The 2016 Minimally Invasive Surgery Symposium (MISS 2016)

| September 1, 2016 | 0 Comments

Las Vegas, Nevada • February 23–26, 2016

by Philip R. Schauer, MD

Philip R. Schauer, MD, is Chief of Minimally Invasive General Surgery and Director of the Cleveland Clinic Bariatric and Metabolic Institute. He is also Professor of Surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He is Past President of the American Society for Metabolic and Bariatric Surgery.

Bariatric Times. 2016;13(9):18–19.

Funding: No funding was provided.

Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

Photos from MISS:
Dr. Philip Schauer on the MISS stage with Dr. Ninh Nguyen.

Dr. Kelvin Higa delivered talks on “Band to Bypass or Sleeve?” and “Literature Review of Revisional Bariatric Surgery.”

Dr. Aurora Pryor’s presentations included “Marginal Ulcer: When to Operate, What to Do,” and “Revisional
Surgery for Inadequate Weight Loss.”

Dr. Francesco Rubino reviewed guidelines for metabolic surgery in the treatment algorithm for type 2 diabetes.

The 2016 Minimally Invasive Surgery Symposium (MISS), which took place February 23 to 26, 2016 at the Encore at Wynn Las Vegas in Nevada, was the 16th year for MISS and featured more than 40 presentations on colon, hernia, foregut, and bariatric/metabolic surgery. MISS 2016 symposium also included laparoscopic suturing skills workshops for practicing general and bariatric surgeons, and scientific poster sessions.

MISS 2016 provided the opportunity for participants to earn up to 31.5 Category 1 credits, as designated by the symposium’s providers, the Global Academy for Medical Education and the University of Cincinnati.

As MISS Executive Director, I have sought to address the educational needs of surgeons and clinicians across the world by featuring forward-looking topics and presentations that directly address current clinical practice, general practice management, and quality improvement processes and national association initiatives from which all surgeons and patients can benefit.

Colon Program Highlights
The Tuesday sessions, directed by MISS Colon Program Co-Directors Morris E. Franklin Jr, MD, FACS, San Antonio, Texas, and John Marks, MD, Wynnewood, Pennsylvania, focused on several critical colon issues. Some topics included laparoscopic and robotic colorectal surgery adoption incidence in the United States and abroad, robotic data in randomized trials, colorectal surgery in the elderly, data and incidence of hand-assisted colectomy, single port colectomy, laparoscopic treatment of Crohn’s and the handling of biologic agents around surgery, and the effects of the Surgical Care Improvement Project (SCIP) on colorectal outcomes.

Hernia Program Highlights
Overseen by MISS Hernia Program Co-Director Guy Voeller, MD, Memphis, Tennessee, the Hernia Program commenced Wednesday and introduced various critical topics. Dr. Voeller stated, “The presentation on ERAS and Preoperative Optimization for Hernia Repair by Dr. Robert Martindale is critical for general surgeons. These are very important topics, with quality being emphasized now by payers and CMS. By the same token, Early Results from Quality Collaboration—What Have We Learned from Michael Rosen is important and timely for the same reason. Quality is now the focus of everyone and everything and the AHSQC is unique and groundbreaking.” Dr. Voeller additionally highlighted the presentation by Todd Heniford, MD, Charlotte, North Carolina, on Prediction and Management of Chronic Groin Pain as an important topic because it is “a devastating complication to patient and surgeon, and it is difficult and complex to deal with.”

Foregut Program Highlights
The Foregut session took place on Wednesday. According to MISS Foregut Co-Director William O. Richards, MD, Mobile, Alabama, “Magnetic Sphincter Augmentation is the Best Operation for GERD” was a key presentation in which Paul Taiganides, MD, FACS, Mount Vernon, Ohio, went over the five-year safety data for the LINX procedure (LINX® Reflux Management System, Torax® Medical, Inc, Shoreview, Minnesota) and the comparison studies comparing outcomes post laparoscopic Nissen and post LINX procedure.

“Dr. Taiganides detailed the excellent safety record, the absence of GI side effects (inability to belch or vomit post-Nissen) and very effective augmentation of the LES (lower esophageal sphincter ), which eliminated GERD symptoms in more than 90 percent of LINX patients. In my opinion,” Dr. Richards concluded, “Dr. Taiganides laid out a powerful argument for performance of the LINX rather than the laparoscopic Nissen in most patients with severe medically refractory GERD.”

Dr. Richards also highlighted the presentation titled, “Gastroenterologist Approach to Barrett’s” by Brooks D. Cash, MD, Mobile, Alabama, as “an outstanding talk that detailed the medical and endoscopic approach to Barrett’s.” He said that it really highlighted the endoscopic advances for treatment and elimination of Barrett’s and when to employ these techniques.

“Dr. Cash detailed the advances in endoscopic imaging and therapy that will make a huge difference in diagnosis, and totally endoscopic treatment of Barrett’s that every surgeon operating on patients with reflux should have knowledge of to enable the best care of their patients,” he concluded.
Dr. Richards also noted that in the same session, the presentation by Jeff Ponsky, MD, Cleveland, Ohio, titled “POEM is the Best Treatment for Achalasia” was very noteworthy.

“Always a great speaker, Dr. Ponsky spoke eloquently regarding the most effective NOTES (Natural Orifice Transluminal Endoscopic Surgery) procedure in the world. He detailed the results and technique for this completely incisionless myotomy for treatment of achalasia.”

