Society of American Gastrointestinal and Endoscopic Surgeons Application Coversheet for Research Award

Project Title: Longitudinal gut microbiota changes after laparoscopic sleeve

Principal Investigator: Santiago Horgan, MD, FACS. Professor of Surgery, Division Chief of Minimally Invasive Surgery. Director of the Minimally Invasive Surgery Fellowship. Director of Bariatric and Metabolic Surgery. Director of the Center for the Future of Surgery. Medical Director for the Simulation Center.

Co-investigators: Shanglei Liu, MD: University of California San Diego, Resident

Ran Bill Luo, MD: University of California San Diego, Minimally Invasive Fellow

Jonathan C. DeLong: University of California San Diego, General Surgery Resident

Rob Knight, PhD: Professor, Department of Pediatrics and Department of Computer Science. University of California San Diego.

Amount Requested: $30,000

Application Due Date: November 4, 2016

Institution/Address: University of California San Diego Center for the Future of Surgery 9500 Gilman Drive, #0740

Phone: 858.246.1005 Fax: 858.246.1066 Email: [email protected] or [email protected]

Start Date of Project End Date of Project June 1, 2017 June 30, 2018

Check should be made payable to The Regents of the Univ. of Calif., U.C. San Diego 200 W. Arbor Drive, Mail Code 8997 San Diego, CA 92103-8997 Attention: Nadine Wilson Phone: 619.471.0720 Email: [email protected] Statement of Funds There are no pending external funds for this project. Needed funding in excess of the $30,000 we are applying for in this grant will be from the University of California San Diego Department of Minimally Invasive Surgery or Department of Computer Science funds.

Summary

The symbiotic relationship between gut flora and the human host is extraordinarily complex and still not fully understood. The genetic makeup of the represented bacterial species in the human GI tract has the potential to express an order of magnitude more genes than are contained within the human genome and may lead to downstream physiologic and hormonal effects [1]. Preliminary work within the gut microbiota field studying the genes contained within non-human cellular intestinal organisms, has elicited a superficial understanding of how this complex ecosystem contributes to disease including [2]. Further, it has been demonstrated that the physical disruption of the GI tract during dramatically alters the populations of bacterial species with their contained genes which may explain why improvements to glucose tolerance and insulin sensitivity are seen before physiologically significant [3]. It is well known that there is variability to bariatric surgery success, which is not simply explained by behavioral differences between patients. The aim of this study is to measure the microbiome of individuals who will undergo laparoscopic and then track the postoperative evolution of the represented bacterial species over time and relate the data to weight loss success. Our goal is to discover predictors of surgical success within the preoperative microbiome and ultimately propose a mechanism for turning a poor weight loss patient into a successful weight loss patient through alterations to the microbiome.

Background

The human is the home to 1014 bacterial organism of up to 1000 different species, the vast majority of which lack virulent qualities and live harmoniously with the human host [4]. The genetic material encoded within the gut flora of an individual is known as the microbiome and contains as much as 100 times more sequence than the human genome [5]. Together, gut microbiota function as a microbial organ and changes to the composition of intestinal bacteria can lead to dysfunction that has been associated with a range of diseases including obesity, , atherosclerosis, autoimmune disease, and [6]. The abundances and types of intestinal flora have been shown to be associated with obesity and there is compelling evidence that it is at least partially a causative relationship.

The gut microbiota is thought to be associated with obesity through four distinct mechanisms. The first is related to increased energy harvesting through fermentation of indigestible dietary carbohydrates into short chain fatty acids (SCFA) that are later turned into more complex lipids in the [7]. Firmicutes species are major producers of SCFAs and have been associated with the obese phenotype in several studies [8]. The second relates to numerous changes in metabolic pathways including carbohydrate and lipid metabolism through regulatory control of the Fasting-induced adipocyte factor (Fiaf), a lipoprotein lipase (LPL) inhibitor [9]. Third ingestion of a high fat diet (HFD) can induce a low grade inflammation by changing the composition of the gut microbiota leading to increased gut permeability and ultimately an increase in proinflammatory plasma lipopolysaccharides (LPS) [10]. And last, several recent studies have suggested that the gut microbiome may influence brain activity and behaviors through alterations of emotional, nociceptive, and social behaviors [11].

Given the sensitivity of the gut microbiota to changes in environmental factors, it is not surprising that reconfiguration of the GI tract during bariatric surgery results in compensatory changes to the gut flora ecosystem. In fact current evidence suggests that the predominant mechanism of weight loss following bariatric surgery may favor microbiome changes over those relating to restriction or malabsorption [12]. In order to prove a causative relationship between an altered microbiome and weight loss, a mouse model of roux-en-y gastric bypass (RYGB) was established and the postoperative gut flora was sampled and sequenced. These bacteria from the post-RYGB mice were then introduced to a mouse line breed and raised in isolation and without any gut flora and the changes seen in the post-RYGB (weight loss, increased cecal short chain fatty acids) were conserved in the non-surgical mice with post-surgical bacteria [13]. Not only does this suggest causation, but it also implies that the lean versus obese phenotype is transmissible.

