Join BTK's Dr. Kevin Kniery for a discussion on How to do a Liver Transplant with Dr. Shah and Dr. Dageforde.



Additional resources:



- Watch: Liver Transplant Surgical Techniques - https://www.youtube.com/watch?v=Vk1Ld7Fp5es



- Listen: 

Surgical Technique: Kidney Transplant (Part 1) https://behindtheknife.org/podcast/surgical-technique-kidney-transplant-part-1/



Surgical Technique: Kidney Transplant (Part 2) 

https://behindtheknife.org/podcast/surgical-technique-kidney-transplant-part-2/



Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

How to do a Liver Transplant with Dr. Shah and Dr. Dageforde

Behind the Knife is the world’s #1 surgery podcast.  From high-yield educational topics to interviews with leaders in the field, Behind the Knife delivers the information you need to know.  Tune in for timely, relevant, and engaging content designed to help you DOMINATE THE DAY!

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Bariatric surgery is an evolving field with new procedures, or variations of old ones, being developed to meet the needs of patients with obesity. The single anastomosis duodenoileal bypass (SADI) and one anastomosis gastric bypass (OAGB) are two such procedures which have recently entered the mainstream conversation. In this episode we will give a brief overview of the SADI and OAGB, go over some short and long term studies evaluating safety and efficacy, and discuss current sentiments about these options and how they may fit into bariatric practice. 



Show Hosts:

Matthew Martin, MD

Adrian Dan, MD

Crystal Johnson-Mann, MD

Paul Wisniowski, MD



Article #1: Chao 2024 - Outcomes of SADI and OAGB Compared to RYGB from the Metabolic and Bariatric Surgery Quality Improvement Program: The North American Experience

Roux-en-Y gastric bypass (RYGB) and duodenal switch are well described procedure for weight loss; however, associated postoperative complications have led to the development of simpler techniques
Single anastomosis duodenoileal bypass (SADI) - modification of the duodenal switch where by a loop of ileum of the bilopancreatic limb approximately 200-300cm from the ileal cecal valve is anastomosed to the distal duodenal cuff of a tubularized stomach
One anastomosis gastric bypass (OAGB) – modification of the RYGB where a loop of jejunum of the bilopancreatic limb approximately 150-200cm from the ligament of treitz is anastomosed to the distal end of a gastric pouch.



There is increasing interest in these procedures given the perceived reduced risk reduction associated with one fewer anastomosis
Currently, there is insufficient data on the safety of these procedures compared to the established RYGB. 
The article utilizes the MBSAQIP database to evaluate each procedure against the RYGB 
Matched groups: SADI vs RYGB and OAGB vs RYGB 
Matched against age, sex, BMI, operative time, and ASA classification
30-day outcomes included complications and health care utilization
Results were analyzed with univariate comparative analysis, and significant outcomes were examined with logistic regression
SADI vs RYGB: SADI independently associated INCREASED odds with staple line leak, sepsis, organ space infection, and pneumonia. 
OAGB vs RYGB: OAGB independently associated with REDUCED odds of SSI, transfusion requirement/GI bleed, ICU admission, bowel obstruction, and healthcare utilization (reoperation, readmissions, and reinterventions)
No significant differences in mortality



Limitation: Article generally reviews technical complications of procedures. Unable to address significant bariatric outcomes such as weight loss and metabolic profile, as well as long term outcomes. 
https://pubmed.ncbi.nlm.nih.gov/38170422/




Article #2: Maud 2019 - Efficacy and safety of OAGB vs RYGB for obesity (YOMEGA trial): A multicentre, randomized, open label, non-inferiority trial






Limited long-term evidence on OAGB
Mostly arising from retrospective analyses and one meta-analysis
Two randomized clinical trials but with poor power and questionable methodology. 



This is a randomized non-inferiority trial of in patients undergoing bariatric surgery  
Randomized into 2 groups: OAGB vs RYGB with 117 patients per group
Patients were followed for 2 years with a loss to follow up of 21% in OAGB and 24% in RYGB cohorts
The primary outcome was weight loss with a noninferiority threshold of 7% assuming 60% weight loss at 2 years. Secondary outcomes included complications and metabolic outcomes
Groups were compared with Student’s T and Wilcoxon tests for quantitative data, and chi-squared and Fischer’s exact for qualitative endpoints. 
Cohorts were analyzed with the intention to treat, and missing data on the primary endpoint was imputed with prediction-based modeling. 



Highlighted Outcomes
Mean percent excess BMI loss of 87.9% in OAGB group compared to 85.8% in RYGB group demonstrating non-inferiority in terms of weight loss
Increased number of serious adverse events (SAE) in the OAGB group, but no difference in the proportion of patients with at least 1 SAE
OAGB demonstrated 70% complete or partial remission of diabetes compared to 44% in RYGB but underpowered to demonstrate significant difference. 
Equal rates of gastritis and esophagitis based on endoscopic biopsy results at 2 years.
There were increased nutritional complications in the OAGB groups with 21% vs 0% in RYGB and high rates of diarrhea/anal fissures 14% vs 0%, respectively. This suggests a greater malabsorptive effect of OAGB. 
There was equal satisfaction in quality of life between RYGB and OAGB on two validated surveys with >80% satisfaction rates.



Limitations
Data was imputed for the primary end point
High rates of loss to follow up in both cohorts
Use of “severe adverse events” instead of Clavien-Dindo classification
Comparison of specific institutional/surgeon technique of OAGB vs RYGB

https://pubmed.ncbi.nlm.nih.gov/30851879/









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Journal Review in Bariatric Surgery: Are Less Anastomoses Better?