Bariatric Program Highlights
MISS Metabolic/Bariatric Program Co-Directors John Dixon, MBBS, PhD, FRACGP, FRCP, Melbourne, Australia, and Bruce Wolfe, Portland, Oregon, provided their thoughts on highlights of the program they oversaw that stretched over Thursday and Friday of the conference. Dr. Dixon stated: “The key messages of the 2016 MISS meeting for me were the maturity of diabetes surgery, specifically Dr. Schauer presenting high-quality data and Dr. Francesco Rubino reviewing the recent landmark 2nd Diabetes Surgery Summit (DSS-II). I also think bringing an evidence base to revisional surgery beyond emotion is critical for the future. Dr. Higa summarized the evidence and gaps well.”

Dr. Wolfe shared that while topics ranged from the relationship of obesity and weight loss to prevention of multiple cancers, dementia, technical aspects of bariatric surgery, and issues relative to access and quality, some of the most valuable content was during the two-part session titled “The Science and Metabolic & Diabetes Surgery.”

“A primary topic for presentation and discussion this year was the status of the development of metabolic surgery as treatment for diabetes as the primary indication for surgery as opposed to weight loss alone,” Dr. Wolfe stated. “Dr. Francesco Rubino highlighted the second Diabetes Surgery Summit in London 2015, at which guidelines were agreed upon by the delegates to the summit. These guidelines were largely based on multiple randomized clinical trials comparing surgical to medical treatment of type 2 diabetes. With the exception of one small LAGB trial, all of the trials showed superior control of diabetes and/or clinical remission. Follow up as long as five years is now reported. Based on these trials, the delegates issued guidelines stating that metabolic surgery should be recommended to treat patients with type 2 diabetes with BMIs of 40kg/m2 or greater and with BMIs 35.0–39.9kg/m2 when hyperglycemia is inadequately controlled.

Dr. Wolfe went on to underscore the importance of this development: “An indication that metabolic surgery should be recommended is a major change for a panel composed of 75 percent medical experts in the treatment of diabetes. Additional guidelines indicate that surgery should be “considered” for patients with type 2 diabetes with BMIs 30–34.9kg/m2 when hyperglycemia is inadequately controlled and that all BMI thresholds should be reconsidered depending on the ancestry of the patient. In patients of Asian descent, the BMI values  should be reduced by 2.5 kg/m2.” Dr. Wolfe noted that at this session, moderated by Dr. Francesco Rubino, the demonstration of the role of both neuroendocrine effects of gastric bypass as well as weight loss was an important part of additional discussion on mechanisms of improvement of diabetes control and/or induction of remission.

Another highlight of the metabolic and bariatric program at MISS was the lunch symposium sponsored by Medtronic (New Haven, Connecticut) that focused on innovative modifications of malabsorptive procedures, including SADI-S (Single-Anastomosis Duodeno-Ileal Bypass with Sleeve), SIPS (Single Loop Switch), and OAGB (One-Anastomosis Gastric Bypass). Surgeons Antonio Torres, MD, PhD, Madrid, Spain, Dana Portenier, MD, Durham, North Carolina, and David Hargroder, MD, Joplin, Missouri, discussed the pros and cons of these procedures. The advantages shared in these presentations included reduced difficulty compared to duodenal switch and reduced operating time. Careful nutritional monitoring is still required for these procedures. Also, short-term outcomes look promising, but more long-term follow-up is required before widespread dissemination.
Another key MISS highlight was the Presidential Address by Raul Rosenthal, MD, Weston, Florida. Dr. Rosenthal is the current President of the American Society for metabolic and Bariatric Surgery (ASMBS). In his address, Dr. Rosenthal emphasized that patient access to surgery remains a top priority of ASMBS. The organization is doing much on a state-by-state basis to improve access to surgery, which has been particularly challenging in this era of healthcare cost containment.

With revisional bariatric surgery increasing at a significant rate, the literature review by Kelvin D. Higa, MD, FACS, Fresno, California, regarding outcomes of revisional bariatric surgery and his summary of the outcome of the first consensus conference on the subject were critical. Also, Drs. Aurora Pryor and Eric DeMaria gave presentations on recommendations for determining criteria for inadequate weight loss, specific operations for inadequate weight loss, and surgical treatment strategies for complications (e.g., marginal ulcers, strictures, and bowel obstructions) are critical topics for surgeons to become educated on as revisional bariatric surgery numbers grow.

Also an important part of the session, Dr. Ali Aminian discussed the trend in extended Deep vein thrombosis (DVT) prophylaxis beyond the hospital stay and pointed out that most DVTs and pulmonary embolisms (PEs) occur after hospital discharge in his presentation titled “DVT Prophylaxis Update: When to Extend?”

Our four-day program concluded Friday morning with a session titled “Controversies and New Frontiers,” which included some of the aforementioned presentations as well as a panel on Surgical Innovation: When is IRB Approval Required, and talks on new technologies, such as vagal blocking, intragastric balloon, duodenal jejunal bypass liner, robotic surgery, and primary endoluminal procedures.

The 2017 MISS will be held February 28 to March 3 at the Encore at Wynn Las Vegas. For complete information as it becomes available, please visit the conference website at


Category: Past Articles, Symposium Synopsis

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