Few data exist comparing presurgical and postsurgical microbiomes in human patients. In a study comparing obese individuals to post-RYGB patients, Zhang et al discovered Firmicutes species dominated in normal weight and obese patients but were markedly reduced in the post surgical patient. Further, hydrogen-producing bacteria as well as hydrogen-using methanogenic Archea were only found in the obese patients [14].

Given the relatively small sample sizes in these studies we sought to look into the longitudinal differences within individual patients as they progress through the bariatric surgery process. We wished to obtain a larger sample size and characterize and discover predictors of weight loss success and weight loss retention in morbidly obese patients undergoing weight loss surgery.

Hypothesis

Hypothesis 1: There will be identifiable changes in the obese patient’s intestinal microbiome as a result of both the pre-operative liquid diet and bariatric surgery.

Prediction: Due to the change in hormonal as well as dietary patterns as a result of the anatomical and lifestyle changes of bariatric surgery, gastric and colonic bacterial makeup should change substantially for our detection methods.

Hypothesis 2: There may be a significant difference in patient outcomes based on the microbiome changes in patients either pre-operatively or post-operatively.

Prediction: There will be predictors of morbidity, complications, and weight loss both short term and long term when analyzing the microbiome makeup.

1) Enrollment of Subjects The hypothesis will be tested using a prospective cohort study with a total of 40 patients who present for evaluation for morbid obesity surgery. Once insurance approval for the procedure it self has been obtained, the patients will then undergo preoperative duodenal washings, gastric biopsies at the time of a preoperative upper . A repeat endoscopy will be performed on the day of surgery where repeat samples will be performed. They will also provide stool samples for microbiome analysis prior to beginning a preoperative liquid diet, near the completion of their liquid diet but prior to surgery, and post operatively at 1 month, 6 months, and 1 year.

The subjects will be recruited from a clinic population at the UCSD metabolic institute. Depending on preliminary results, there may be more subjects added if needed to increase the power of the study.

Inclusion Criteria: All patients who meet NIH criteria to undergo morbid obesity surgery and who are able to provide informed consent.

Exclusion Criteria: 1) Patients who do not meet NIH criteria for morbid obesity surgery 2) Patients who are unable to provide informed consent 3) Patients under the age of 18.

2) Data Collection Shotgun metagenomic sequencing will be performed in the laboratory under the supervision of Rob Knight, PhD. The gut microbiome will be analyzed with paired-end metagenomic shotgun sequencing (MGS) on a HiSeq 4000, generating an average of 3.0 Gb of data (about 10 million reads) per sample. Quality control and removal of sequence reads mapping to the human genome will be done after which the microbiome sequence reads will be profiled for taxonomy with MetaPhlAn 2.0 and function with HUMAnN2 to predict the abundance of microorganisms and functional pathways. In addition, from the same gastrointestinal aliquot sample, we will perform targeted sequencing using the 16S rRNA gene, a commonly surveyed bacterial marker gene which will allow comparison to extensive external datasets, such as the American Gut Project. These newly analyzed stool samples will then facilitate comparison not only with the shotgun metagenomic sequencing results, but to those generated by other institutions available for comparison.

3) Research Design Aim 1: To study the human microbiome in a large cohort of morbidly obese patients and analyze changes in specific time periods Hypothesis: There will be identifiable changes in the obese patient’s intestinal microbiome as a result of both the pre-operative liquid diet and bariatric surgery.

To test this, we will plan to recruit new obese patients who are routinely referred to our bariatric surgery clinic. They will be consented for the study pending inclusion and exclusion criteria described above. Then, we will ask them to obtain samples at the following time points with corresponding sample:

Pre-operatively at initial endoscopy (prior to a liquid diet) – stool sample x 3, gastric washing Post-liquid diet / time of surgery - stool sample x 3, gastric washing Post-operatively at 1 month - stool sample x 1 Post-operatively 6 months - stool sample x 1 Post-operatively 1 year - stool sample x 1

The initial samples prior to surgery will require more stool sample (hence the 3x per visit before the operation) to establish background colonic flora for comparison. Each of these samples will be sent to Prof. Knight’s lab for metagenomics sequencing.

Aim 2: Discover predictors in the microbiome changes that may lead to improved patient outcomes: post-operative complications, percentage weight loss, resolution of co- morbidities. Hypothesis: There may be a significant difference in patient outcomes based on the microbiome changes in patients either pre-operatively or post-operatively.

