Dr. Azagury is a minimally invasive surgeon specializing in digestive surgery, bariatric surgery and general surgery.

Dr. Azagury was trained both in Europe and the United States and is board certified in surgery in Switzerland, his home country. After completing his residency in Switzerland, he undertook a research fellowship focusing on novel minimally invasive techniques at Brigham and Women's Hospital and Harvard Medical School in Boston. He continued his time at the same institution and completed a clinical fellowship in bariatric and minimally invasive surgery. Thriving to innovate in patient care, he pursued further training in medical innovation at Stanford University where he was the 2011-2012 Grube Biodesign fellow. He then returned to Switzerland to become responsible for bariatric surgery at Geneva University Hospital.

Dr. Azagury combines his clinical experience and his passion for innovation to focus on reducing the impact of surgical procedures on patients. He thrives in multidisciplinary collaborations and is always interested in surgical teaching and mentoring.

Alongside his clinical practice, Dr. Azagury is a faculty member at the Stanford Center for Biodesign. He is the assistant director of specialty fellowship program and co-directs the Japan Biodesign partnership program. He is also a faculty member and teaches in multiple medical innovation programs across Europe.

He is the father of three and is fluent in French and Spanish.

Clinical Focus

  • General Surgery
  • Bariatric Surgery
  • Minimally Invasive Surgery

Academic Appointments

Administrative Appointments

  • Assistant Director, Biodesign Specialty Fellowship Program, Stanford Byers Center for Biodesign (2014 - Present)

Honors & Awards

  • Post Medical Diploma Research Grant Award., Arditi Foundation prize (2001)

Boards, Advisory Committees, Professional Organizations

  • Member, Association for Academic Surgery (2014 - Present)
  • Associate Fellow, American College of Surgeons (2010 - Present)
  • Member, ASMBS (American Society for Metabolic and Bariatric Surgery) (2010 - Present)
  • Member, SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) (2009 - Present)
  • Member, Swiss Medical Federation (2005 - Present)

Professional Education

  • Fellowship:Stanford University (2012) CA
  • Fellowship:Brigham and Women's Hospital Harvard Medical School (2011) MA
  • Fellowship:Geneve Univeristy Medical School (2009) Switzerland
  • Residency:Geneve Univeristy Medical School (2009) Switzerland
  • Internship:Hopital de Morges (2002) Switzerland
  • Medical Education:Geneve Univeristy Medical School (2001) Switzerland
  • Fellowship, Stanford University Biodesign Program, Medtech Innovation (2012)
  • Fellowship, Brigham & Women's Hospital, Harvard Medical School, Minimally Invasive & Bariatric Surgery (2011)
  • Research Fellowship, Brigham and Women's Hospital & Harvard Medical School, Developmental Endoscopy (2010)
  • Board Certification: General Surgery, Swiss Medical Federation (FMH), (2008)
  • Board Certification, Swiss Federal Medical Society, General Surgery (2008)
  • Residency, Geneva University Hospital, Surgery (2007)
  • MD, Geneva University School of Medicine, Medicine (2001)

Community and International Work

  • Swiss Federal Humanitarian Aid Corps


    Member, Medical team of Swiss Rescue (Surgeon)



    Ongoing Project


    Opportunities for Student Involvement



  • Dan E. Azagury, Mary K. Garrett, David Gal, Raymond Bonneau. "United States Patent US 20140000622 A1 Devices and methods for preventing tracheal aspiration", Dec 21, 2011
  • David Gal, Raymond Bonneau, Mary K. Garrett, Dan E. Azagury. "United States Patent US 20130165944 A1 Apparatus, systems, and methods for removing obstructions in the urinary tract.", Dec 15, 2011

Current Research and Scholarly Interests

I have multiple research focus areas, with the underlying goal of reducing the impact of surgery on patients.
This involves better understanding the current procedures, and I therefore focus on outcomes research particularly in bariatric surgery.
This also means studying current was of practicing medicine and surgery to determine if old habits are still valid today.
Lastly I think the reduction in surgical impact will come from innovation and I focus both on teaching innovation to physicians - or physicians to be - as well as developing and evaluating novel devices.

2017-18 Courses

All Publications

  • Quality of Life After Bariatric Surgery. Current obesity reports Mazer, L. M., Azagury, D. E., Morton, J. M. 2017; 6 (2): 204-210


    The purpose of this review is to provide an introduction to quality of life (QOL) outcomes after bariatric surgery and a summary of the current evidence.QOL has been emphasized in bariatric surgery since the NIH Consensus Conference statement in 1991. Initial studies were limited to 1- and 2-year follow-up. More recent findings have expanded the follow-up period up to 12 years, providing a better description of the impact on long-term QOL. Overall, there is little to no consensus regarding the definition of QOL or the ideal survey. Bariatric surgery has the greatest impact on physical QOL, and the impact on mental health remains unclear. There are some specific and less frequently reported threats to quality of life after bariatric surgery that are also discussed. Obesity has a definite impact on quality of life, even without other comorbidities, and surgery for obesity results in significant and lasting improvements in patient-reported quality of life outcomes. This conclusion is limited by a wide variety of survey instruments and absence of consensus on the definition of QOL after bariatric surgery.

    View details for DOI 10.1007/s13679-017-0266-7

    View details for PubMedID 28527103

  • Buttressing of the EEA stapler during gastrojejunal anastomosis decreases rate of bleeding-related complications for laparoscopic gastric bypass. Surgery for obesity and related diseases Ichter, Z. A., Voeller, L., Rivas, H., Khoury, H., Azagury, D., Morton, J. M. 2017


    Bariatric surgery is a well-tolerated and effective treatment for severe obesity. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. In particular, buttressing of the staple line in sleeve gastrectomy has decreased rates of clinically significant postoperative bleeding. The present study investigates the effectiveness of buttressing the circular stapled anastomosis during laparoscopic Roux-en-Y gastric bypass (LRYGB).Academic, accredited hospital.A total of 253 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 125 of these cases. Demographic information was collected from both groups preoperatively. Surgical characteristics were also obtained analyzed using unpaired t or χ(2) tests.Patients in both buttressing and nonbuttressing groups were on average 46 years old and predominantly female (79.2% versus 74.2% female, respectively), with a body mass index of approximately 48 kg/m(2). Postoperative weight loss did not significantly differ between groups at any time point (buttressing versus nonbuttressing percentage of excess weight loss: 39.5% versus 41.5% at 3 mo, P = .3860; 56.4% versus 56.7% at 6 mo, P = .9341). There were no significant differences for operating time, length of stay, readmissions, or reoperations. Complications due to strictures were found to be lower for the buttressing group (0% buttressing versus 2.3% nonbuttressing, P = .0851). Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was used (0% buttressing versus 3.1% nonbuttressing, P = .0463).Buttressing of the gastrojejunal anastomosis during LRYGB significantly reduces bleeding-related complications and increases tolerability of the procedure.

    View details for DOI 10.1016/j.soard.2017.01.019

    View details for PubMedID 28325504

  • Characterizing Readmissions After Bariatric Surgery. Journal of gastrointestinal surgery Garg, T., Rosas, U., Rogan, D., Hines, H., Rivas, H., Morton, J. M., Azagury, D. 2016; 20 (11): 1797-1801


    Readmissions are an important quality metric for surgery. Here, we compare characteristics of readmissions across laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), and adjustable gastric band (LAGB).Demographic, intraoperative, anthropometric, and laboratory data were prospectively obtained for 1775 patients at a single academic institution. All instances of readmissions within 1 year were recorded. Data were analyzed using STATA, release 12.For the 1775 patients, 113 (6.37 %) were readmitted. Mean time to readmission was 52.1 days. Of all the readmissions, 64.6 % were within 30 days, 22.1 % from 30 to 90 days, 1.77 % from 90 to 180 days, and 11.5 % from 180 to 365 days. Incidence of 30-day readmissions varied across surgeries (LRYGB: 7.17 %; LAGB: 3.05 %; LSG: 4.25 %, p = 0.04). Time to readmission varied as well, with 90.0 % of LSG and 80.0 % of LABG patients within the first 30 days, versus 60.8 % of LRYGB (p = 0.02). The most common causes of readmissions were gastrointestinal issues related to index procedure (34.5 %) and did not vary across surgeries. In multivariable logistic regression, index hospital length of stay (LOS) was associated with readmission (OR = 1.07, 95 % CI 1.02-1.13, p = 0.01).Readmissions after bariatric surgery are associated with high index hospital LOS, and a measureable proportion of procedure-related readmissions can occur up to 1 year, especially for LRYGB.

