Global Benchmark Values for Laparoscopic Roux-en-Y-Gastric Bypass: a Potential New Indicator of the Surgical Learning Curve

Staple Line Reinforcement during Sleeve Gastrectomy with SeamGuard: Single-Center Retrospective Case-Control Study over a 5-Year Period

Introduction: Various techniques and reinforcements have been proposed over the years in order to prevent leaks and bleeding after sleeve gastrectomy (LSG). The aim of this study was to retrospectively compare the staple line complication (SLC) rate in patients who underwent LSG with the use of bioabsorbable membrane (GORE® SEAMGUARD®, GoR) for staple line versus those who received no reinforcement. Methods: Data on all consecutive patients undergoing LSG between 1 January 2014 and 31 December 2018 were retrospectively reviewed. Patients were divided into two groups: the GoR+ group if the SeamGuard (GoR) was used and the GoR- group if no reinforcement was applied on the staple line. Preoperative demographics and rate of SLC were compared between groups. All cases of SLC coming from other centers were also reviewed. Results: A total number of 626 LSGs were performed at our institution during the study period. GoR was applied in 450 (71.9%) cases (GoR+ group), while NR was used in 176 (28.1%) patients (GoR- group). Two (1.13%) cases of leaking and two (1.13%) cases of bleeding occurred in the GoR- group, while no SLC was recorded in patients who received GoR (p < 0.05). Thirteen cases of SLC coming from other institutions were treated at our hospital; all these cases were performed without any SLR. Conclusion: In our case series, the use of GoR reduced the rate of SLC after LSG. In all cases of SLC coming from other institutions, no reinforcement had been applied on the staple line during LSG.

Comparison of 2D 4K vs. 3D HD laparoscopic imaging systems in bariatric surgery: study protocol for a randomized controlled prospective trial

BACKGROUND

Vision is an important and defining element of laparoscopy and significantly affects the outcome of surgery in terms of time, error, and precision. Several new imaging systems have become available for laparoscopic surgery, including three-dimensional (3D) high-definition (HD) and two-dimensional (2D) ultra-high-resolution (4K) monitors. 3D HD systems offer a number of potential benefits to surgeons and patients over traditional 2D systems, including reduced operating time, blood loss, and hospital stay. However, the performance of 3D systems against the new, ultra-high definition 4K systems is barely known and highly controversial. There is a paucity of studies comparing them in clinical settings. The aim of this study is to compare 2D 4K and 3D HD perspectives in gastric bypass surgery.

METHODS

Forty-eight patients with an indication for gastric bypass will be randomized to receive laparoscopic gastric bypass surgery using either 2D 4K or 3D HD systems. The operations will be performed by a well-coordinated team of three senior surgeons. The primary outcome is operative time. Secondary outcomes include intraoperative complications, blood loss, operator workload as assessed by the validated Surg-TLX questionnaire, and postoperative complications according to the Clavien-Dindo classification. An interim analysis is planned after enrollment of 12 participants for each group.

DISCUSSION

This prospective, randomized trial is designed to test the hypothesis that the use of a 3D HD system will result in a significant improvement in operative time compared to a 2D 4K system in bariatric surgery. The objective is to provide clinical evidence for new laparoscopic imaging systems and to evaluate potential benefits.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov under the identifier NCT05895058. Registered 30 May 2023. BASEC2023-D0014 [Registry ID Swissethics, approved 3 May 2023]. SNCTP000005489 [SNCTP study register, last updated 13 July 2023].

Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy

BACKGROUND

Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks.

METHODS

Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years.

RESULTS

A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass.

CONCLUSION

The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.

Initial experience with laparoscopic gastric bypass in an Australian general foregut surgery unit

BACKGROUND

Laparoscopic gastric bypass (LGB) is an increasingly utilized approach to bariatric surgery in Australia. A high proportion of those procedures are revisional due to Australia's legacy of laparoscopic adjustable gastric banding (LAGB), which is not the case internationally. The aim of this study was to compare post-operative outcomes in an Australian general foregut surgery unit against benchmarks published in the literature.