This will be a prospectively collected data of what we would normally collect for our bariatric surgery patient including vital signs, weight, any labs or medical records collected as part of routine care. At the end of the 1 year follow up, we will be able to run single and multi-variate analysis to identify any correlations between intestinal microbiome changes with clinical outcomes.

4) Statistical Analysis and Sample Size As the taxonomy and makeup of the human microbiome is able to change frequently, a difference within individual patients should be easily detected. To analyze the pooled data between the different groups, we will begin with 40 patients in our sample size. Depending on the results, these numbers may need to be increased in order to show significance and increase power of the study. Based on previous studies [14] few patient numbers were able to demonstrate significant microbiome differences.

We will utilize the QIIME and QIITA microbial analysis enviroments to enable evaluation of microbial communities as a whole. These software packages were developed by the Knight lab and collaborators and process raw sequences into interpretable data and provide a means for database deposition. For Aim 1 of our study the gut micriobiome in our study will serve as the dependent variable with the weight loss as an independent variable. A systematic comparison between the 16S rRNA deep sequencing and shotgun metagenomics will be used for predictors of successful weight loss for Aim 2 of our study.

Preliminary Data There is currently no preliminary data on this subject

5) Potential Pitfalls Given the numerous variables in all microbiome there is a possibility that there may not exist a large difference between patients who are successful with their weight loss and those who are not. There may also be confounding environmental factors that can alter the microbiome of these individual patients.

6) Timetable We plan to enroll patients as soon as the IRB, which has been submitted at the time of this grant application, is approved. Preliminary target date will be June 1st, 2017. Data acquisition for the preoperative microbiome samples should be completed by June 1st 2018. Post-operative data collection should be completed by June 1st 2019. Data analysis will be performed on an ongoing basis to look for the need to increase sample size, as well as to detect differences. Preliminary results will be published when available.

Budget

Budget Justification No member of the team will have his or her salary paid through the grant

1. Samples run initially (gastric biopsy + duodenal washing + stool x3) = 5, 5 samples after liquid diet, 3 stool samples at 1 month, 3 stool samples at 6 months, and 3 stool stamples at 12 months. Total = 19 samples (Round to 20) 2. 40 patients x 20 samples = 800 total samples 3. Basic lab costs 800 samples x $5 = $4,000 4. Microbiome gene sequencing kits 800 samples x $16 = $12,800 5. Sample cups and stool kits, sterilization 800 samples x $5 = $4,000 6. Travel costs for one research resident or fellow to present at scientific meeting. ($700)

References

1. Ley RE, Turnbaugh PJ, Klein S, Gordon JI. Microbial ecology: human gut microbes associated with obesity. Nature, 444(7122), 1022-1023 (2006). 2. Tsai F, Coyle WJ. The microbiome and obesity: is obesity linked to our gut flora? Curr Gastroenterol Rep, 11(4), 307-313 (2009). 3. Reed MA, Pories WJ, Chapman W et al. Roux-en-Y gastric bypass corrects hyperinsulinemia implications for the remission of type 2 diabetes. J Clin Endocrinol Metab, 96(8), 2525-2531 (2011). 4. Stephani J, Radulovic K, Niess JH. Gut microbiota, probiotics and inflammatory bowel disease. Arch Immunol Ther Exp (Warsz), 59(3), 161-177 (2011). 5. Valsecchi C, Carlotta Tagliacarne S, Castellazzi A. Gut Microbiota and Obesity. J Clin Gastroenterol, 50 Suppl 2, Proceedings from the 8th Probiotics, Prebiotics & New Foods for Microbiota and Human Health meeting held in Rome, on September 13-15, 2015, S157-S158 (2016). 6. Nehra V, Allen JM, Mailing LJ, Kashyap PC, Woods JA. Gut Microbiota: Modulation of Host Physiology in Obesity. Physiology (Bethesda), 31(5), 327- 335 (2016). 7. Backhed F, Ding H, Wang T et al. The gut microbiota as an environmental factor that regulates fat storage. Proc Natl Acad Sci U S A, 101(44), 15718-15723 (2004). 8. Ley RE, Backhed F, Turnbaugh P, Lozupone CA, Knight RD, Gordon JI. Obesity alters gut microbial ecology. Proc Natl Acad Sci U S A, 102(31), 11070-11075 (2005). 9. Everard A, Lazarevic V, Derrien M et al. Responses of gut microbiota and glucose and lipid metabolism to prebiotics in genetic obese and diet-induced leptin-resistant mice. Diabetes, 60(11), 2775-2786 (2011). 10. Furet JP, Kong LC, Tap J et al. Differential adaptation of human gut microbiota to bariatric surgery-induced weight loss: links with metabolic and low-grade inflammation markers. Diabetes, 59(12), 3049-3057 (2010). 11. Mayer EA, Knight R, Mazmanian SK, Cryan JF, Tillisch K. Gut microbes and the brain: paradigm shift in neuroscience. J Neurosci, 34(46), 15490-15496 (2014). 12. Aron-Wisnewsky J, Dore J, Clement K. The importance of the gut microbiota after bariatric surgery. Nat Rev Gastroenterol Hepatol, 9(10), 590-598 (2012). 13. Ridaura VK, Faith JJ, Rey FE et al. Gut microbiota from twins discordant for obesity modulate metabolism in mice. Science, 341(6150), 1241214 (2013). 14. Zhang H, DiBaise JK, Zuccolo A et al. Human gut microbiota in obesity and after gastric bypass. Proc Natl Acad Sci U S A, 106(7), 2365-2370 (2009).