    View details for PubMedID 27613733

  • How can we deal with the GERD treatment gap? Annals of the New York Academy of Sciences Triadafilopoulos, G., Azagury, D. 2016; 1381 (1): 14-20


    Patients experiencing heartburn and acid regurgitation despite proton pump inhibition therapy who are averse to antireflux surgery fall into what is called the gastroesophageal reflux disease (GERD) treatment gap. This gap may be potentially addressed by several endoscopic and laparoscopic techniques, including gastric bypass surgery for those patients who are obese. These novel techniques do not significantly alter the anatomy of the esophagogastric junction, minimizing short- and long-term adverse effects. This review provides an overview of the assessment of patients with refractory GERD and highlights the strengths and weaknesses of these minimally invasive therapies.

    View details for DOI 10.1111/nyas.13104

    View details for PubMedID 27384084

  • Bariatric Surgery Outcomes in US Accredited vs Non-Accredited Centers: A Systematic Review. Journal of the American College of Surgeons Azagury, D., Morton, J. M. 2016; 223 (3): 469-477


    Accreditation for bariatric surgery has been scrutinized recently for its impact on surgical outcomes. This study aimed to systematically examine the medical literature to examine the impact of bariatric accreditation on surgical outcomes.The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and checklist were used. The MEDLINE database was searched for the following terms (2000 through September 2014): gastric bypass or bariatric surgery or sleeve gastrectomy or vertical banded gastroplasty or biliopancreatic diversion or duodenal switch or adjustable gastric band or weight loss surgery and accreditation or center of excellence or credentialing or national coverage decision or CMS or Medicare. Only studies in English and articles comparing accredited with non-accredited centers were included. Quality was assessed using the Newcastle-Ottawa scale for evaluation of all studies.Thirteen studies were published in a very short time frame and covered >1.5 million patients. Ten of the 13 studies identified a substantial benefit of Center of Excellence accreditation for risk-adjusted outcomes. Six of the 8 studies reported a considerable reduction in mortality in patients operated on in Centers of Excellence, with odds ratios ranging from 2.26 to 3.57 for non-accredited centers; 2 studies showed no significant difference. Similarly, morbidity was reduced in 8 of 11 studies, although more discreetly, with odds ratios ranging from 1.09 to 1.39.This study found that the preponderance of medical evidence supports accreditation for bariatric surgery.

    View details for DOI 10.1016/j.jamcollsurg.2016.06.014

    View details for PubMedID 27423398

  • Bariatric Surgery: Overview of Procedures and Outcomes. Endocrinology and metabolism clinics of North America Azagury, D. E., Morton, J. M. 2016; 45 (3): 647-656


    Bariatric surgery is the most efficient and long-lasting weight loss therapy available. Its safety has improved over tenfold over the last decade. With the advent of laparoscopy, mortality rates of are now under 1 per 1400 cases in accredited centers. Gastric bypass reduces diabetes-related mortality by 92% over 7 years and long lasting remission has been demonstrated in observational studies covering >10,000 patients and multiple randomized control trials. The benefit of bariatric surgery on diabetes is so substantial that these procedures should be considered in all type 2 diabetic patients with a BMI > 35 kg/m(2).

    View details for DOI 10.1016/j.ecl.2016.04.013

    View details for PubMedID 27519136

  • Patient Safety and Quality Improvement Initiatives in Contemporary Metabolic and Bariatric Surgical Practice. Surgical clinics of North America Azagury, D. E., Morton, J. M. 2016; 96 (4): 733-742


    Patient safety and quality improvement have been part of bariatric surgery since its inception, and there have been significant improvements in outcomes of bariatric surgery over the past 2 decades. A strong accreditation program exists. This program defines 2 tiers of accredited centers: low-acuity and comprehensive centers similar to the trauma systems. Accreditation has been shown to have a favorable impact on outcomes of bariatric surgery. Bariatric surgery lends itself well to improvements in processes and use of perioperative protocols, such as ulcer and thromboembolic prophylaxis prevention or gallstone prevention and management.

    View details for DOI 10.1016/j.suc.2016.03.014

    View details for PubMedID 27473798

  • National prevalence, causes, and risk factors for bariatric surgery readmissions AMERICAN JOURNAL OF SURGERY Garg, T., Rosas, U., Rivas, H., Azagury, D., Morton, J. M. 2016; 212 (1): 76-80


    Readmissions are often used as a quality metric particularly in bariatric surgery.Laparoscopic Roux en Y gastric bypass, laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy were identified using Current Procedure Terminology codes in the 2012 National Surgical Quality Improvement Program public use file.A total of 18,296 patients were included, 10,080 (55.1%) were laparoscopic Roux en Y gastric bypass, 1,829 (10.0%) were laparoscopic adjustable gastric banding, and 6,387 (34.9%) were laparoscopic sleeve gastrectomy. Among all patients, 955 (5.22%) were readmitted. Patients with readmissions had a higher proportion of body mass index greater than 50 (30.2% vs 24.6%, P < .001), higher index operative time (132 minutes vs 115, P < .001) and greater proportion with length of stay greater than 4 days (9.57% vs 3.36%, P < .001). Readmitted patients were more likely to have diabetes (31.1% vs 27.7%, P = .02), chronic obstructive pulmonary disease (2.63% vs 1.72%, P = .04), and hypertension (54.5% vs 50.8%, P = .03). Overall, 40.6% of readmitted patients had a complication. Common readmissions were gastrointestinal-related (45.0%), dietary (33.5%), and bleeding (6.57%). Readmission was independently associated with African-American race (odds ratio [OR] = 1.53, P = .02), complication (OR = 11.3, 95%, P < .001), and resident involvement (OR = .53, P = .04).A 30-day readmission after bariatric surgery is prevalent and closely associated with complications.

    View details for DOI 10.1016/j.amjsurg.2016.01.023

    View details for Web of Science ID 000378063100011

    View details for PubMedID 27133197

  • A postoperative nutritional consult improves bariatric surgery outcomes. Surgery for obesity and related diseases Garg, T., Birge, K., Ulysses Rosas, Azagury, D., Rivas, H., Morton, J. M. 2016; 12 (5): 1052-1056


    Bariatric surgery is the most effective treatment for obesity. Guidelines for optimizing postoperative care are emerging, and roles of the surgeon and registered dietician (RD) have opportunities for coordination.The study objective was to better define the appropriate guidelines for postoperative care by investigating whether a combined surgeon and RD follow-up for the initial postoperative visit within 2 to 6 weeks after surgery improves patient outcomes.The setting was an accredited bariatric hospital in an academic setting.A retrospective analysis of a prospective database was performed on patients who underwent bariatric surgery and were followed up by either a surgeon alone or by a surgeon and RD for initial postoperative visit.There were 302 patients in the surgeon follow-up group and 268 in the RD follow-up. Patients in the RD follow-up group had significantly fewer readmissions due to dietary-related problems (9 versus 0; P = .004), more favorable 3-month change in serum thiamine (-30.5 versus-4.04; P = .002), high-density lipoprotein (-3.42 versus-1.67; P = .053), and triglycerides (-17.5 versus-31.5; P = .03), and trended lower number of minor complications (16 versus 6; P = .08). No significant differences in percent excess weight loss were observed at all time points after surgery. Multivariate logistic models controlling for demographic features found that RD follow-up predicted 3-month increase in thiamine (odds ratio = 2.49; P<.000) and high-density lipoprotein cholesterol (OR = 1.73; P = .01), and decrease in total cholesterol (OR = 1.58; P = .03) and triglycerides (OR = 1.55; P = .03).Follow-up with a surgeon and RD for the initial postoperative visit may help improve patient outcomes.

    View details for DOI 10.1016/j.soard.2016.01.008

    View details for PubMedID 27220825

  • Lipids and bariatric procedures Part 2 of 2: scientific statement from the American Society for Metabolic and Bariatric Surgery (ASMBS), the National Lipid Association (NLA), and Obesity Medicine Association (OMA) SURGERY FOR OBESITY AND RELATED DISEASES Bays, H., Kothari, S. N., Azagury, D. E., Morton, J. M., Nguyen, N. T., Jones, P. H., Jacobson, T. A., Cohen, D. E., Orringer, C., Westman, E. C., Horn, D. B., Scinta, W., Primack, C. 2016; 12 (3): 468-495


    Bariatric procedures generally improve dyslipidemia, sometimes substantially so. Bariatric procedures also improve other major cardiovascular risk factors. This 2-part Scientific Statement examines the lipid effects of bariatric procedures and reflects contributions from authors representing the American Society for Metabolic and Bariatric Surgery (ASMBS), the National Lipid Association (NLA), and the Obesity Medicine Association (OMA). Part 1 was published in the Journal of Clinical Lipidology, and reviewed the impact of bariatric procedures upon adipose tissue endocrine and immune factors, adipose tissue lipid metabolism, as well as the lipid effects of bariatric procedures relative to bile acids and intestinal microbiota. This Part 2 reviews: (1) the importance of nutrients (fats, carbohydrates, and proteins) and their absorption on lipid levels; (2) the effects of bariatric procedures on gut hormones and lipid levels; (3) the effects of bariatric procedures on nonlipid cardiovascular disease (CVD) risk factors; (4) the effects of bariatric procedures on lipid levels; (5) effects of bariatric procedures on CVD; and finally, (6) the potential lipid effects of vitamin, mineral, and trace element deficiencies, that may occur after bariatric procedures.