Join Drs. Jason Bingham (@BinghamMd) and Patrick Georgoff (@georgoff) for a thought-provoking discussion with titans of hernia surgery Drs. Todd Heniford (@THeniford) and Michael Rosen (@MikeRosenMD).  You don't want to miss this one!  This episode goes deep, touching on some of the most vexing questions in the world of abdominal wall reconstruction.  



Highlights: 

Hernia is chronic disease process.  Surgeons should act like it and patients need to understand this.  
Follow-up data is hard to come by and therefore limited.  Studies must be interpreted with this in mind.
Hernia surgery is sexy, which is both exciting and concerning.
"Technology is not useful until it is boring."  New techniques and devices can hurt patients.  
Complicated hernias should be sent to hernia centers.  Otherwise, general surgeons are more than capable of doing the repair.

Link to paper: https://jamanetwork.com/journals/jamasurgery/fullarticle/2816986



Link to ACHQC: https://achqc.org/



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Are we failing our patients? Ventral hernia recurrence with Drs. Todd Heniford and Michael Rosen

Join the Behind the Knife Surgical Oncology Team as we discuss the presentation, work-up, and management of gastric cancer.



Hosts:

- Timothy Vreeland, MD, FACS (@vreelant) is an Assistant Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at Brooke Army Medical Center

- Connor Chick, MD (@connor_chick) is a Surgical Oncology fellow at Ohio State University.

- Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a PGY-6 General Surgery resident at Brooke Army Medical Center

- Beth (Elizabeth) Carpenter, MD (@elizcarpenter16) is a PGY-5 General Surgery resident at Brooke Army Medical Center



Learning Objectives:

In this episode, we review the basics of gastric cancer, including presentation, work-up, staging, and treatment modalities as well as high yield topics including the Siewert classification system. We also briefly discuss trials establishing peri-operative chemotherapy regimens for gastric cancer and the controversy of D1 vs. D2 lymphadenectomy.



Links to Papers Referenced in this Episode



Perioperative Chemotherapy versus Surgery Alone for Resectable Gastroesophageal Cancer.

NEJM 2006 Jul;355(1):11-20.

https://www.nejm.org/doi/full/10.1056/NEJMoa055531



Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesphageal junction adenocarcinoma (FLOT4): a randomized, phase2/3 trial

Lancet 2019 May;393(10184):1948-1957.

https://pubmed.ncbi.nlm.nih.gov/30982686/



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Clinical Challenges in Surgical Oncology: Gastric Cancer

Join Drs. Peter Marcello, Jonathan Abelson, Tess Aulet and special guest Dr. Philip Fleshner as they discuss the management of small bowel strictures in Crohn’s disease. 



Learning Objectives

1.    Discuss the role for J-pouch in a patient with inflammatory bowel disease

2.    Identify the key steps in creation of the J-pouch and technical considerations.

3.    Describe post operative complications and management in patients with a J-pouch



Video Link: https://www.youtube.com/watch?v=_PMFaQHah5A



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Clinical Challenges in Colorectal Surgery: J Pouch Creation and Management of Postoperative Pouch Complications

How is each release of the TAR contributing to the final tension on the anterior and posterior fascia? Join Drs. Michael Rosen, Benjamin T. Miller, Sara Maskal, and Ryan C. Ellis as they discuss their group’s recent cohort study of tensiometry in 100 TARs. 



Hosts: 

- Michael Rosen, Cleveland Clinic

- Benjamin T. Miller, Cleveland Clinic

- Sara Maskal, Cleveland Clinic

- Ryan C. Ellis, Cleveland Clinic, @ryanellismd



Learning objectives: 

- Review the steps of a TAR

- Understand the changes in tension on the anterior and posterior fascia with each step of the TAR

- Think about the application this data has to similar operations



References: 



Miller BT, Ellis RC, Petro CC, Krpata DM, Prabhu AS, Beffa LRA, Huang LC, Tu C, Rosen MJ. Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release. JAMA Surg. 2023 Dec 1;158(12):1321-1326. doi: 10.1001/jamasurg.2023.4847. PMID: 37792324; PMCID: PMC10551814. https://pubmed.ncbi.nlm.nih.gov/37792324/



Miller BT, Ellis RC, Walsh RM, Joyce D, Simon R, Almassi N, Lee B, DeBernardo R, Steele S, Haywood S, Beffa L, Tu C, Rosen MJ. Physiologic tension of the abdominal wall. Surg Endosc. 2023 Dec;37(12):9347-9350. doi: 10.1007/s00464-023-10346-w. Epub 2023 Aug 28. PMID: 37640951. https://pubmed.ncbi.nlm.nih.gov/37640951/



Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990 Sep;86(3):519-26. doi: 10.1097/00006534-199009000-00023. PMID: 2143588. https://pubmed.ncbi.nlm.nih.gov/2143588/



Hope WW, Williams ZF, Rawles JW 3rd, Hooks WB 3rd, Clancy TV, Eckhauser FE. Rationale and Technique for Measuring Abdominal Wall Tension in Hernia Repair. Am Surg. 2018 Sep 1;84(9):1446-1449. PMID: 30268173. https://pubmed.ncbi.nlm.nih.gov/30268173/



Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  



If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen


How to do a Liver Transplant with Dr. Shah and Dr. Dageforde

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