METHODS

This is retrospective cohort study of morbidly obese patients undergoing primary or revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic one anastomosis gastric bypass (OAGB) with the two senior authors between 5 May 2015 and 27 June 2019. Perioperative data for the unit's first 100 cases were collected prospectively, stored on a unit database and analysed. Post-operative complications at 30 days, 90 days, mortality, length of hospital stay, and Defined Adverse Events were chosen as indicators of the perioperative outcome (as defined in the Monash Bariatric Surgery Registry).

RESULTS

In this cohort, 35% of procedures were RYGB and 65% were OAGB. The majority (58%) were revisional procedures. Most patients (74%) were female. The median age was 50. The comorbidity profile of the population was similar to those published internationally. The median hospital stay was 4 days. There was no mortality. Early complications occurred in 9% of patients, with 3% occurring late.

CONCLUSION

Outcomes of our first 100 cases are comparable with those recorded in the literature, notwithstanding a much higher proportion of revisional cases. LGB can be safely introduced in Australian general foregut surgery units by experienced laparoscopic surgeons.

Comparative Analysis of Laparoscopic Gastrectomy Versus Laparoscopic-Assisted Gastrectomy: Postoperative Complications

The evolution of laparoscopic surgery in gastric cancer has advanced significantly, with benefits over open surgery initially demonstrated in early gastric cancer and later in advanced stages. This study aims to evaluate postoperative complications, surgical outcomes, and anastomosis safety by comparing laparoscopic gastrectomy and laparoscopic-assisted gastrectomy. This retrospective, observational, analytical study included patients diagnosed with gastric cancer who underwent laparoscopic gastrectomy at a university hospital from January 2006 to February 2018. Patients were initially divided into two groups based on the type of anastomosis: laparoscopic gastrectomy (intracorporeal anastomosis) and laparoscopic-assisted gastrectomy (extracorporeal anastomosis). Further secondary analysis was done with subgroups based on the type of gastrectomy and anastomosis performed. A total of 139 patients were analyzed, showing significant differences in postoperative complications between the two surgical approaches. The laparoscopic-assisted group exhibited a higher rate of complications. The laparoscopic approach (with intracorporeal anastomosis) was found to have a lower risk of complications and morbidity/mortality compared to the laparoscopic-assisted approach. Laparoscopic gastrectomy with intracorporeal anastomosis resulted in lower morbidity and mortality than laparoscopic-assisted gastrectomy. The technique of partial gastrectomy with intracorporeal anastomosis was associated with the lowest rate of postoperative complications.

Evaluation of Alternate Laparoscopic Stapling Device for Bariatric Surgery

BACKGROUND

As laparoscopic bariatric surgical techniques have matured, the incidence of complications has decreased over time. Surgical stapling devices are commonly used for resection and anastomosis of gastric tissue during bariatric surgery. The purpose of this study is to assess and compare complication rates and clinical outcomes between patient cohorts using 2 different approved stapling devices.

MATERIALS AND METHODS

Clinical outcomes were retrospectively compared for patients undergoing bariatric surgery between April 2019 and December 2020 using laparoscopic surgical stapling device A (LSSD-A) against outcomes between January 2017 and September 2018 using laparoscopic surgical stapling device B (LSSD-B). Tradenames for LSSD-A and LSSD-B were AEON Endostapler and Endo GIA with Tri-Staple Technology, respectively.

RESULTS

In all, 814 patients underwent laparoscopic bariatric operation using LSSD-A and 1034 using LSSD-B. Laparoscopic surgery included sleeve gastrectomy (n=1359, 73.5%), Roux-en-Y gastric bypass (RYGB) (n=425, 23.0%), and single anastomosis duodenoileostomy with gastric sleeve (n=64, 3.5%). Stapler-related complications were evenly distributed over the 20.9-month LSSD-B study period. No stapler-related complications were seen in the last 13 months of the LSSD-A study period, during which time 428 (52.5%) laparoscopic bariatric operations were performed. One staple line leak was observed, occurring in the LSSD-B group. Patients undergoing laparoscopic RYGB with LSSD-A had fewer overall complications, fewer transfusions, and fewer reoperations for staple line bleeding.