    View details for DOI 10.1016/j.soard.2016.01.007

    View details for Web of Science ID 000376223300004

    View details for PubMedID 27050404

  • American Society for Metabolic and Bariatric Surgery position statement on long-term survival benefit after metabolic and bariatric surgery SURGERY FOR OBESITY AND RELATED DISEASES Kim, J., Eisenberg, D., Azagury, D., Rogers, A., Campos, G. M. 2016; 12 (3): 453-459


    The following position statement has been issued by the American Society for Metabolic and Bariatric Surgery in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the benefit of metabolic and bariatric surgery on long-term survival. An overview of the current available published peer-reviewed scientific evidence is presented.

    View details for DOI 10.1016/j.soard.2015.11.021

    View details for Web of Science ID 000376223300001

    View details for PubMedID 26944548

  • Twelve key nutritional issues in bariatric surgery. Clinical nutrition Thibault, R., Huber, O., Azagury, D. E., Pichard, C. 2016; 35 (1): 12-17


    In morbidly obese patients, i.e. body mass index ≥35, bariatric surgery is considered the only effective durable weight-loss therapy. Laparoscopic Roux-en-Y gastric bypass (LRYGBP), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS) are associated with risks of nutritional deficiencies and malnutrition. Therefore, preoperative nutritional assessment and correction of vitamin and micronutrient deficiencies, as well as long-term postoperative nutritional follow-up, are advised. Dietetic counseling is mandatory during the first year, optional later. Planned and structured physical exercise should be systematically promoted to maintain muscle mass and bone health. In this review, twelve key perioperative nutritional issues are raised with focus on LRYGBP and LSG procedures, the most common current bariatric procedures.

    View details for DOI 10.1016/j.clnu.2015.02.012

    View details for PubMedID 25779332

  • Lipids and bariatric procedures part 1 of 2: Scientific statement from the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and Obesity Medicine Association: FULL REPORT. Journal of clinical lipidology Bays, H. E., Jones, P. H., Jacobson, T. A., Cohen, D. E., Orringer, C. E., Kothari, S., Azagury, D. E., Morton, J., Nguyen, N. T., Westman, E. C., Horn, D. B., Scinta, W., Primack, C. 2016; 10 (1): 33-57


    Bariatric procedures often improve lipid levels in patients with obesity. This 2 part scientific statement examines the potential lipid benefits of bariatric procedures and represents the contributions from authors representing the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and the Obesity Medicine Association. The foundation for this scientific statement was based on published data through June 2015. Part 1 of this 2 part scientific statement provides an overview of: (1) adipose tissue, cholesterol metabolism, and lipids; (2) bariatric procedures, cholesterol metabolism, and lipids; (3) endocrine factors relevant to lipid influx, synthesis, metabolism, and efflux; (4) immune factors relevant to lipid influx, synthesis, metabolism, and efflux; (5) bariatric procedures, bile acid metabolism, and lipids; and (6) bariatric procedures, intestinal microbiota, and lipids, with specific emphasis on how the alterations in the microbiome by bariatric procedures influence obesity, bile acids, and inflammation, which in turn, may all affect lipid levels. Included in part 2 of this comprehensive scientific statement will be a review of (1) the importance of nutrients (fats, carbohydrates, and proteins) and their absorption on lipid levels; (2) the effects of bariatric procedures on gut hormones and lipid levels; (3) the effects of bariatric procedures on nonlipid cardiovascular disease (CVD) risk factors; (4) the effects of bariatric procedures on lipid levels; (5) effects of bariatric procedures on CVD; and finally, (6) the potential lipid effects of vitamin, mineral, and trace element deficiencies that may occur after bariatric procedures. This document represents the full report of part 1.

    View details for DOI 10.1016/j.jacl.2015.12.002

    View details for PubMedID 26892120

  • Lipids and bariatric procedures part 1 of 2: Scientific statement from the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and Obesity Medicine Association: EXECUTIVE SUMMARY. Journal of clinical lipidology Bays, H. E., Jones, P. H., Jacobson, T. A., Cohen, D. E., Orringer, C. E., Kothari, S., Azagury, D. E., Morton, J., Nguyen, N. T., Westman, E. C., Horn, D. B., Scinta, W., Primack, C. 2016; 10 (1): 15-32


    Bariatric procedures often improve lipid levels in patients with obesity. This 2-part scientific statement examines the potential lipid benefits of bariatric procedures and represents contributions from authors representing the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and the Obesity Medicine Association. The foundation for this scientific statement was based on data published through June 2015. Part 1 of this 2-part scientific statement provides an overview of: (1) adipose tissue, cholesterol metabolism, and lipids; (2) bariatric procedures, cholesterol metabolism, and lipids; (3) endocrine factors relevant to lipid influx, synthesis, metabolism, and efflux; (4) immune factors relevant to lipid influx, synthesis, metabolism, and efflux; (5) bariatric procedures, bile acid metabolism, and lipids; and (6) bariatric procedures, intestinal microbiota, and lipids, with specific emphasis on how the alterations in the microbiome by bariatric procedures influence obesity, bile acids, and inflammation, which in turn, may all affect lipid levels. Included in part 2 of this comprehensive scientific statement will be a review of: (1) the importance of nutrients (fats, carbohydrates, and proteins) and their absorption on lipid levels; (2) the effects of bariatric procedures on gut hormones and lipid levels; (3) the effects of bariatric procedures on nonlipid cardiovascular disease risk factors; (4) the effects of bariatric procedures on lipid levels; (5) effects of bariatric procedures on cardiovascular disease; and finally (6) the potential lipid effects of vitamin, mineral, and trace element deficiencies that may occur after bariatric procedures. This document represents the executive summary of part 1.

    View details for DOI 10.1016/j.jacl.2015.12.003

    View details for PubMedID 26892119

  • Image-guided surgery. Current problems in surgery Azagury, D. E., Dua, M. M., Barrese, J. C., Henderson, J. M., Buchs, N. C., Ris, F., Cloyd, J. M., Martinie, J. B., Razzaque, S., Nicolau, S., Soler, L., Marescaux, J., Visser, B. C. 2015; 52 (12): 476-520

    View details for DOI 10.1067/j.cpsurg.2015.10.001

    View details for PubMedID 26683419

  • SAGES TAVAC safety and effectiveness analysis: da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA). Surgical endoscopy Tsuda, S., Oleynikov, D., Gould, J., Azagury, D., Sandler, B., Hutter, M., Ross, S., Haas, E., Brody, F., Satava, R. 2015; 29 (10): 2873-2884


    The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

    View details for DOI 10.1007/s00464-015-4428-y

    View details for PubMedID 26205559

  • Small bowel obstruction: A practical step-by-step evidence-based approach to evaluation, decision making, and management. journal of trauma and acute care surgery Azagury, D., Liu, R. C., Morgan, A., Spain, D. A. 2015; 79 (4): 661-668


    The initial goal of evaluating a patient with SBO is to immediately identify strangulation and need for urgent operative intervention, concurrent with rapid resuscitation. This relies on a combination of traditional clinical signs and CT findings. In patients without signs of strangulation, a protocol for administration of Gastrografin immediately in the emergency department efficiently sorts patients into those who will resolve their obstructions and those who will fail nonoperative management.Furthermore, because of the unique ability of Gastrografin to draw water into the bowel lumen, it expedites resolution of partial obstructions, shortening time to removal of nasogastric tube liberalization of diet, and discharge from the hospital. Implementation of such a protocol is a complex, multidisciplinary, and time-consuming endeavor. As such, we cannot over emphasize the importance of clear, open communication with everyone involved.If surgical management is warranted, we encourage an initial laparoscopic approach with open access. Even if this results in immediate conversion to laparotomy after assessment of the intra-abdominal status, we encourage this approach with a goal of 30% conversion rate or higher. This will attest that patients will have been given the highest likelihood of a successful laparoscopic LOA.