Local/Institution Review Board IRB approval is pending at the time of this grant submission.

Available Resources: University of California San Diego (UCSD) Minimally Invasive Surgery Department The Division of Minimally Invasive Surgery (MIS) is a specialty division within the Department of Surgery at UCSD. It is known for excellence in bariatric, foregut, and surgery. The Division has a fellowship program, which trains two clinical MIS fellows per year. In addition to the clinical fellowship, the Division provides salary support to 3-5 research fellows, comprised of UCSD residents and international surgeons.

University of California San Diego (UCSD) Center for the Future of Surgery The Center for the Future of Surgery (CFS) is the surgical simulation facility at UCSD. The CFS is located in the Medical Education and Telemedicine (MET) Building. The building houses a research suite where physicians and scientists collaborate across disciplines to innovate, four surgical suites with twenty-two work stations all equipped with the latest surgical, robotic, laparoscopic and microscopic technology used for SAGES-courses, a simulation center with an operating room, an intensive care unit, an emergency room and a medical/surgical hospital room. Residents in general surgery, urology, obstetrics and gynecology, anesthesiology, neurosurgery, and orthopedic surgery train in the CFS. In addition to the equipment and facility itself, the CFS has a robust staff including secretaries, veterinarians, anesthesia technicians, and a lab manager. This facility offers the investigators a perfect opportunity to work in a scientific environment, ensuring close coordination of clinical, research and educational endeavors.

BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors in the order listed on Form Page 2. Follow this format for each person. DO NOT EXCEED FOUR PAGES.

Horgan, Santiago MD, FACS POSITION TITLE Professor of Surgery eRA COMMONS USER NAME (credential, e.g., agency login) Chief, Division of Minimally Invasive Surgery shorgan Director, Minimally Invasive Fellowship EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable.) DEGREE INSTITUTION AND LOCATION MM/YY FIELD OF STUDY (if applicable) Nuestra Senora de Guadalupe Buenos Aires B.S. 06/1984 Medicine

Buenos Aires University MD 06/1990 Medicine

Hospital de Clinica, University of Buenos Aires N/A 06/1995 General Surgery Resident Laparoscopic Surgery University of Washington Medical Center N/A 06/1996 Fellowship University of Washington Medical Center N/A 06/1997 Esophageal Fellowship

A. Personal Statement The goal of this project is to create a method to gage ergonomics in surgeons and provide real-time feedback for subjects to correct inappropriate postures in the operating room. I have been the principal investigator in other research projects involving surgeons and residents. I have a strong background in surgical research, mostly in the field of laparoscopic, endo-luminal, and robotic surgery, with history of successful and productive publications. My current clinical and research focus areas include novel technologies in laparoscopic and robotic surgery.

B. Positions and Honors Positions 1987-1989 Assistant Professor in Anatomy: Medicine University, Buenos Aires 1995 - 1998 Instructor, Department of Surgery: University of Washington 1998-present Professor of Surgery, University of Buenos Aires, Argentina 2000-present Honorary Professor of Surgery. University of Tucuman, Argentina 1999 – 2005 Assistant Professor of Surgery, University of Illinois at Chicago

2005-2006 Associate Professor of Surgery Chief Minimally Invasive and Robotic Surgery Director Minimally Invasive Surgery Fellowship Director Surgical Education Laboratory Co-Director Swallowing Center University of Illinois at Chicago

2006-Present Professor of Surgery Chief, Division of Minimally Invasive Surgery Vice Chairman, Business Development Founder and Director of Bariatric and Metabolic Institute Director Minimally Invasive Surgery Fellowship Director of the Center for the Future of Surgery University of California, San Diego Medical Director of the Simulation Center

