Marc A. Ward M.D.

Ward, M.A., Ebrahim, A., Clothier, J.S., Prajapati, P.K., Ogola, G.O., Davis, D.G. and Leeds, S.G. (2020). “Factors that promote successful endoscopic management of laparoscopic sleeve gastrectomy leaks.” Surg Endosc Aug 11. [Epub ahead of print.].

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INTRODUCTION: Staple line leaks following laparoscopic sleeve gastrectomy (LSG) are associated with significant morbidity and mortality. Endoluminal techniques, including stent placement and endoluminal vacuum therapy (EVAC), have become viable options to treat these patients without the need for additional surgery. The purpose of this study was to define the conditions where certain endoscopic therapies are most likely to succeed compared to surgery. METHODS: An IRB approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to March 2019. All patients who were treated for gastrointestinal leaks following LSG were included. Endpoints include success of leak closure and hospital-related morbidity for the patients treated solely by endoscopic only methods (EP) compared to the additional surgery group (SP). RESULTS: There were 39 patients (33 females; 6 males) with a median age of 45.9 years. The EP group included 23 patients (59%), whereas SP included 16 patients (31%). On average, the SP had longer days from sentinel surgery to our hospital admission (70 vs 41), a higher percentage of previous bariatric surgery prior to sentinel LSG (50% vs 17%), and a higher readmission rates following discharge (50% vs 39%). Total length of stay was also higher in the SP compared to the EP (45.4 vs 11). Using this data, a treatment algorithm was developed to optimally treat future patients who suffer from gastrointestinal leaks following LSG. CONCLUSIONS: Endoscopic therapies, such as EVAC, stent placement, internal drainage, and over-the-scope clips, have a higher chance of success if performed earlier to their sentinel surgery and if patients have had no prior bariatric surgeries. Patients who require additional surgery tend to have longer hospital stays and readmission rates. Using the treatment algorithm provided can help determine when endoscopic therapies are likely to succeed.

Leeds, S. G., A. Ebrahim, E. M. Potter, J. S. Clothier, P. Prajapati, G. O. Ogola and M. A. Ward (2020). “The role of preoperative workup in predicting dysphagia, dilation, or explantation after magnetic sphincter augmentation.” Surg Endosc May 27. [Epub ahead of print].

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BACKGROUND: Magnetic sphincter augmentation (MSA) is a surgical treatment for gastroesophageal reflux disease using a ring of titanium beads to improve the function of the lower esophageal sphincter. Prior to implantation, a comprehensive preoperative esophageal workup is required to determine patient candidacy in an effort to reduce the dysphagia, dilation, and explantation rate of the device. This study was designed to assess the best predictors for these endpoints. METHODS: A prospectively maintained IRB-approved database was retrospectively reviewed for patients undergoing MSA implantation. Patients were divided into 3 groups, those that needed no intervention, those that needed medical intervention with oral steroids for reported dysphagia, and surgical intervention, which included endoscopic dilation and/or surgical explantation. Primary endpoints included preoperative objective and subjective testing from a comprehensive esophageal workup including intraoperative notation of number of beads on the device. RESULTS: There were 99 patients eligible for the study with a mean age of 52 and mean follow-up of 10.2 months. Mean BMI was 27 and 59% were female. The no-intervention group had 59 patients, medical intervention group had 25 patients, and surgical intervention group had 15 patients. Preoperative esophageal manometry findings, pH testing off medications, endoscopic and radiologic evaluation showed no difference between the 3 groups. No differences were seen in preoperative subjective evaluations based on GERD-HRQL or RSI scores. There was no difference in average number of beads on the device between the 3 groups. CONCLUSION: A comprehensive esophageal workup is important to confirm the presence of gastroesophageal reflux disease and rule out other esophageal pathology. However, this study shows that a preoperative comprehensive esophageal workup does not predict which patients will develop dysphagia or require either medical or surgical interventions following MSA implantation.

Ward, M. A., T. Hassan, J. S. Burdick and S. G. Leeds (2019). “Endoscopic vacuum assisted wound closure (EVAC) device to treat esophageal and gastric leaks: assessing time to proficiency and cost.” Surg Endosc 33(12): 3970-3975.