    View details for DOI 10.1097/TA.0000000000000824

    View details for PubMedID 26402543

  • Does perioperative nutrition and oral carbohydrate load sustainably preserve muscle mass after bariatric surgery? A randomized control trial SURGERY FOR OBESITY AND RELATED DISEASES Azagury, D. E., Ris, F., Pichard, C., Volonte, F., Karsegard, L., Huber, O. 2015; 11 (4): 920-926


    Perioperative nutrition and preoperative oral carbohydrate loading (CHL) have a beneficial impact on the outcomes of gastrointestinal oncological surgery. However no data exists on their effect on morbidly obese patients.Our aim was to establish the short-term and long-term impact of these modalities, notably on metabolically active lean body mass (LBM) - an important factor in maintaining long-term weight loss.Patients undergoing laparoscopic Roux-en-Y gastric bypass were randomized to standard management or intervention: CHL drinks consumed 12 and 2 hours presurgery, and immediate postoperative peripheral parenteral nutrition. The primary outcome measured was LBM, measured by Bioelectrical Impedance Analysis (BIA), one and 12 months postsurgery. Secondary outcomes included excess weight loss (EBWL), 30-day complication rate, and length of stay.Of the 203 randomized patients, 198 were included in the analysis. All 101 patients in the control group completed the one-year follow up and 76 completed the BIA. In the intervention group, 93 of 97 patients completed the one-year follow-up and 71 completed the BIA. At one and 12 months follow-up, body composition, LBM, or EBWL were comparable. There was no difference in operative outcomes, complications rates, or length of stay. There was no adverse effect in the intervention group.In a highly homogeneous group of morbidly obese patients with one-year follow-up, CHL and short-term parenteral nutrition did not lead to significant or sustained LBM preservation or modification in EBWL. There was no significant decrease in complications or length of stay. Our study confirms the safety of these interventions, even in previously unstudied Type 2 diabetic patients.

    View details for DOI 10.1016/j.soard.2014.10.016

    View details for Web of Science ID 000359329500037

    View details for PubMedID 25851776

  • ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management SURGERY FOR OBESITY AND RELATED DISEASES Kim, J., Azagury, D., Eisenberg, D., DeMaria, E., Campos, G. M. 2015; 11 (4): 739-748

    View details for DOI 10.1016/j.soard.2015.05.001

    View details for Web of Science ID 000359329500001

    View details for PubMedID 26071849

  • Deep brain stimulation for obesity: rationale and approach to trial design. Neurosurgical focus Ho, A. L., Sussman, E. S., Pendharkar, A. V., Azagury, D. E., Bohon, C., Halpern, C. H. 2015; 38 (6): E8-?


    Obesity is one of the most serious public health concerns in the US. While bariatric surgery has been shown to be successful for treatment of morbid obesity for those who have undergone unsuccessful behavioral modification, its associated risks and rates of relapse are not insignificant. There exists a neurological basis for the binge-like feeding behavior observed in morbid obesity that is believed to be due to dysregulation of the reward circuitry. The authors present a review of the evidence of the neuroanatomical basis for obesity, the potential neural targets for deep brain stimulation (DBS), as well as a rationale for DBS and future trial design. Identification of an appropriate patient population that would most likely benefit from this type of therapy is essential. There are also significant cost and ethical considerations for such a neuromodulatory intervention designed to alter maladaptive behavior. Finally, the authors present a consolidated set of inclusion criteria and study end points that should serve as the basis for any trial of DBS for obesity.

    View details for DOI 10.3171/2015.3.FOCUS1538

    View details for PubMedID 26030708

  • Deep brain stimulation for obesity: rationale and approach to trial design NEUROSURGICAL FOCUS Ho, A. L., Sussman, E. S., Pendharkar, A. V., Azagury, D. E., Bohon, C., Halpern, C. H. 2015; 38 (6)

    View details for DOI 10.3171/2015.3.FOCUS1538

    View details for Web of Science ID 000355539900008

    View details for PubMedID 26030708

  • Do adverse childhood experiences affect surgical weight loss outcomes? Journal of gastrointestinal surgery Lodhia, N. A., Rosas, U. S., Moore, M., Glaseroff, A., Azagury, D., Rivas, H., Morton, J. M. 2015; 19 (6): 993-998


    Bariatric surgery is an effective and enduring treatment for obesity; however, variation in weight loss may occur following surgery. Many factors beyond technical considerations may influence postoperative outcomes. A better understanding of the influence of adverse childhood experiences (ACE) on surgical weight loss may improve preoperative care. Demographic and preoperative and postoperative data were prospectively obtained for 223 patients undergoing bariatric surgery. All cases were completed laparoscopically without serious complication. Patients completed the ACE questionnaire, which assesses childhood maltreatment. Patients had an average age of 48 years and 77 % were female. There was a significant reduction from preoperative to 12-month postoperative BMI (45 to 31 kg/m(2), p ≤ 0.01). The average ACE score was 2.9 and these patients were more likely than population norms to have an ACE score ≥4 (35.9 vs. 12.5 %, p < 0.001). There was a positive correlation between the number of preoperative comorbidities and preoperative ACE score (R = 0.112, p = 0.09). Patients with a high ACE score (≥6) vs. patients low ACE scores had a higher postoperative BMI at 6-months (36.9 vs. 33.4 kg/m(2), p = 0.03) and 12-months postoperatively (34.5 vs. 30.5 kg/m(2), p = 0.07). High ACE patients had higher total cholesterol (191 vs. 169 mg/dL, p = 0.02) and LDL cholesterol (116 vs. 94 mg/dL, p = 0.02) than low ACE patients 12-months postoperatively. A high preoperative ACE score decreases weight loss following bariatric surgery and may warrant an increased preoperative counseling.

    View details for DOI 10.1007/s11605-015-2810-7

    View details for PubMedID 25832488

  • Deep Brain Stimulation for Obesity. Cureus Ho, A. L., Sussman, E. S., Zhang, M., Pendharkar, A. V., Azagury, D. E., Bohon, C., Halpern, C. H. 2015; 7 (3)


    Obesity is now the third leading cause of preventable death in the US, accounting for 216,000 deaths annually and nearly 100 billion dollars in health care costs. Despite advancements in bariatric surgery, substantial weight regain and recurrence of the associated metabolic syndrome still occurs in almost 20-35% of patients over the long-term, necessitating the development of novel therapies. Our continually expanding knowledge of the neuroanatomic and neuropsychiatric underpinnings of obesity has led to increased interest in neuromodulation as a new treatment for obesity refractory to current medical, behavioral, and surgical therapies. Recent clinical trials of deep brain stimulation (DBS) in chronic cluster headache, Alzheimer's disease, and depression and obsessive-compulsive disorder have demonstrated the safety and efficacy of targeting the hypothalamus and reward circuitry of the brain with electrical stimulation, and thus provide the basis for a neuromodulatory approach to treatment-refractory obesity. In this study, we review the literature implicating these targets for DBS in the neural circuitry of obesity. We will also briefly review ethical considerations for such an intervention, and discuss genetic secondary-obesity syndromes that may also benefit from DBS. In short, we hope to provide the scientific foundation to justify trials of DBS for the treatment of obesity targeting these specific regions of the brain.

    View details for DOI 10.7759/cureus.259

    View details for PubMedID 26180683

  • Robotic single-site cholecystectomy JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES Morel, P., Buchs, N. C., Iranmanesh, P., Pugin, F., Buehler, L., Azagury, D. E., Jung, M., Volonte, F., Hagen, M. E. 2014; 21 (1): 18-25


    Minimally invasive approaches for cholecystectomy are evolving in a surge for the best possible clinical outcome for the patients. As one of the most recent developments, a robotic set of instrumentation to be used with the da Vinci Si Surgical System has been developed to overcome some of the technical challenges of manual single incision laparoscopy.From February 2011 to February 2013, all consecutive robotic single site cholecystectomies (RSSC) were prospectively collected in a dedicated database. Demographic, intra- and postoperative data of all patients that underwent RSSC at our institution were analyzed. Data were evaluated for the overall patient cohort as well as after stratification according to patient BMI (body mass index) and surgeon's experience.During the study period, 82 patients underwent robotic single site cholecystectomy at our institution. The dominating preoperative diagnosis was cholelithiasis. Mean overall operative time was 91 min. Intraoperative complications occurred in 2.4% of cases. One conversion to open surgery due to the intraoperative finding of a gallbladder carcinoma was observed and two patients needed an additional laparoscopic trocar. The rate of postoperative complications was 4.9% with a mean length of stay of 2.4 days. No significant differences were observed when comparing results between robotic novices and robotic experts. Patients with higher BMI trended towards longer surgical console and overall operative time, but resulted in similar rates of conversions and complications when compared to normal weight patients.Robotic Single-Site cholecystectomy can be performed safely and effectively with low rates of complications and conversions in patients with differing BMI and by surgeons with varying levels of experience.