Honors 1993 Annual scholarship: Medicine University, Buenos Aires, Argentina 1995 Roemmers Gold Medal Award: “Liver Ischemia After Reperfusion in Pigs.” 2001 Class Act Winner: University of Illinois at Chicago 2001 Young Surgeon Award: Surgical Society of the Alimentary Tract 2001: Research Award. SAGES 2003 The Distinguished Robotic Surgeon Award-Pioneer in Evolution and Advancement of DaVinci General Surgery, From Intuitive Surgical Corp. 2005 Accesit award for best paper presentation ¨Lessons learned after 420 minimally invasive robotic assisted procedures¨. 76º Congreso Argentino de Cirugía 2005 2009 Health Care Champions Award. UC San Diego Medical Center 2010 Who's Who in America 2011 (65th Edition) 2010 HealthLeaders 20- 20 People who Make Healthcare Better 2010 2011 San Diego Magazine HealthLeaders- 50 People to Watch 2011 2012 San Diego Metropolitan Magazine- “2012 Metro Mover”

C. Selected Peer-review Publications 1. Horgan S, Sinanan M, Helton S, Pellegrini C. Use of Laparoscopic techniques improves outcome from adrenalectomy. Am J Surg. 1997 May; 173:371-4. 2. Horgan S, Hudda K, Eubanks T, Pellegrini CA: Does Botulinum Toxin injection make esophagomyotomy a more difficult operation. Surgical Endoscopy. 1999 Jun; 13(6):576-9. 3. Horgan S, Jacobs G, Eubanks T, Pellegrini C: Repair of Paraesophageal . Am J. Surg. 1999 May; 177(5):354-58. PMID: 10365868 4. Horgan S, Pohl D, Bogetti D, Eubanks T, Pellegrini CA: Failed Antireflux surgery: What have we learned from reoperations. Arch Surg. 1999 Aug; 134:809-17. 5. Horgan S, Vanuno D. Robots in Laparoscopic Surgery. Journal of Laparoendoscopic and Advanced Surgical Techniques. 2001 Dec; 11(6):415-9. 6. Horgan S, Vanuno D, Benedetti E. Review article. Early experience with Robotic assisted laparoscopic donor nephrectomy. Surgical Endoscopy & Percutaneous techniques 2002 Feb; 12:1:64-70. 7. Horgan S, Vanuno D, Pierpaolo Sileri, Cicolese L, Benedetti E. Robotic assisted donor nephrectomy for kidney transplantation. Transplantation. 2002 May; 73(9):1474-9. 8. Horgan S, Berger R, Elli E, Espat J. Robotic Assisted Minimally Invasive Transhiatal . Am Surg. 2003 Jul; 69(7):624-26. PMID: 12889629 9. Jacobsen G, Berger R, Horgan S. The Role of Robotic Surgery in Morbid Obesity. J Laparoendosc Adv Surg Tech. 2003 Aug; 13(4): 279-283. 10. Talamini MA, Chapman S, Horgan S, Melvin WS. A prospective analysis of 211 robotic-assisted surgical procedures. Surg Endosc. 2003 Oct; 17(10):1521-4. 11. Varela JE, Elli EF, Vanuno D, Horgan S. Mini-laparoscopic placement of a catheter Surg Endosc. 2003 Dec; 17(12): 2025-7. 12. Elli E, Espat NJ, Berger R, Jacobsen G, Knoblock L, Horgan S. Robotic-assisted thoracoscopic resection of esophageal leiomyoma. Surg Endosc. 2004 Apr; 18(4):713-6. 13. Elli EF, Jacobsen G, Horgan S. Endoscopic treatment of gastroesophageal reflux. J Laparoendosc Adv Surg Tech A. 2004 Aug; 14(4):244-9. PMID: 15345166 14. Jacobsen G, Elli F, Horgan S. Robotic surgery update. Surg Endosc. 2004 Aug; 18(8):1186-91. 15. Horgan S, Holterman MJ, Jacobsen GR, Browne AF, Berger RA, Moser F, Holterman AX. Laparoscopic adjustable gastric banding for the treatment of adolescent morbid obesity in the United States: a safe alternative to gastric bypass. J Pediatr Surg. 2005 Jan; 40(1):86-90; 90-1. 16. Melvin W, Dundon J, Talamini M, Horgan S. Computer-enhanced robotic telesurgery minimizes esophageal perforation during . Surgery. 2005 Oct; 138(4): 553-8; 558-9. 17. Melvin W S, Dundon J, Talamini M, Horgan S. Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy. Surgery. 2005 Oct; 138(4):553-8; 558-9. 18. Horgan S, Galvani C, Gorodner MV, Omelanczuck P, Elli F, Moser F, Durand L, Caracoche M, Nefa J, Bustos S, Donahue P, Ferraina P. Robotic-assisted Heller myotomy vs Laparoscopic Heller myotomy for the treatment of esophageal achalasia: Multicenter study. J Gastrointest Surg. 2005 Nov 1; 9(8): 1020-1030. 19. Galvani C, Gorodner M, Moser F, Baptista M, Chretien C, Berger R, Horgan S. Laparoscopic versus laparoscopic Roux-en-Y gastric bypass: ends justify the means? Surg Endosc. 2006 Jun; 20(6):934-41. 20. Moser F, Gorodner M, Galvani C, Baptista M, Chretien C, Horgan S. Pouch enlargement and band slippage: two different entities. Surg Endosc. 2006 July; 1021-9. 21. Galvani CA, Gorodner MV, Moser F, Jacobsen G, Chretien C, Espat NJ, Donahue P, Horgan S. Robotically assisted laparoscopic transhiatal esophagectomy. Surg Endosc. 2008 Jan; 22(1):188-95. 22. Fischer LJ, Jaconsen G, Wong B, Thompson K, Bosia J, Talamini M, Horgan S. NOTES laproscoopic-assisted transvaginal sleeve gastrectomy in humans— description of preliminary experience in the United States. Surg Obes Relat Dis. 2009 Sept-Oct; 5 (5):633-6. 23. Jacobsen GR, Thompson K, Spivack A, Fischer L, Wong B, Cullen J, Bosia J, Whitcomb E, Lucas E, Talamini M, Horgan S. Initial experience with transvaginal incisional . Hernia. 2010 Feb; 14(1):89-91. 24. Harnsberger CR, Broderick RC…Horgan S. Magnetic lower esophageal sphincter augmentation device removal. Surg Endosc. 2015 Apr; 29(4):986-6. 25. Broderick RC, Fuchs HF…Horgan S. The price of decreased mortality in the operative management of diverticulitis. Surg Endosc. 2015 May; 29(5):1185-91. 26. Barajas-Gamboa JS, Acosta G,… Horgan S. Laparo-endoscopic transgastric resection of gastric submucosal tumors. Surg Endosc. 2015 Aug; 29(8): 2149-57. 27. Harnsberger CR, McLemore EC…Horgan S. Foramen of Winslow hernia: a minimally invasive approach. Surg Endosc. 2015 Aug; 29(8): 2385-8.

