Alexander R. Aurora’s scientific contributions

Surgeons are the directors of the future in surgery. Since the dawn of surgery, surgeons have been pushing the envelope and impatiently awaiting technology to catch up. In the early days of surgery, there was more interest in how large an incision could be made and how much exposure could be achieved. Patients were proud to show off their stem-to-stern incision and brag they survived. In this new era, surgery has taken a 180° turn, and we pride ourselves on doing the most surgery through the smallest incision, or even better, no incision. This has been the birth of scarless surgery. Although laparoscopy has been practiced since the early 1900s, it was not until the advent of the charge-coupled device (CCD) that videoscopic surgery rose to prime time.

The concept of natural orifice surgery introduced by Kalloo in 2004 created excitement and hope for a new type of surgery with less pain, quicker recovery, and improved cosmesis. The first NOTES procedure performed by Kalloo was a NOTES transgastric gastrojejunostomy in a porcine model. NOTES has expanded by leaps and bounds since its inception with human cases of almost every speciality tackled by multiple natural orifices. Enthusiasts have pushed the frontier of NOTES past its expectations and although it has not yet become mainstream, it is ingrained in surgery to stay. In the future, the NOTES approach will not exist in a vacuum, but rather will be merged with other endoscopic and laparoscopic methods to provide enhanced therapy. Specifically, development of a stable surgical platform from which to operate and a dependable closure device will catapult NOTES into the mainstream. Development of these devices is well under way, with multiple closure devices, operating platforms, and hemostatic devices already being used in both animal and human models. Nonetheless, industry will have to step up to keep pace with the ever-expanding applications surgeons can imagine for this technology.

Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation. An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were "sleeve gastrectomy" OR "gastric sleeve" AND "leak." We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation. The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) > 50 kg/m(2)] and 2.2% for BMI < 50 kg/m(2). Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of cases. Most leaks were diagnosed after discharge. Endoscopic management is a viable option for leaks and was documented in 11% of cases as successful. Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4%. Attention to detail specifically at the esophagogastric junction cannot be stressed enough. Careful patient selection (BMI < 50 kg/m(2)) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will happen after patient discharge.