    View details for DOI 10.1002/jhbp.36

    View details for Web of Science ID 000328792500006

    View details for PubMedID 24142898

  • Patient safety and surgical innovation-complementary or mutually exclusive? Patient safety in surgery Azagury, D. E. 2014; 8 (1): 17-?

    View details for DOI 10.1186/1754-9493-8-17

    View details for PubMedID 24690567

  • Robotic distal pancreatectomy: a valid option? MINERVA CHIRURGICA Jung, M. K., Buchs, N. C., Azagury, D. E., Hagen, M. E., Morel, P. 2013; 68 (5): 489-497


    Although reported in the literature, conventional laparoscopic approach for distal pancreatectomy is still lacking widespread acceptance. This might be due to two-dimensional vision and decreased range of motion to reach and safely dissect this highly vascularized retroperitoneal organ by laparoscopy. However, interest in minimally invasive access is growing ever since and the robotic system could certainly help overcome limitations of the laparoscopic approach in the challenging domain of pancreatic resection, notably in distal pancreatectomy. Robotic distal pancreatectomy with and without spleen preservation has been reported with encouraging outcomes for benign and borderline malignant disease. As a result of upgraded endowristed manipulation and three-dimensional visualization, improved outcome might be expected with the launch of the robotic system in the procedure of distal pancreatectomy. Our aim was thus to extensively review the current literature of robot-assisted surgery for distal pancreatectomy and to evaluate advantages and possible limitations of the robotic approach.

    View details for Web of Science ID 000327754000007

    View details for PubMedID 24101006

  • Real-time near-infrared fluorescent cholangiography could shorten operative time during robotic single-site cholecystectomy SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Buchs, N. C., Pugin, F., Azagury, D. E., Jung, M., Volonte, F., Hagen, M. E., Morel, P. 2013; 27 (10): 3897-3901


    With the introduction of a new platform, robotic single-site cholecystectomy (RSSC) has been reported as feasible and safe for selected cases. In parallel, the development of real-time near-infrared fluorescent cholangiography using indocyanine green (ICG) has been seen as a help during the dissection, even if the data are still preliminary. The study purpose is to report our experience with ICG RSSC and compare the outcomes to standard RSSC.From February 2011 to December 2011, 44 selected patients underwent RSSC for symptomatic cholelithiasis. Among them, 23 (52.3%) were included in an experimental protocol using the ICG, and the remainder (47.7%) underwent standard RSSC. There was no randomization. The endpoints were the perioperative outcomes. This is a prospective study, approved by our local Ethics Committee.There were no differences in terms of patients' characteristics, except that there were more male patients in the ICG group (47.8 vs. 9.5%; p = 0.008). Regarding the surgical data, the overall operative time was shorter for the ICG group, especially for patients with a body mass index (BMI) ≤25 (-24 min) but without reaching statistical significance (p = 0.06). For BMI >25, no differences were observed. Otherwise, there were no differences in terms of conversion, complications, or length of stay between both groups.A RSSC with a real-time near-infrared fluorescent cholangiography can be performed safely. In addition, for selected patients with a low BMI, ICG could shorten the operative time during RSSC. Larger studies are still required before drawing definitive conclusions.

    View details for DOI 10.1007/s00464-013-3005-5

    View details for Web of Science ID 000324268200052

    View details for PubMedID 23670747

  • Resection or reduction? The dilemma of managing retrograde intussusception after Roux-en-Upsilon gastric bypass SURGERY FOR OBESITY AND RELATED DISEASES Varban, O., Ardestani, A., Azagury, D., Lautz, D. B., Vernon, A. H., Robinson, M. K., Tavakkoli, A. 2013; 9 (5): 725-730


    Retrograde intussusception (RI) at the jejunojejunostomy can occur after Roux-en-Y gastric bypass (RYGB). Although this complication is rare, it has been encountered more frequently as the number of bariatric procedures have increased. Little data is available to assist surgeons with the optimal management of this condition. Our objectives were to identify the risk factors for RI after RYGB and report on outcomes after surgical intervention at a tertiary academic surgical unit.We used our prospective longitudinal institutional bariatric surgical database to identify patients with post-RYGB RI from 1996 to 2011.We identified 28 post-RYGB RI cases. The median interval between RYGB and RI was 52 months, and the median percentage of excess weight loss was 75%. Patients presented with acute symptoms in 36% of the cases. All patients underwent surgical exploration, including resection and revision of the jejunojejunostomy (46%) or operative reduction with or without enteropexy (54%). Those undergoing resection had a longer hospital stay but similar 30-day complication rates. At a median follow-up of 9 months, only 1 recurrence was documented.RI is a rare and late complication of RYGB and typically occurs after significant weight loss. In the presence of ischemia or nonreducible RI, resection and revision of the jejunojejunostomy is recommended. In less acute patients, laparoscopic management with reduction and/or enteropexy offers a reduced hospital length of stay while maintaining equivalent morbidity and low recurrence compared with resection.

    View details for DOI 10.1016/j.soard.2012.05.004

    View details for Web of Science ID 000325782900026

    View details for PubMedID 22738754

  • Contemporary Management of Adult Intussusception: Who Needs a Resection? WORLD JOURNAL OF SURGERY Varban, O. A., Ardestani, A., Azagury, D. E., Kis, B., Brooks, D. C., Tavakkoli, A. 2013; 37 (8): 1872-1877


    Surgical resection is often recommended in adults with intestinal intussusception (AI) because of its potential association with malignancy. We provide a contemporary algorithm for managing AI by focusing on the probability of discovering a lead point.This is a retrospective study of adult patients with computed tomography (CT)-confirmed intussusception who underwent operative management of AI between 1996 and 2011 at a single academic institution.Sixty-four patients were diagnosed with AI by CT scan and then managed operatively. The incidence of colonic (CI), small bowel (SBI), and retrograde intussusception (RI) was 14, 55, and 31 %, respectively. All patients with CI had a lead point, whereas none were found among patients with RI. Some 46 % of patients with SBI had a lead point. The probability of discovering a lead point in SBI was increased by past history of malignancy (RR, 3.7, p < 0.001), a mass seen on preoperative CT scan (RR, 2.9, p = 0.005), and age over 60 years (RR, 2.2, p = 0.07).A pathologic lead point is likely with CI but not with RI. Patients with SBI who are over the age of 60 years and have a history of malignancy or a mass noted on CT scan have a higher likelihood of harboring a pathologic lead point.

    View details for DOI 10.1007/s00268-013-2036-3

    View details for Web of Science ID 000322023600019

    View details for PubMedID 23571865

  • [Robotic general surgery: where do we stand in 2013?]. Revue médicale suisse Buchs, N. C., Pugin, F., Ris, F., Jung, M., Hagen, M. E., Volonté, F., Azagury, D., Morel, P. 2013; 9 (391): 1317-1322


    While the number of publications concerning robotic surgery is increasing, the level of evidence remains to be improved. The safety of robotic approach has been largely demonstrated, even for complex procedures. Yet, the objective advantages of this technology are still lacking in several fields, notably in comparison to laparoscopy. On the other hand, the development of robotic surgery is on its way, as the enthusiasm of the public and the surgical community can testify. Still, clear clinical indications remain to be determined in the field of general surgery. The study aim is to review the current literature on robotic general surgery and to give the reader an overview in 2013.

    View details for PubMedID 23875261

  • [Medical technology innovation: why get involved and how?]. Revue médicale suisse Azagury, D. E., Buchs, N. C., Volonté, F., Morel, P. 2013; 9 (391): 1323-1326


    Medical technologies are an intrinsic part of our daily practice. More than a simple recipient of novel medical devices, clinicians have a unique role to play in medtech innovation. They are invaluable assets for testing devices and guiding manufacturers towards the most clinically relevant solutions. More importantly, they have a direct view on patient needs and can therefore identify unmet clinical needs. As these skills are not part of medical school curricula, new centers in medtech innovation education are arising across Europe following the success of US programs. These centers offer a full curriculum in medtech innovation so that doctors can more actively participate and foster innovation in their field. This new knowledge can allow us to initiate our own innovations and potentially influence the future of our own practice.