D. Research Support 2015 BAROnova Using the TransPyloric Shuttle® System: A Multicenter, Prospective, Randomized, Controlled, Double-Blinded, Parallel-Design Study (ENDObesity®II Study $1,183,000

2015 Medigus A Worldwide Post-Market Surveillance Registry to assess the Medigus Ultrasonic Surgical Endostapler (MUSE™) System for the treatment of GERD $275,000

BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors in the order listed on Form Page 2. Follow this format for each person. DO NOT EXCEED FOUR PAGES.

NAME POSITION TITLE Luo, Ran Bill Minimally Invasive Surgery Research Fellow eRA COMMONS USER NAME (credential, e.g., agency login) rluo EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable.) DEGREE INSTITUTION AND LOCATION MM/YY FIELD OF STUDY (if applicable)

University of California, Los Angeles B.S. 06/06 Neuroscience

University of California, Davis M.D. 06/10 Medicine

Northwestern Memorial Hospital N/A 06/15 General Surgery

University of California, San Diego N/A 07/18 Minimally Invasive Surgery Fellowship

A. Personal Statement Dr. Luo is currently a research fellow in the department of Minimally Invasive Surgery at the University of California, San Diego. His interests in morbid obesity and bariatric patient outcomes has led him to pursue multiple avenues to analyze how different factors can influence weight loss and maintenance of weight loss long-term.

B. Positions and Honors Positions 2010-2015 General Surgery Resident, Northwestern Memorial Hospital 2015-2016 Research Fellow, UCSD Department of Minimally Invasive Surgery 2016-2017 Clinical Fellow, UCSD Department of Minimally Invasive Surgery

Honors 2003 – 2006 Undergraduate Provost/Deans Letters 2003 – 2006 2006 Phi Beta Kappa 2008 – 2009 UC Davis SOM Clerkship Honors: Surgery, Primary Care, and Pediatric 2012 - 2014 Northwestern Hospital Department of Surgery Outstanding Teacher Award

Professional Associations 2009 – Present Alpha Omega Alpha Honor Society 2010 – Present American College of Surgeons 2012 – Present Society of American Gastrointestinal and Endoscopic Surgeons 2015 – Present American Society for Metabolic and Bariatric Surgery

C. Selected Peer-reviewed Publications 1. Luo RB, Montalvo D, Horgan S. POEM after gastric bypass: an effective solution for de novo achalasia. 2016 Publication pending. Surg Obes Rel Dis. 2. Luo RB, Montalvo D, Suzuki T, Sandler BJ, Jacobsen GR, Horgan S. Complications of robotic foregut: risks and advantages. 2016 Publication pending. Minerva Chirurgica. 3. Luo RB, Liu S, DeLong JC, Sandler BJ, Jacobsen GR, Horgan S. Laparoscopic gastropleural fistula repair: A minimally invasive solution for a complex problem. 2016 Publication pending. J Laparoendosc Adv Surg Tech A.

D. Research Support Current clinical fellowship is sponsored through the Department of Minimally Invasive Surgery at University of California, San Diego.

BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors in the order listed on Form Page 2. Follow this format for each person. DO NOT EXCEED FOUR PAGES.

NAME POSITION TITLE Liu, Shanglei Minimally Invasive Surgery Research Fellow eRA COMMONS USER NAME (credential, e.g., agency login) s5liu EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable.) DEGREE INSTITUTION AND LOCATION MM/YY FIELD OF STUDY (if applicable)

University of California, San Diego B.S. 06/07 Bioengineering

University of California, San Diego M.D. 06/12 Medicine

University of California, San Diego N/A Ongoing General Surgery

Minimally Invasive University of California, San Diego N/A Ongoing Surgery Research Fellowship

Medical Device University of California, San Diego M.A.S. Ongoing Engeineering

A. Personal Statement Dr. Liu is currently a research fellow in the department of Minimally Invasive Surgery at the University of California, San Diego (UCSD). Simultaneously, he is also obtaining his Masters in Advanced Studies (M.A.S) degree in Medical Devices Engineering. After 2 years of this research fellowship, he will return to residency and complete his training in general surgery at UCSD.

B. Positions and Honors Positions 2012-2019 General Surgery Resident, UCSD Department of Surgery 2015-2017 Research Fellow, UCSD Department of Minimally Invasive Surgery

Honors 2009 Summer NIH Research Grant for Medical Students 2014 UCSD “Nicholas Halasz” Surgical Consultation Award

C. Selected Peer-reviewed Publications 1. S. Liu, S. Ho, M. Krinksy, “Quality of resection during : are we achieving polyp clearance?” Digestive Disease Science, 2012, 57(7):1786-91. 2. S. Ho, B. Aqel, E. Dieperink, S. Liu, L. Tetrick, Y.Falck-Ytter, C. DeComarmond, C. Smith, D. McKee, W. Boyd, C. Kulig, E. Bini, M. Pedrosa, “U.S. Multicenter Pilot Study of Daily Consensus Interferon (CIFN) Plus Ribavirin for “Difficult-to-treat” HCV Genotype 1 Patients.” Digestive Disease Science, 2011, 56:880-888 3. H. Dong, S. Ki-Nam, J. Li, J. Estrema, T. Ornelas, F. Nguyen, S. Liu, S. Ramamoorthy, S. Ho, J. Carethers, J. Chow, “Molecular mechanisms underlying Ca2+-mediated motility of human pancreatic duct cells,” American Journal of Physiology Cell Physiology, 2010, 299:C1493-C1503 4. J. Lee, V. Reis, S. Liu, L. Conn, EJ, Groessl, T. Ganiats, S. Ho, “Improving Fecal Occult Testing Compliance Using a Mailed Educational Reminder,” Journal of General Internal Medicine, Vol 24, Number 11, 1192-1197 5. E. VanKleek, S. Liu, L. Conn, A. Hoadley, S. Ho, “Improving the Effectiveness of Testing in a Primary Care Clinic by Direct Colonoscopy Referral for Positive Tests.” Journal of Healthcare Quality, 2009, j.1945- 1474.2009.00071.x

D. Research Support Current research fellowship is sponsored through the Department of Minimally Invasive Surgery at University of California, San Diego.

BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors. Follow this format for each person. DO NOT EXCEED FIVE PAGES.

NAME: DeLong, Jonathan Crawford eRA COMMONS USER NAME (credential, e.g., agency login): jdelong

POSITION TITLE: General Surgery Resident

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable. Add/delete rows as necessary.)

DEGREE Completion Date FIELD OF STUDY INSTITUTION AND LOCATION (if applicable) MM/YYYY

The College of William & Mary B.A. 05/2009 Government Eastern Virginia Medical School M.D. 05/2013 Medical Doctor University of California, San Diego Residency Ongoing General Surgery

A. Personal Statement

I am a general surgery resident at the University of California San Diego Department of Surgery. I am currently completing my second of 2 years in the research lab through the Divisions of Minimally Invasive Surgery and Surgical Oncology. We have a vibrant collaborative environment on campus with multidisciplinary resources at our disposal which has cultivated a working relationship with our microbiome faculty to explore the relationship between gut ecology and obesity—particularly how it relates to bacterial colonization changes after bariatric surgery and whether we can discover predictors of success after surgery or even modifications that can ensure it.

I will enter my third year of clinical training as a PGY-5 in July of 2017. I intend to take advantage of our institutional strengths of surgical oncology and minimally invasive surgery during my time in San Diego. After residency I intend to pursue a fellowship in surgical oncology in a program that demonstrates integration of new technology and one that has utilizes the remarkable recent advancement in minimally invasive technique.