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BACKGROUND: Endoluminal vacuum therapy (EVAC) is an emerging procedure used to treat anastomotic leaks and/or perforations that would otherwise require surgery. The aim of this study was to determine time to proficiency in EVAC and the cost effectiveness of the procedure. METHODS: We retrospectively reviewed a prospectively maintained IRB approved database for all patients undergoing EVAC after esophageal and gastric complications between October 2013 and December 2017. Proficiency was determined by obtaining predicted estimates and analyzing the point at which average procedure time plateaued based on case volume. Total cost was calculated based on supplies and location where the procedure was performed. RESULTS: There were 50 patients (17 males, 33 female), with a mean age of 52.1 years. EVAC was placed in 23 (46%) patients with esophageal injuries and 28 (56%) with gastric injuries. Two advanced endoscopists performed all EVAC procedures in this study (1 surgeon, 1 gastroenterologist). The average procedure time for all patients was 43.5 min and the average wheel in/wheel out time for all patients was 75.6 min. Analysis of the trend based on average procedure times for EVAC revealed that proficiency was obtained after 10 cases. Total cost of the procedure is significantly lower in the GI lab compared to the operating room ($4528 vs. $11889). The majority of EVAC were performed in the GI lab (62%) compared to the operating room (38%). CONCLUSION: Successful outcomes in managing anastomotic leaks or intestinal perforations non-operatively has led to an increased interest in EVAC. For advanced endoscopists, time to proficiency is approximately 10 cases. Performing the procedure in the GI lab has a 2.5 reduction in total cost compared to the operating room.

Ward, M. A., A. Ebrahim, J. Kopita, L. Arviso, G. O. Ogola, B. Buckmaster and S. G. Leeds (2019). “Magnetic sphincter augmentation is an effective treatment for atypical symptoms caused by gastroesophageal reflux disease.” Surg Endosc Dec 2. [Epub ahead of print].

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BACKGROUND: The purpose of this study was to determine whether magnetic sphincter augmentation (MSA) could effectively treat patients with gastroesophageal reflux disease (GERD) who suffer primarily from atypical symptoms due to laryngopharyngeal reflux (LPR). MSA has been shown to treat typical symptoms of GERD with good success, but its effect on atypical symptoms is unknown. METHODS: A retrospective review of a prospectively maintained institutional review board-approved database was conducted for all patients who underwent MSA between January 2015 and December 2018. All patients had objective confirmation of GERD from ambulatory pH monitoring off anti-reflux medications (DeMeester score > 14.7). Symptoms were assessed preoperatively and at 1 year postoperatively using GERD Health-Related Quality of Life (GERD-HRQL) and Reflux Symptom Index (RSI) questionnaires. RESULTS: There were 86 patients (38 males; 48 females) with a median age of 51.5 years. Total GERD HRQL scores improved from a mean of 38.79 to 6.53 (p < 0.01) and RSI scores improved from a mean of 20.9 to 8.1 (p < 0.01). Atypical symptoms evaluated from the RSI questionnaire include hoarseness, throat clearing, postnasal drip, breathing difficulties, and cough. All atypical symptoms were significantly improved at 1 year following MSA (p < 0.01). All three typical symptoms of heartburn, dysphagia, and regurgitation were significantly improved based on pre and postoperative GERD HRQL questionnaires (p < 0.02). Ninety-one percent of patients were off their PPI and dissatisfaction with their current therapy decreased from 95% preoperatively to 13% postoperatively. CONCLUSION: MSA is an effective treatment for typical and atypical GERD symptoms.

Garbarino, G. M., U. Marchese, R. Tobome, M. A. Ward, E. Vibert, B. Gayet, D. Cherqui and D. Fuks (2019). “Laparoscopic versus open unisegmentectomy in two specialized centers. Feasibility and short-term results.” HPB (Oxford) Oct 28. [Epub ahead of print].

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BACKGROUND: Anatomical segmentectomy is defined as the complete removal of the Couinaud’s segment. The aim of this study was to compare the perioperative outcomes of laparoscopic (LS) versus open (OS) unisegmentectomy in two high volume centers. METHODS: A retrospective review of all consecutive unisegmentectomies from 2007 to 2017 was performed at the Institut Mutualiste Montsouris and at the Hepatobiliary Center of Paul Brousse Hospital. RESULTS: A total of 177 patients underwent unisegmentectomy: 58 LS vs 52 OS in the anterolateral segments, 33 LS vs 34 OS in the posterosuperior segments. HCC were more frequent in the OS group, whereas colorectal liver metastases were more frequently treated with LS. Blood loss (200 vs. 400 ml, p = 0.006), operative time (238 vs. 267 min, p = 0.048) and median length of stay (6 vs. 8 days, p = 0.036) were significantly lower in the LS group. The resection margins (4 mm vs. 2 mm, p = 0.763) and the overall morbidity did not differ between the two groups. In the posterosuperior segment, OS group had more pulmonary complications (9 vs. 29%, p = 0.035). CONCLUSION: Laparoscopic anatomical unisegmentectomies for selected patients, even with postero-superior based tumors, in specialized centers seems to be safe and feasible.