    View details for PubMedID 23875262

  • Does laparoscopic gastric banding create hiatal hernias? SURGERY FOR OBESITY AND RELATED DISEASES Azagury, D. E., Varban, O., Tavakkolizadeh, A., Robinson, M. K., Vernon, A. H., Lautz, D. B. 2013; 9 (1): 48-54


    We hypothesized that laparoscopic adjustable gastric band (LAGB) placement might result in the development of a hiatal hernia (HH) over time. The objective of our study was to determine whether HHs develop after LAGB in the setting of a university hospital.We retrospectively reviewed all outcomes for consecutive LAGB patients in our institutional, longitudinal prospective bariatric surgical database to identify those patients without evidence of a HH at LAGB placement, who subsequently underwent delayed HH repair.From 2005 to 2009, 695 gastric bands were implanted. Twelve patients (1.72%) were identified who had no radiographic or intraoperative evidence of a HH at LAGB placement and who subsequently underwent HH repair at re-exploration. Patients presented 18 ± 10 months after band placement. Of these patients, 75% presented with gastroesophageal reflux disease or food intolerance (50% with gastroesophageal reflux disease alone). Also, 2 presented with acute pain due to band slippage and 1 with chronic pain and vomiting. In 50% of the patients, revision procedures detected the HH at operation despite negative preoperative studies.In our series, a significant HH developed in 1.7% of LAGB patients who had no clinically identifiable HH at LAGB placement. Persistent dysphagia after band deflation requires careful inspection of the hiatus during surgical revision, even in the absence of radiologic depiction of HH, and might represent an underlying etiology of LAGB dysfunction. This complication, along with esophageal dilation and annular pouch dilation, might represent a constellation of conditions with a common etiology. From the results of our small series, we raise the question of the existence of chronic backpressure created by LAGB restriction and accounting for these complications.

    View details for DOI 10.1016/j.soard.2011.07.015

    View details for Web of Science ID 000314669900008

    View details for PubMedID 21925963

  • Robotic revisional bariatric surgery: a comparative study with laparoscopic and open surgery. The international journal of medical robotics + computer assisted surgery : MRCAS 2013


    Revisional bariatric procedures (RBP) can be technically challenging. While robotics might provide help for complex procedures, the study aim was to report our experience with robotic RBP.From March 2000 to June 2013, 60 consecutive RBP (11 robotic, 21 laparoscopic, 28 open) have been prospectively entered into a dedicated database and reviewed retrospectively. Outcomes have been compared between the three approaches.The robotic group had fewer complications (0 vs. 14.3% for laparoscopy, vs. 10.7% for open; P > 0.05), but took longer than the other approaches (352 vs. 270 vs. 250 minutes respectively; P < 0.05). There were fewer conversions in the robotic group (0 vs. 14.3% for laparoscopy; P > 0.05), and a significantly shorter hospital stay (6 vs. 8 vs. 9 days, respectively).Robotic RBP is feasible and safe, but at the price of a longer operative time. The exact role of robotics remains yet to be defined for this indication in larger studies. Copyright © 2013 John Wiley & Sons, Ltd.

    View details for DOI 10.1002/rcs.1549

    View details for PubMedID 24167029

  • Establishing a reproducible large animal survival model of laparoscopic Roux-en-Y gastric bypass SURGERY FOR OBESITY AND RELATED DISEASES Escareno, C. E., Azagury, D. E., Flint, R. S., Nedder, A., Thompson, C. C., Lautz, D. B. 2012; 8 (6): 764-769


    The advent of metabolic surgery and the increasing focus on the substantial resolution rate of type 2 diabetes after laparoscopic Roux-en-Y gastric bypass (LRYGB) call for additional fundamental investigations as to the mechanisms behind this effect. These investigations require an adequate animal model. Our objective was to develop a reproducible survival model of LRYGB performed in a large animal at a tertiary university hospital.LRYGB was performed on 11 Yorkshire pigs that where then followed for 6 weeks. The operative time, morbidity, and mortality were recorded for each case. Necropsy was performed, and the anastomoses were harvested and inspected for leaks.The surgical technique and difficulties are carefully described. Of the 11 pigs, 10 survived to the end of the study period. The 1 death was from intraoperative cardiac dysrhythmia. The postoperative complications consisted of a postoperative febrile episode in 2 pigs. The mean initial weight was 31.5 ± 3.4 kg. The mean operative time was 214 ± 71 minutes. No anastomotic leaks were identified at necropsy or on histologic examination of anastomoses. The mean weight gain at the end of the study period was .8 ± 1.4 kg compared with an expected 17.5 kg weight gain.We have described an effective survival porcine model of LRYGB that can be consistently reproduced. This will enable additional investigation into the complex physiologic mechanisms that control hunger, weight loss, and the development, as well as resolution, of type 2 diabetes, potentially leading to the development of novel, targeted bariatric procedures and diabetic treatments.

    View details for DOI 10.1016/j.soard.2011.05.021

    View details for Web of Science ID 000311919800022

    View details for PubMedID 21996597

  • Real-time computed tomography-based augmented reality for natural orifice transluminal endoscopic surgery navigation. British journal of surgery Azagury, D. E., Ryou, M., Shaikh, S. N., San José Estépar, R., Lengyel, B. I., Jagadeesan, J., Vosburgh, K. G., Thompson, C. C. 2012; 99 (9): 1246-1253


    Natural orifice transluminal endoscopic surgery (NOTES) is technically challenging owing to endoscopic short-sighted visualization, excessive scope flexibility and lack of adequate instrumentation. Augmented reality may overcome these difficulties. This study tested whether an image registration system for NOTES procedures (IR-NOTES) can facilitate navigation.In three human cadavers 15 intra-abdominal organs were targeted endoscopically with and without IR-NOTES via both transgastric and transcolonic routes, by three endoscopists with different levels of expertise. Ease of navigation was evaluated objectively by kinematic analysis, and navigation complexity was determined by creating an organ access complexity score based on the same data.Without IR-NOTES, 21 (11·7 per cent) of 180 targets were not reached (expert endoscopist 3, advanced 7, intermediate 11), compared with one (1 per cent) of 90 with IR-NOTES (intermediate endoscopist) (P = 0·002). Endoscope movements were significantly less complex in eight of the 15 listed organs when using IR-NOTES. The most complex areas to access were the pelvis and left upper quadrant, independently of the access route. The most difficult organs to access were the spleen (5 failed attempts; 3 of 7 kinematic variables significantly improved) and rectum (4 failed attempts; 5 of 7 kinematic variables significantly improved). The time needed to access the rectum through a transgastric approach was 206·3 s without and 54·9 s with IR-NOTES (P = 0·027).The IR-NOTES system enhanced both navigation efficacy and ease of intra-abdominal NOTES exploration for operators of all levels. The system rendered some organs accessible to non-expert operators, thereby reducing one impediment to NOTES procedures.

    View details for DOI 10.1002/bjs.8838

    View details for PubMedID 22864885

  • Magnetic pancreaticobiliary stents and retrieval system: obviating the need for repeat endoscopy (with video) GASTROINTESTINAL ENDOSCOPY Ryou, M., Cantillon-Murphy, P., Shaikh, S. N., Azagury, D., Ryan, M. B., Lang, J. H., Thompson, C. C. 2012; 75 (4): 888-892


    Plastic stents are routinely placed in the pancreaticobiliary system to facilitate drainage. A second endoscopy is often required for stent removal. We have developed magnetic pancreaticobiliary stents that can be removed by using an external hand-held magnet, thereby obviating the need for a second endoscopy.To develop and test magnetic pancreaticobiliary stents and retrieval system in ex-vivo and in-vivo porcine models.Animal laboratory.Benchtop and animal study.5 pigs.Design: Computer simulations determined both the optimal design of cylindrical magnets attached to the distal aspect of existing plastic stents and the optimal design of the external hand-held magnet. Benchtop ex-vivo experiments measured magnetic force to validate the design. In-vivo analysis: In 5 Yorkshire pigs, magnetic stents were deployed into the common bile duct by using a conventional duodenoscope. An external hand-held magnet was applied for stent removal. Stent insertion and removal times were recorded.Technical feasibility.Magnetic stents of varying lengths and calibers were successfully created. In ex-vivo testing, the capture distance was 10.0 cm. During in-vivo testing, the magnetic stents were inserted and removed easily. The mean insertion and removal times were 3.2 minutes and 33 seconds, respectively.Animal study, small numbers.Magnetic pancreaticobiliary stents and associated retrieval system were successfully designed and tested in the acute porcine model. An external, noninvasive means of stent removal potentially obviates the need for a second endoscopy, which could represent a major gain both for patients and in health care savings.