CONCLUSIONS

Both LSSD-A and LSSD-B were safe and effective in the performance of laparoscopic bariatric operations with low complication rates and comparable clinical performance in sleeve gastrectomy and single anastomosis duodenoileostomy with gastric sleeve. Statistically significant differences in complication rates were observed in RYGB favoring LSSD-A.

Young-IFSO Bariatric/Metabolic Surgery Training and Education Survey

BACKGROUND

This international Young-IFSO survey aims to address variations, trends, and obstacles in bariatric/metabolic surgery (BMS) training globally, since expectations and resources differ among young surgeons.

METHODS

The Young-IFSO scientific team designed an online confidential questionnaire with 50 questions analyzing the individual BMS training. The survey link was sent to all IFSO/ASMBS members and was shared in social media. All Young-IFSO members (age up to 45 years) were invited to participate between 16 December 2022 and 4 February 2023.

RESULTS

A total of 240 respondents from 61 countries took the survey. Most respondents (70.24%) described their current position as a consultant surgeon with an average of 5.43 years' experience working in BMS, and 55% are working in a bariatric center of excellence. More than 50% of the respondents performed none or less than 10 BMS during residency. Preparation of the stomach and stapling during sleeve gastrectomy (SG) were the first steps performed, and SG was the first BMS completed as a first operating surgeon by most of the respondents (74%). In total, 201 (84.45%) surgeons reported to perform scientific work. Most respondents (90.13%) reported that surgical mentorship had improved their surgical skills.

CONCLUSION

This international experts' survey underlines the lack of a standardized global surgical curriculum of BMS during residency. It shows that SG is the single most performed procedure by young surgeons. These data might underline the importance of advancing surgical education in BMS, and accredited fellowship programs should be offered globally to maintain and raise quality of BMS.

Classification of Adverse Events in Adult Surgery

Successful surgery combines quality (achievement of a positive outcome) with safety (avoidance of a negative outcome). Outcome assessment serves the purpose of quality improvement in health care by establishing performance indicators and allowing the identification of performance gaps. Novel surgical quality metric tools (benchmark cutoffs and textbook outcomes) provide procedure-specific ideal surgical outcomes in a subgroup of well-defined low-risk patients, with the aim of setting realistic and best achievable goals for surgeons and centers, as well as supporting unbiased comparison of surgical quality between centers and periods of time. Validated classification systems have been deployed to grade adverse events during the surgical journey: (1) the ClassIntra classification for the intraoperative period; (2) the Clavien-Dindo classification for the gravity of single adverse events; and the (3) Comprehensive Complication Index (CCI) for the sum of adverse events over a defined postoperative period. The failure to rescue rate refers to the death of a patient following one or more potentially treatable postoperative adverse event(s) and is a reliable proxy of the institutional safety culture and infrastructure. Complication assessment is undergoing digital transformation to decrease resource-intensity and provide surgeons with real-time pre- or intraoperative decision support. Standardized reporting of complications informs patients on their chances to realize favorable postoperative outcomes and assists surgical centers in the prioritization of quality improvement initiatives, multidisciplinary teamwork, surgical education, and ultimately, in the enhancement of clinical standards.

Is an Early Resumption of a Regular Diet After Laparoscopic Roux-en-Y Gastric Bypass Safe?

Background

Return to a normal diet is a crucial step after bariatric surgery. Proximal anastomosis is a source of concern for early feeding as the passage of solid food through a recent anastomosis could well increase pressure and the risk of leakage. This study aims to assess the safety of an early normal diet after a laparoscopic Roux-en-Y gastric bypass (LRYGB).

Materials and Methods

All consecutive patients undergoing primary LRYGB between January 2015 and December 2020 were included prospectively. Three postoperative pureed diets were compared at 4 weeks, 2 weeks, and 1 week. All-cause morbidity at 90 days was the main outcome. Overall complications, severe complications (Clavien-Dindo ≥ grade 3a), length of hospital stay, number of emergency, and unplanned consultations during the 3 postoperative months were recorded for each group.

