed tomography scan has a higher sensitivity compared to real-time PCR and can potentially be used to assist in the diagnosis, particularly in elderly patients.

Background: Optimal postoperative pain therapy for patients undergoing minimally invasive surgery remains controversial. The aim of this meta-analysis was to compare the efficacy and safety of the novel laparoscopic-guided transversus abdominis plane block (L-TAP) to other analgesic alternatives in adults undergoing minimally invasive surgery. Study design: A systematic literature search of several databases was conducted according to the PRISMA guidelines through March 9, 2020, to identify randomized controlled trials (RCTs) reporting on L-TAP. Primary outcomes were pain scores at rest and movement at 24 hours postoperatively. Secondary outcomes included postoperative pain scores at 0-4 and 48 hours, opioid consumption, hospital stay, functional recovery, patient satisfaction, and adverse events. Results: Nineteen RCTs with 1983 patients were included. All trials compared L-TAP with ultrasound-guided transversus abdominis plane block (US-TAP), local infiltration analgesia (LIA), or inactive control; none controlled for epidural analgesia. Methodological quality of these RCTs ranged from moderate to high. L-TAP provided comparable pain control compared with US-TAP, and better early pain control compared with LIA. Recovery parameters, 24-hour opioid consumption, and postoperative nausea and vomiting (PONV) were comparable between L-TAP and US-TAP. Meanwhile, 24-hour opioid consumption, PONV incidence, hospital stay, and patient satisfaction were in favor of L-TAP compared with LIA. None of the studies reported adverse events related to L-TAP procedure. Conclusion: L-TAP is safe, and superior to LIA with respect to early pain control, opioid consumption, and patient satisfaction in adults undergoing minimally invasive surgery. Given its equivalence to US-TAP, L-TAP can be used as a safer and pragmatic alternative to epidural analgesia in this patient population.

Background Transversus abdominis plane (TAP) block is a form of regional anesthesia that has been increasingly employed in minimally invasive surgery. The data regarding its use in laparoscopic bariatric surgery however is still limited and at times controversial. Objectives The aim of this meta-analysis was to assess the efficacy of TAP block after laparoscopic bariatric surgery. Materials A systematic search was conducted through the Embase, Cochrane Collaboration, and PubMed databases for randomized controlled trials (RCTs) evaluating the effects of TAP block in patients undergoing laparoscopic bariatric surgery. Meta-analysis was performed using a random-effects model. Primary endpoints were late (24 hours) pain scores at rest and on movement. Secondary endpoints included early (0–3 hours) pain scores at rest and on movement, opioid consumption, time to ambulation, length of hospital stay, and adverse events. Results Ten RCTs met our inclusion criteria with 404 patients in the TAP block groups, and 413 patients in the control groups. TAP block was associated with significantly improved late pain scores (at rest, standardized mean difference (SMD) –0.95, P < 0.001; on movement, SMD −1.04, P = 0.01), and early pain scores ( at rest, SMD –1.81, P < 0.001; on movement, SMD –1.80, P < 0.001), reduced postoperative opioid consumption at 24 hours (SMD –2.23 mg IV morphine, P < 0.001), a shorter time to ambulation (SMD –1.07 hours, P < 0.001), and reduced incidence of postoperative nausea and vomiting (OR 0.20, P = 0.01). No significant difference was noted regarding length of hospital stay (P = 0.70). Postoperative TAP block administration resulted in greater effects on opioid consumption at 24 hours compared with preoperative block administration. Finally, none of the studies reported any adverse effect of local anesthetic. Conclusion Given the significant impact on early and late postoperative pain, opioid consumption, and postoperative recovery, and the low risk profile, TAP block using a short-acting anesthetic should be encouraged in routine practice in patients undergoing laparoscopic bariatric surgery.

The intragastric balloon has become a widespread modality for weight reduction in the obese population. It eliminates major issues with surgery, such as difficult accessibility, high costs, patient non-preference, and the potential morbidity and mortality. Therefore, minimally invasive and effective methods are needed for the treatment of obesity. As such, intragastric balloon was recently reintroduced as an endoscopic bariatric treatment option. The aim of this chapter is to look at the indication and the uses of intragastric balloon in obese patients.

Background: To date, there have been no large-scale enhanced recovery projects in bariatric surgery in the United States. Objective: The aim of this project was to implement an enhanced recovery protocol for selected Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program centers and determine its impact on length of stay, bleeding, readmissions, and reoperation rates. Setting: University and private practice programs, United States. Methods: Participating sites were identified based on historical extended length of stay (ELOS, ≥4 d). A 6-month run-up period was used to allow implementation of the protocol. Primary bariatric procedures were included in the analysis, which compared ELOS from historic data (2016) with outcomes during the Employing Enhanced Recovery Goals in Bariatric Surgery (ENERGY) project. Relationships between adherence to the 26 process measures and ELOS were analyzed. Specific adverse 30-day outcomes were monitored. Results: Thirty-six centers participated in the project. The final analytic sample consisted of 18,048 cases total over a 24-month period, including 8946 from the 2016 calendar year and 9102 from the ENERGY period. The overall rates of ELOS for pre- and postintervention were 8.1% and 4.5%, respectively, without increasing readmission rates, reoperation rates, or overall morbidity. Bleeding rates increased from .8% preintervention to 1.1% during ENERGY (adjusted P = .06). There was a significant association between increased adherence score and decreased odds of ELOS (P < .01). Conclusion: Implementation of a large-scale enhanced recovery project is feasible and results in decreased ELOS without increasing overall adverse events or readmissions. Increased adherence to the protocol was closely associated with decreased ELOS. The ENERGY protocol or similar enhanced recovery pathways should be implemented on a larger scale to further improve the care and outcomes of bariatric surgery patients.

Improved fertility following a Roux-en-Y gastric bypass (RYGB) can lead to pregnancy and increase the risk of internal herniation. A developing fetus and symptoms of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. The aim of this systematic review is to summarize the literature regarding internal hernias during pregnancy, their management, and patient outcomes. A comprehensive literature search was undertaken on PubMed and Google Scholar to identify cases of internal hernias presenting during pregnancy after RYGB. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for eligibility and inclusion of articles. Twenty-seven articles, with a total of 59 patients, regarding internal herniation during pregnancy after RYGB were identified. Epigastric pain and nausea and vomiting was the most common presentation. Regardless of orientation of the Roux limb and despite previous closure of mesenteric defects, internal herniation can still occur. A triad of epigastric pain, pregnancy, and a history of RYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis. Prompt bariatric consultation and rapid intervention will improve maternal and fetal outcomes.