    View details for DOI 10.1016/j.gie.2011.09.051

    View details for Web of Science ID 000302186100027

    View details for PubMedID 22226385

  • Laparoscopic cholecystectomy after a quarter century: why do we still convert? Annual Meeting of the Society-of-American-Gastrointestinal-and-Endoscopic-Surgeons (SAGES) Lengyel, B. I., Azagury, D., Varban, O., Panizales, M. T., Steinberg, J., Brooks, D. C., Ashley, S. W., Tavakkolizadeh, A. SPRINGER. 2012: 508–13


    Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. However, conversion to open surgery is sometimes needed. The factors underlying a surgeon's decision to convert a laparoscopic case to an open case are complex and poorly understood. With decreasing experience in open cholecystectomy, this procedure is however no longer the "safe" alternative it once was. With such an impending paradigm shift, this study aimed to identify the main reasons for conversion and ultimately to develop guidelines to help reduce the conversion rates.Using the National Surgical Quality Improvement Program (NSQIP) database and financial records, the authors retrospectively reviewed 1,193 cholecystectomies performed at their institution from 2002 to 2009 and identified 70 conversions. Two independent surgeons reviewed the operative notes and determined the reasons for conversion. The number of ports at the time and the extent of dissection before conversion were assessed and used to create new conversion categories. Hospital length of stay (LOS), 30-day complications, operative times and charges, and hospital charges were compared between the new groups.In 91% of conversion cases, the conversion was elective. In 49% of these conversions, the number of ports was fewer than four. According to the new conversion categories, most conversions were performed after minimal or no attempt at dissection. There were no differences in LOS, complications, operating room charges, or hospital charges between categories. Of the six emergent conversions (9%), bleeding and concern about common bile duct (CBD) injury were the main reasons. One CBD injury occurred.In 49% of the cases, conversion was performed without a genuine attempt at laparoscopic dissection. Considering this new insight into the circumstances of conversion, the authors recommend that surgeons make a genuine effort at a laparoscopic approach, as reflected by placing four ports and trying to elevate the gallbladder before converting a case to an open approach.

    View details for DOI 10.1007/s00464-011-1909-5

    View details for Web of Science ID 000299293500031

    View details for PubMedID 21938579

  • Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes ENDOSCOPY Azagury, D. E., Abu Dayyeh, B. K., Greenwalt, I. T., Thompson, C. C. 2011; 43 (11): 950-954


    Marginal ulcers are one of the most common complications after gastric bypass. Reported incidence varies widely (0.6-16 %) and pathogenesis is unclear. The aim of the present study was to describe characteristics, risk factors, management, and outcomes of endoscopically documented ulcers.Data from all patients diagnosed with marginal ulcers at endoscopy between 2003 and 2010 were retrospectively reviewed.A total of 103 patients with marginal ulcers presented with pain (63 %) and/or bleeding (24 %), a median of 22 months after surgery. Ulcers were located on the anastomosis (50 %) or the jejunum (40 %); sutures were visible in 35 %, and gastrogastric fistulae in 8 %. The mean pouch length was 5.6 cm. Diabetes (odds ratio [OR] 2.5; P = 0.03), smoking (OR 2.5; P = 0.02), and gastric pouch length (OR 1.2; P = 0.02) were significantly associated with marginal ulcer formation on univariate analysis; diabetes was significantly associated on multivariate analysis (OR 5.6; P = 0.003). The risk of developing a marginal ulcer decreased with time (OR 0.8; P < 0.01) and was not associated with the use of nonsteroidal anti-inflammatory drugs. At first endoscopic follow-up, 67 % of ulcers had healed. Recurrence occurred in four patients and nine patients required surgical revision.The vast majority of marginal ulcers had a favorable outcome after medical treatment. However, 9 % of patients eventually required surgical revision. Therefore, endoscopic follow-up is essential. Diabetes, smoking, and long gastric pouches were significant risk factors for marginal ulcer formation, suggesting increased acid exposure and mucosal ischemia are both involved in marginal ulcer pathogenesis. Management of these factors may prove effective in managing marginal ulcers, and tailoring postoperative proton pump inhibitor therapy to patients with multiple risk factors could be effective.

    View details for DOI 10.1055/s-0030-1256951

    View details for Web of Science ID 000296749000005

    View details for PubMedID 21997722

  • An implantable wireless biosensor for the immediate detection of upper GI bleeding: a new fluorescein-based tool for diagnosis and surveillance (with video). Gastrointestinal endoscopy Ryou, M., Nemiroski, A., Azagury, D., Shaikh, S. N., Ryan, M. B., Westervelt, R. M., Thompson, C. C. 2011; 74 (1): 189-194 e1


    Early recurrent hemorrhage after endoscopic intervention for acute upper GI bleeding (UGIB) can approach 20% and leads to increased morbidity and mortality. Little has changed over the past several decades regarding immediate posthemorrhage surveillance, and there has likewise been no significant improvement in outcomes.To develop and test an endoscopically implantable wireless biosensor for real-time detection of fluorescein-labeled blood in ex vivo and in vivo porcine models of UGIB.Animal laboratory.Benchtop and acute animal studies.Five pigs.UGIB models were surgically created in living pigs. Biosensors were endoscopically deployed in the stomach using standard endoscopic clips. The ability to detect acute UGIB and estimated blood loss leading to biosensor activation were recorded. Feasibility of wireless data transmission out of the body to an external computer and cell phone was assessed.Technical feasibility and immediate complications.A porcine UGIB model was successfully created. Biosensors were able to detect all acute bleeding events and wirelessly transmit out of the body, and successfully sent an emergency text message to the intended cell phone in all cases. Average estimated blood loss leading to biosensor activation was 30 mL (10-75 mL).Animal study; small numbers.An endoscopically implantable wireless biosensor successfully detected acute hemorrhage in a porcine UGIB model and sent an emergency cell-phone alert in real time.

    View details for DOI 10.1016/j.gie.2011.03.1182

    View details for PubMedID 21704817

  • Obesity overview: epidemiology, health and financial impact, and guidelines for qualification for surgical therapy. Gastrointestinal endoscopy clinics of North America Azagury, D. E., Lautz, D. B. 2011; 21 (2): 189-201


    The aim of this article is to describe the context in which this issue of Gastrointestinal Endoscopy Clinics of North America is established. The authors review the current worldwide dimensions and trends of the obesity epidemic; associated mortality and comorbid diseases including diabetes, cancer, cardiovascular disease and obstructive sleep apnea; the financial impact of obesity; and current national and international guidelines for referral and qualification for surgical treatment of obesity.

    View details for DOI 10.1016/j.giec.2011.02.001

    View details for PubMedID 21569972

  • Smart Self-Assembling MagnetS for ENdoscopy (SAMSEN) for transoral endoscopic creation of immediate gastrojejunostomy GASTROINTESTINAL ENDOSCOPY Ryou, M., Cantillon-Murphy, P., Azagury, D., Shaikh, S. N., Ha, G., Greenwalt, I., Ryan, M. B., Lang, J. H., Thompson, C. C. 2011; 73 (2): 353-359


    Gastrojejunostomy is important for palliation of malignant gastric outlet obstruction and surgical obesity procedures. A less-invasive endoscopic technique for gastrojejunostomy creation is conceptually attractive. Our group has developed a compression anastomosis technology based on endoscopically delivered self-assembling magnets for endoscopy (SAMSEN) to create an instant, large-caliber gastrojejunostomy.To develop and evaluate an endoscopic means of gastrojejunostomy creation by using SAMSEN.Developmental laboratory and animal facility.Animal study and human cadaveric study.Yorkshire pigs (7 cadaver, 5 acute); human (1 cadaver).A transoral procedure for SAMSEN delivery was developed in porcine and human cadaver models. Subsequently, gastrojejunostomy creation by using SAMSEN was performed in 5 acute pigs. The endoscope was advanced into the peritoneal cavity through the gastrotomy, and a segment of the small bowel was grasped and pulled closer to the stomach. An enterotomy was created, and a custom overtube was advanced into the small bowel for deployment of the first magnetic assembly. Next, a reciprocal magnetic assembly was deployed in the stomach. The 2 magnetic systems were mated under fluoroscopic and endoscopic guidance. Contrast studies assessed for gastrojejunostomy leak. Immediate necropsies were performed.Technical feasibility and complications.Gastrojejunostomy creation by using SAMSEN was successful in all 5 animals. Deep enteroscopy was performed through the stoma without difficulty. No leaks were identified on contrast evaluation. At necropsy, the magnets were properly deployed and robustly coupled together, resistant to vigorous tissue manipulation.Acute animal study.Endoscopic creation of immediate gastrojejunostomy by using SAMSEN is technically feasible.