Results

Three hundred and sixty-seven patients with a mean BMI of 42.10 kg/m² (± SD: 4.78) were included. All-cause morbidity at 90 days was 11.7% (43/367) and no significant difference was observed between the 3 groups. Adjustment for patients and operative cofounders did not demonstrate any increased risk of postoperative complications between the 3 groups, with an odds ratio of 1, 1.23(95% CI [0. 55–2.75]), and 1.14 (95% CI [0.49, 2.67]) for groups 1, 2, and 3 respectively. Severe complications (Clavien-Dindo ≥ grade 3a) and emergency or unplanned consultations were also similar in the 3 groups.

Conclusion

Return to a normal diet 1 week after LRYGB did not increase short-term morbidity and unplanned consultations. It may be safe and contribute to patient comfort.

Graphical abstract

Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures

OBJECTIVE

To define "best possible" outcomes for secondary bariatric surgery (BS).

BACKGROUND

Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS.

METHODS

Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years.

RESULTS

The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.

CONCLUSION

Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Learning curve and global benchmark values of laparoscopic sleeve gastrectomy: results of first 100 cases of a newly trained surgeon in an Italian center of excellence

To evaluate whether the learning curve for sleeve gastrectomy could be completed after 50 cases. First 100 patients undergoing LSG under a newly trained laparoscopic surgeon were included in this study and divided into two groups of 50 consecutive patients each. Perioperative outcomes were compared to recently introduced global benchmarks. Short-term weight loss was calculated as Total Weight Loss Percent (%TWL) and complications were classified in accordance with the Clavien-Dindo classification. CUSUM analysis was performed for operative time and hospital stay. Mean preoperative age and BMI were 41.8 ± 10.3 years and 42.9 ± 5.4 kg/m2, respectively. Demographics and rate of patients with previous surgery were comparable preoperatively in the two groups. Mean operative time was 92.1 ± 19.3 min and hospital stay was 3.4 ± 0.6 days as per our standard protocol of discharge. Uneventful postoperative course was recorded in 93% of patients and only one case of staple line leak was registered in the first 50 cases (group 1). No statistical difference in BMI and %TWL was found between the two groups at any time of follow-up. Comparison between two groups showed a significant reduction in hospital stay and operative time after the first 50 LSGs (p < 0.05). LSG can be performed by newly trained surgeons proctored by senior tutors. At least 50 cases are needed to meet global benchmark cut-offs and few more cases may be required to reach the plateau of the learning curve.

Analysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgery

BACKGROUND

Hundreds of thousands of patient-safety clinical incidents are reported to the National Reporting and Learning System (NRLS) database in England and Wales every year. The purpose of this study was to identify bariatric surgery-related learning points from these incidents.

METHODS

We analysed bariatric surgery-related clinical incidents reported to the NRLS database between 01 April 2005 and 31st October 2020. The authors used their experience to identify learning themes, attribute severity, and design a safety checklist from these reported incidents.

RESULTS

We identified 541 bariatric surgery-related clinical incidents in 58 different themes. Preoperative, intraoperative, and postoperative incidents represented 30.3% (N = 164), 38.1% (N = 206), and 31.6% (N = 171) incidents respectively. One hundred fifty (27.7%), 244 (45.1%), and 147 (27.2%) incidents were attributed high, medium, and low severity respectively. The most commonly reported high severity theme was the failure of thromboprophylaxis (50; 9.2%). Intraoperative high severity incidents included 17 incidents of stapling of orogastric/nasogastric tubes or temperature probes, 8 missed needles, 8 broken graspers, and 6 incidents of band parts left behind. Postoperatively, the most commonly reported high severity theme was improper management of diabetes mellitus (DM) (35; 6.5%). Medication errors represented a significant proportion of the medium severity incidents.

CONCLUSION

We identified 58 specific themes of bariatric surgery-related clinical incidents. We propose specific recommendations for the prevention of each theme and a safety checklist to help improve the safety of bariatric surgery worldwide.