B. Positions and Honors

Positions and Employment 2013- Resident, Department of Surgery, University of California, San Diego, San Diego, CA 2015- Research Fellow, Department of Surgical Oncology & Minimally Invasive Surgery, University of California, San Diego, San Diego, CA

Other Experience and Professional Memberships 2010-2013 Chair, Vice Chair, Secretary Treasurer (sequential 1 year terms), Medical Society of Virginia – Medical Student Section 2010-2011 Committee Member, American Medical Association – Medical Student Section Committee on Legislation and Advocacy 2015- Resident Member, American College of Surgeons 2015- Candidate Member, Society of American Gastrointestinal and Endoscopic Surgeons

Honors 2010 Monthly Hero, Eastern Virginia Medical School, For Co-founding Medical Students United for Haiti 2016 Award Recipient, American College of Surgeons 2016 Leadership & Advocacy Summit Resident Grant

C. Contribution to Science

Over the course of the last 14 months, I have entered the realms of preclinical and clinical research in the first collaborative Fluorescence Guided Surgery Research Fellowship in the Departments of Surgical Oncology and Minimally Invasive Surgery. This is an exciting and rapidly evolving field for which I have quickly developed experience and enthusiasm. My second publication, entitled, Current status and future perspectives of fluorescence-guided surgery for cancer, chronicles the recent advances in this exciting field and underscores the work that still needs to be done before the full potential of fluorescence guided surgery can be realized. This grant will facilitate our progress. Through the leadership and guidance of my accomplished mentors for whom I have profound respect, I intend to cultivate their sense of intellectualism and scientific curiosity that has served them so well in their successful careers.

1) DeLong, JC, Chakedis, JM, Hosseini, A, Kelly, KJ, Horgan, S, Bouvet, M. Indocyanine green (ICG) fluorescence-guided laparoscopic adrenalectomy. Journal of Surgical Oncology. Vol. 112, Iss. 6, 2015. 2) DeLong, JC, Hoffman, RM, Bouvet, M. Current status and future perspectives of fluorescence-guided surgery for cancer. Expert Review of Anticancer Therapy. Vol. 16, Iss. 1, 2016 3) Murakami, T, DeLong, JC, Eilber FC, Zhao M, Zhang Y, Zhang N, Singh A, Russell T, Deng S, Reynoso J, Quan C, Hiroshima Y, Matsuyama R, Chishima T, Tanaka K, Bouvet M, Chawla S, Endo I, Hoffman RM. Tumor-targeting Salmonella typhimurium A1-R in combination with doxorubicin eradicates soft tissue sarcoma in a patient-derived orthotopic xenograft (PDOX) model. Oncotarget. Accepted for Publication January 27, 2016.

D. Research Support

Department of Minimally Invasive Surgery – UC San Diego Department of Surgical Oncology – UC San Diego Participation in SAGES

Dr. Santiago Horgan MD FACS has participated in SAGES since 1999 and is actively involved on multiple levels currently. He is currently on the SAGES Board of Governors, co-chair for the Robotic Task Force Committee, and part of both the credentialing committee and standards of practice committee. Dr. Horgan received a research award in 2001, and has received SAGES grants in the past for the development of a video- endoscopic surgical training (1997) and for the Development of a web-based system for evaluating laparoscopic skills of surgical residents (2001). In addition, Dr. Horgan has mentored many surgical residents and minimally invasive fellows who have gone on to have productive careers in minimally invasive surgery with active memberships in SAGES.

Dr. Ran B. Luo MD has been a candidate member of SAGES since 2013. He has submitted multiple abstracts to Surgical Endoscopy in the past, and most recently, presented multiple podium abstracts at the 2016 SAGES meeting in Boston, MA. He has also submitted multiple abstracts to the 2017 SAGES meeting in Houston, which will be his fourth SAGES meeting.

Dr. Shanglei Liu MD is a resident at the University of California San Diego Department of Surgery. He has just completed his third year of residency and is currently in his second year of a two-year research fellowship through the Department of Minimally Invasive Surgery. He is a current candidate member of SAGES and most recently presented multiple podium abstracts at the 2016 SAGES meeting in Boston, MA. He has submitted multiple abstracts to the 2017 meeting in Houston, which will be his second SAGES meeting.

Dr. Jonathan C. DeLong MD has been a candidate member of SAGES since 2016 and is a current resident at the University of California San Diego Department of Surgery. He has completed 2 clinical years of residency and is in his second year of a two-year joint research fellowship through the divisions of minimally invasive surgery and surgical oncology. He has presented multiple podium abstracts at the 2016 SAGES Annual Meeting in Boston, MA and has several abstracts pending for the upcoming 2017 SAGES Annual Meeting in Houston, TX.

Dr. Rob Knight PhD is a professor at University of California San Diego in the Departments of Pediatrics and Computer Science. He is not a SAGES member, but will be working closely with the principal investigator and the co-investigators as the microbiome consultant, with access to multiple PhD and post-doctoral scholars.

Appendices None