    View details for DOI 10.1016/j.gie.2010.10.024

    View details for Web of Science ID 000287001900025

    View details for PubMedID 21183179

  • Comment on: Effect of staple height on gastrojejunostomy during laparoscopic gastric bypass: a multicenter prospective randomized trial SURGERY FOR OBESITY AND RELATED DISEASES Azagury, D. E., Lautz, D. B. 2010; 6 (5): 482-484

    View details for Web of Science ID 000282673400005

    View details for PubMedID 20870180

  • A Magnetic Retrieval System for Stents in the Pancreaticobiliary Tree IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING Cantillon-Murphy, P., Ryou, M., Shaikh, S. N., Azagury, D., Ryan, M., Thompson, C. C., Lang, J. H. 2010; 57 (8): 2018-2025


    Clinical endoscopic intervention of the pancreaticobiliary tree [endoscopic retrograde cholangiopancreatography (ERCP)] often concludes with the insertion of a temporary plastic stent to reduce the risk of post-ERCP complications by promoting continued flow of bile and pancreatic fluids. This stent is later removed once the patient has fully recovered, but today this necessitates a second endoscopic intervention. The final goal of this work is to obviate the second intervention. This is to be achieved by adding a magnetic ring to the stent such that the stent is removed using a hand-held magnet, held in a suitable position ex vivo . This paper details the design, optimization, and both ex vivo and in vivo testing of the magnetized stent and hand-held magnet, which has been accomplished to date. The optimized design for the hand-held magnet and the modified stent with a magnetic attachment performs in line with simulated expectations, and successful retrieval is achieved in the porcine ex vivo setting at 9-10 cm separation. This is comparable to the mean target capture distance of 10 cm between the entry point to the biliary system and the closest cutaneous surface, determined from random review of clinical fluoroscopies in ten human patients. Subsequently, the system was successfully tested in vivo in the acute porcine model, where retrieval at an estimated separation of 5-6 cm was captured on endoscopic video. These initial results indicate that the system may represent a promising approach for the elimination of a second endoscopic procedures following placement of pancreatic and biliary stents.

    View details for DOI 10.1109/TBME.2010.2045653

    View details for Web of Science ID 000282000900022

    View details for PubMedID 20483696

  • Management of acute gastrothorax with respiratory distress: insertion of nasogastric tube as a life saving procedure EUROPEAN JOURNAL OF EMERGENCY MEDICINE Azagury, D. E., Karenovics, W., Staehli, D. M., Mathis, J., Schneider, R. 2008; 15 (6): 357-358


    An 86-year-old patient was transferred to our institution with acute respiratory distress. A tension pneumothorax was suspected, but needle decompression was unsuccessful. Instead of the suspected pneumothorax, the chest radiograph revealed a large 'tension gastrothorax'. In a matter of seconds, the insertion of a nasogastric tube resulted in drastic improvement of the critical clinical state. Acute tension gastrothorax is a rare, but classic, complication of paraoesophageal hernias. Its clinical presentation can be dramatic and rapidly lethal, immediate action is therefore warranted. Nasograstric tube insertion is a life saving procedure to be undertaken without delay. However, tension gastrothorax is a rare entity. Therefore, if tension pneumothorax is suspected, needle decompression should not be delayed.

    View details for DOI 10.1097/MEJ.0b013e32830346c3

    View details for Web of Science ID 000261398600013

    View details for PubMedID 19078843

  • Isolated alveolar echinococcosis of the spleen - clinical presentation and management review SWISS MEDICAL WEEKLY Karenovics, W., Azagury, D. E., Groebli, Y. 2008; 138 (45-46): 689-690


    Alveolar echinococcosis is a zoonosis which infects primarily the liver, and secondary involvement of other organs is common. However, exclusive extrahepatic involvement is exceedingly rare, and isolated splenic involvement even more so. Workup, differential diagnosis and management of isolated splenic alveolar echinococcosis are discussed and literature is reviewed based on a clinical case.

    View details for Web of Science ID 000261118700006

    View details for PubMedID 19043815

  • Bouveret's syndrome: Management and strategy of a rare cause of gastric outlet obstruction DIGESTION Buchs, N. C., Azagury, D., Chilcott, M., Nguyen-Tang, T., Dumonceau, J., Morel, P. 2007; 75 (1): 17-19

    View details for DOI 10.1159/000101561

    View details for Web of Science ID 000246059700004

    View details for PubMedID 17429202

  • Preoperative work-up in asymptomatic patients undergoing Roux-en-Y gastric bypass: Is endoscopy mandatory? OBESITY SURGERY Azagury, D., Dumonceau, J. M., Morel, P., Chassot, G., Huber, O. 2006; 16 (10): 1304-1311


    We aimed to determine before Roux-en-Y gastric bypass (RYGBP) in asymptomatic morbidly obese patients: 1) the prevalence of abnormal findings at upper gastrointestinal (UGI) endoscopy; 2) Helicobacter pylori (HP) status; 3) clinical consequences of these findings; and 4) associated costs.We retrospectively reviewed 468 consecutive patients, excluded those with UGI symptoms, drug intake or previous UGI endoscopy/surgery, and analyzed findings in the 319 remaining patients (68%).There were abnormal findings in 147 patients (46%), including 54 hiatal hernias and 146 parietal (i.e. mucosal or submucosal) lesions. The most significant were 7 ulcers and 2 gastric polyposis. HP was detected (using CLO-test) in 124 patients (39%). Histopathological examination of biopsies was abnormal in 109/161 patients (68%), and disclosed mainly chronic gastritis (n=98). Abnormal findings were more frequent in HP-positive compared to HP-negative patients (94 vs 51%, P<0.001). Findings had clinical implications in only 4% of patients: delayed surgery (7 ulcers), prophylactic gastrectomy (2 gastric polyposis), unnecessary work-up (3 irrelevant/false-positive diagnoses), and inclusion in a screening program (1 Barrett's esophagus). Mean cost of complete UGI work-up was 389 euro/patient.Asymptomatic morbidly obese patients frequently harbour UGI lesions warranting UGI work-up before RYGBP. However, routine endoscopy presents drawbacks. We propose a less invasive strategy which reduces costs and limits false-positive results and the subsequent investigations that they require. In our series, it would have missed two gastric polyposis only, for which no formal recommendation has yet been issued. This strategy could be a valuable alternative to routine UGI endoscopy before RYGBP in asymptomatic patients.

    View details for Web of Science ID 000241209200007

    View details for PubMedID 17059738

  • Reflux, dysphagia, and gas bloat after laparoscopic fundoplication in patients with incidentally discovered hiatal hernia and in a control group SURGERY Triponez, F., Dumonceau, J. M., Azagury, D., Volonte, F., Slim, K., Mermillod, B., Huber, O., Morel, P. 2005; 137 (2): 235-242


    Laparoscopic fundoplication effectively controls reflux symptoms in patients with gastroesophageal reflux disease (GERD). However, symptom relapse and side effects, including dysphagia and gas bloat, may develop after surgery. The aim of the study was to assess these symptoms in patients who underwent laparoscopic fundoplication, as well as in control subjects and patients with hiatal hernia.A standardized, validated questionnaire on reflux, dysphagia, and gas bloat was filled out by 115 patients with a follow-up of 1 to 7 years after laparoscopic fundoplication, as well as by 105 subjects with an incidentally discovered hiatal hernia and 238 control subjects.Patients who underwent fundoplication had better reflux scores than patients with hiatal hernia ( P = .0001) and similar scores to control subjects ( P = .11). They also had significantly more dysphagia and gas bloat than patients with hiatal hernia and controls ( P < .005 for all comparisons). Gas bloat and dysphagia were more severe in hiatal hernia patients than in controls ( P < 0.005). After fundoplication, the 25% of the patients with the shortest follow-up (1.5 +/- 0.2 years) and the 25% patients with the longest follow-up (5.8 +/- 0.6 years) had similar reflux, dysphagia, and gas bloat scores ( P = .43, .82, and .85, respectively).In patients with severe GERD, laparoscopic fundoplication decreases reflux symptoms to levels found in control subjects. These results appear to be stable over time. However, patients who underwent fundoplication experience more dysphagia and gas bloat than controls and patients with hiatal hernia-symptoms that should be seen as a side effect of the procedure and of GERD itself.

    View details for DOI 10.1016/j.surg.2004.07.016

    View details for Web of Science ID 000226873700017

    View details for PubMedID 15674207

  • [Intestinal barotrauma after diving--mechanical ileus in incarceration of the last loop of the small intestine between a mobile cecum and sigmoid]. Swiss surgery = Schweizer Chirurgie = Chirurgie suisse = Chirurgia svizzera Haller, C., Guenot, C., Azagury, D., Rosso, R. 2003; 9 (4): 181-183


    A few hours after a self-contained underwater breathing apparatus (SCUBA) dive at 30 meters depth, a 49 years-old man complained of diffuse abdominal pain with nausea and vomitus. A laparotomy was performed 36 hours after a conservative treatment because of persistent mechanical small bowel obstruction. The last ileal loop was strangulated between a mobile ceacum and a long sigmoid loop. The man never had previous abdominal surgery. In absence of intestinal necrosis, a caecopexy was done and there was no post-operative complications. The gas distension during the ascension following the Boyle-Mariotte law and its distribution induced in this man with a special anatomy a mechanical small bowel obstruction. The treatment of mobile caecum and the literature of abdominal barotrauma is reviewed.

    View details for PubMedID 12974175